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Carbohydrate Counting
Can’t tell your Carbs from
your Proteins?
www.diabetes.co.za
Carbohydrate counting is essential when it comes to matching
your insulin to the different types and amounts of carbohydrates you
eat. Take control of your health by visiting the Accu-Chek website to
see what diabetes management solutions and support options are
available to you.
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Table of contents
1.Introduction
1
2. What is carbohydrate counting?
3. Why count carbohydrates?
4.
What foods contain carbohydrate?
2
5.
6.
Are some carbohydrates better for me?
How much carbohydrate do I need?
3
7.
What about protein?
4
8.
9.
What about fat?
What about alcohol?
5
10. Carbohydrates & the Glycemic Index
6
11. How to count carbohydrates
i) The Carbohydrate Exchange System
ii) Carbohydrate Gram Counting
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12. Reading food labels for carbohdyrate counting
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13. Tools needed for carbohydrate counting
14. Insulin-to-carbohydrate ratio
11
15. Why is it essential to keep detailed records?
16. Insulin sensitivity factor (ISF)
17. Correction dose (CD)
12
18. Steps to successful carbohydrate counting
19.Summary
13
20. The Carbohydrate Exchange System
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Introduction
The main nutrient in food that affects blood glucose levels is carbohydrate. This book will
introduce you to counting the amount of carbohydrates there are in the food you eat, along
with matching this with the correct dose of insulin.
What is carbohydrate counting?
Carbohydrate counting is a meal planning method, which allows you to match your insulin
doses to the different types and amounts of carbohydrates you eat. If you know which
foods contain carbohydrates and you know the amount of carbohydrates you are eating,
then you can enjoy a greater variety of meal and snack choices (including sugar and sugarcontaining foods) which will still keep your blood glucose levels within the correct range.
Why count carbohydrates?
Carbohydrates (starches and sugars) account for most of the glucose in the bloodstream,
especially right after meals. In fact, 90 to 100% of the digestible carbohydrates we eat
appear in the blood as glucose within 15 minutes to 2 hours after they are eaten. In other
words, blood glucose levels are mainly increased by foods containing carbohydrates.
The more carbohydrates you eat, the higher the blood glucose level rises. Counting
carbohydrates allows you to measure the impact a meal could have on your blood glucose
level.
For example, 2 slices of bread will make your blood glucose level go higher than 1 slice,
while 3 slices will make it go higher than 2.
When you eat carbohydrates, insulin is required to transport the glucose out of the
bloodstream and into the body’s cells. This means that the more carbohydrates you eat the
more insulin you need and the less carbohydrates you eat, the less insulin you need.
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The insulin dose will need to match the amount of carbohydrates eaten. Eating
too many carbohydrates, however, will result in larger doses of insulin being required and
high levels of insulin may cause carbohydrates to be stored as fats (i.e. cause weight gain)
and may stop your body from burning its own fat stores (i.e. prevent weight loss).
What foods contain carbohydrate?
Carbohydrates are found in starches and sugars. (Sugars may be added to food or may be
naturally present in foods.) The following foods contain carbohydrates:
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Are some carbohydrates better for me?
In a healthy meal plan, most carbohydrates should come from nutrient-dense foods like
whole grains, legumes, fruits, vegetables and low-fat dairy products. Nutrient-dense foods
contain a high volume of vitamins, minerals and fibre. Some sugary foods can be included
in your meal plan but should be limited as they are often high in fat and calories (such as
cakes, biscuits, pastries and chocolates) and they include very few of the healthy nutrients.
Eating these foods too often may result in weight gain and higher lipid (blood fat) levels.
Use common sense and indulge in moderation! Carbohydrate counting will help you decide
how to include these foods in your meal plan.
How much carbohydrate do I need?
When using carbohydrate counting, there is temptation to “splurge” on sweets and other
favourite foods and adjust the insulin dose accordingly - however, the extra calories add up
and weight-gain is likely. The amount of carbohydrate that is best for you depends on your
age, height, weight, level of physical activity, current blood glucose levels and your blood
glucose targets. Your dietician will help you work out how many carbohydrates you need
based on these factors.
While learning to count carbohydrates, eating the same amount of carbohydrate each day
makes controlling your blood glucose levels much easier. You will know when your blood
glucose levels are going to rise and by how much. It makes sense that if you have a small
bowl of cereal at breakfast one day and a large bowl of the same cereal the next day, your
blood glucose level will go higher on the second day.
However, when you eat the same amount of
carbohydrates each day, you can then focus on
getting the correct dose of insulin to deal with the rise
you expect to see in your blood glucose level.
Being consistent with the amount of carbohydrates
you eat during the initiation phase will help you and
your Diabetes team to quickly and easily calculate
your personal insulin requirements. This allows for
more flexibility later on.
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What about protein?
Approximately 50-60% of the protein we eat is broken down and converted into glucose by
the liver. This glucose from proteins appear in the bloodstream several hours after eating (as
opposed to carbohydrates, whereby 90-100% is absorbed from the gut straight away into
the bloodstream).
In other words, proteins have a much lower effect on blood glucose levels compared to
carbohydrates - that is why you do not actually have to count them.
If your blood glucose goals are not being achieved when counting carbohydrates alone, or if
you eat larger than usual amounts of protein, then you will need to do a blood glucose test
before the next meal to determine the effect of the protein.
This blood glucose value will be a reasonable indicator of the effect of the protein eaten at
the previous meal (provided there have been no snacks between the meals). Blood glucose
control can then be compared to the period when carbohydrates were counted alone or
when smaller portions of protein were eaten.
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What about fat?
Fat has no direct effect on the blood glucose level and that is why you do not actually have
to count it. However, it does affect the blood glucose level indirectly by slowing the emptying
of the food from the stomach.
This means that the glucose from the meal is absorbed more slowly into the bloodstream
and therefore does not cause a rapid rise in the blood glucose level. For this reason, it is
important to include a small amount of healthy fat at each meal.
However, eating too much fat at each meal delays the emptying of the stomach too much.
This results in an increased blood glucose level about 5 -12 hours after eating i.e. a high fat
lunch can increase the blood glucose level before supper and a high fat supper can increase
the blood glucose level the next morning.
It is important for you to know, however, that many foods that contain proteins and fats also
contain carbohydrates, which means that they still need to be counted.
These include cakes, pies, pastries, full cream milk and ice-cream, chocolates, crisps,
takeaways, hot chips, processed meat such as sausages, crumbed and fried fish and
chicken, pizzas, pastas, casseroles, stews, soups, sauces and some salad dressings.
What about alcohol?
No extra insulin is needed for the alcohol content of one or two low-carbohydrate alcoholic
drinks, such as 1-2 light beers, 120-240ml dry wine or 25-50ml spirits. One or two of these
drinks can usually be added to a normal meal plan with little effect on the blood glucose
level.
Some alcoholic drinks, however, may contain carbohydrates that need to be counted.
Examples include ciders and fruity alcoholic drinks (such as Esprit Fruit Ales, Bacardi
Breezers, Archers Schnapps Aquas and Smirnoff Spins), sweet wines, liqueurs, margaritas,
and other alcoholic drinks made with syrup, fruit juice, Red Bull and regular drinks such as
tonic water, lemonade or coke.
If a consistent problem of hyperglycaemia is observed after drinking then you may benefit
from giving half the usual units per carbohydrate portion.
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Giving the normal insulin dose for this carbohydrate is not usually recommended because of
the increased risk of delayed hypoglycaemia (hypo or low blood glucose) during the night
and the next morning.
This is because the liver cannot make new glucose while it is processing alcohol. This
prevents the body’s normal protective mechanism from kicking in if the blood glucose level
falls too low during or after drinking. Since alcohol can impair reasoning, extra care is called
for in calculating insulin doses when drinking. Additional blood glucose testing, particularly
before bed and the next morning, is required after alcohol consumption to prevent
unrecognised hypoglycaemia.
You can reduce the risk of having a hypo by:
• having a meal containing carbohydrates before or while you are drinking alcohol
• eating a snack containing carbohydrates before bed
• reducing the dose of insulin at breakfast the next morning
• restricting your alcohol intake to no more than one to two standard drinks per
day (as mentioned above)
Alcohol should be avoided by those with raised triglyceride levels, uncontrolled blood
glucose levels, pregnant women or any other medical condition in which alcohol is
restricted. Alcohol adds very little nutritional value to the meal plan and is high in calories, so
you may need to cut down or avoid it if you are trying to lose weight or avoid gaining weight.
Carbohydrates & the Glycemic Index (GI)
The glycemic index rates on a scale from 0-100, how fast a carbohydrate-containing food is
digested into glucose and how quickly, and how high it raises the blood glucose level. Pure
glucose, which is absorbed into the bloodstream the quickest, has the value of 100. The
closer the value of a carbohydrate-containing food is to 0, the slower it is absorbed into the
bloodstream.
Low GI foods (GI ≤ 55) are useful before exercise and as a bedtime snack.
Intermediate GI foods (GI = 56-69) are useful during and after moderate to strenuous
aerobic exercise.
High GI foods (GI ≥ 70) are eaten to raise low blood glucose levels, or during and after
endurance exercise (> 90 minutes).
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Which type of person with Diabetes benefits most from using the GI?
• Those using a regular short-acting insulin at each meal such as Actrapid or Humulin R
• Those using a regular pre-mixed insulin twice a day (before breakfast and supper) such as Actraphane or Humulin 30/70
• Those who are only injecting an intermediate or long-acting insulin, such as Lantus, Levemir, Humulin N or Protaphane
• Those who are taking oral glucose-lowering medications
These types of people with diabetes can use this concept to help them make wise food
choices, but frequent blood glucose testing 2 hours after a meal, is the best way to see
the effect that specific carbohydrates have on their own blood glucose levels. They may
discover some carbohydrate foods cause a higher after-meal glucose rise than others. In
noticing this, they can establish their own personal “glycemic index” and make decisions
about food choices, portion sizes and doses of insulin and/or medication, that will result in
the best possible glucose control.
However, for people with diabetes who are on an insulin pump or who are injecting a
rapid-acting insulin analogue (e.g. Humalog, Apidra or NovoRapid) before each meal, the
glycemic index should not be the foundation of the meal plan.
Instead, the pre-meal insulin doses should be adjusted based on the amount
of carbohydrate eaten and less on the type of carbohydrate (i.e. the GI).
How to count carbohydrates
There are 2 basic methods of counting carbohydrates. The best method for a given
individual is the easiest one to use and that produces the desired level of blood glucose
control. Many people use a combination of both methods:
1. The Carbohydrate Exchange System
2. Carbohydrate Gram Counting
1. The carbohydrate exchange system
This method uses food groups called “exchanges” (or portions or servings).
Food exchange lists assign an average carbohydrate value per exchange to all the foods
within a food group.
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The food groups are listed below, followed by the number of grams of carbohydrate per
exchange, as well as the number of portions of carbohydrate.
One exchange (or portion or serving) of each food containing carbohydrates has ~15
grams of carbohydrate.
The following exchanges, portions or servings, are each one-carbohydrate choice equalling
~ 15 grams of carbohydrate. Thus, each of these choices will affect your blood glucose level
the same way:
•1 medium apple – from the Fruit list
•½ cup cereal - from the Starch list
•1 cup milk - from the Milk list
So whether you eat 1 medium apple (one carbohydrate exchange) or ½ cup of cereal
(one carbohydrate exchange) or drink one cup of milk (one carbohydrate exchange),
each different food exchange will affect your blood glucose about the same because each
contains almost equal amounts of carbohydrate. All carbohydrate-containing foods are
counted equally (See the attached Carbohydrate Exchange List).
Because exchange values are averages, they are not accurate for every food in a group. If
blood glucose goals are not being met, try the more precise carbohydrate gram counting
method.
2. Carbohydrate gram counting
Another way to count carbohydrates is to add up the exact number of grams of
carbohydrates in each meal or snack. Food labels and reference books are great tools for
carbohydrate gram counting.
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Reading food labels for carbohydrate counting
1.
2.
3.
4.
5.
6.
Read the “Nutrition Information” on the label very carefully.
Look for the serving size.
Look for the TOTAL carbohydrate value (this includes the grams of sugar & starch)
for this serving size.
Work out how many servings you are going to eat (MORE or LESS than the
serving size).
Multiply the number of servings you are going to eat by the grams of total
carbohydrate per serving.
This will give you the total number of grams of carbohydrate for the quantity
of that food that you are going to eat.
The following are sources of sugar and starch that may appear on a list of ingredients
and contribute to the total carbohydrate content of the food:
You will find a great number of foods targeted at
people with Diabetes. However, the wording on
the label of a product can be incredibly misleading.
Any foods labelled “Suitable for Diabetics”,
“Sugar-free”, “No sugar added”, “Sucrose-free” or
“100% pure”, are only free of added sucrose they however contain other types of sugars and
starches (as mentioned above), which will
contribute to the total carbohydrate content of the
food i.e. sucrose-free or sugar-free does not mean
that it is carbohydrate-free.
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Using the “Kellogg’s Hi-Fibre Bran” label below as an example:
1. Read the “Nutrition Information”
NUTRITION INFORMATION
Serving Size: 150ml (40g)
Number of servings per pack: 9
2.
3.
4.
Per 100g
Per 40g
%RDA**
per serving
Energykj
cal
1097
261
428
102
---
Proteing
13
5
9%
Carbohydrateg
Sugar
g
Starch
g
45
13
32
18
5
13
----
Fibre*g
27
11
25-30g
per day
Total Fat
Saturated fat
Monosaturated fat
Polyunsaturated fat
3
0.4
0.5
2
1
0.2
0.2
0.8
--
g
g
g
g
Serving size = 150ml/40g
TOTAL carbohydrate value per serving = 18g
How many servings are you going to eat?
• If you eat ½ a serving, then you will be eating 9g (18g x ½) carbohydrate
• If you eat 1 serving, then you will be eating 18g (18g x 1) carbohydrate
• If you eat 2 servings, then you will be eating 36g (18g x 2) carbohydrate
To find out how many carbohydrate (carb) exchanges, servings, or portions a food contains,
either you can use the table below or you can divide 15 into the total grams of carbohydrate.
Grams of Carb
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Count as the following Carb Serving/Exchange/Portions
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So from the example:
• 1 serving = 18g carbohydrate:
° Using the table above, 18g = 1 carbohydrate exchange or
° 18g ÷ 15g = 1.2 ~ 1 carbohydrate exchange
• 2 servings = 36g carbohydrate:
° Using the table above, 36g = 2½ carbohydrate exchanges or
° 36g ÷ 15g = 2.4 ~ 2½ carbohydrate exchanges
Tools needed for carbohydrate counting
Insulin-to-carbohydrate ratio
The amount of insulin required to cover a given number of carbohydrates is called the
“Insulin-to-Carbohydrate Ratio”.
There is a unique, personal ratio between the amount of insulin you need to “match” or
“cover”, to the amount of carbohydrates you eat. This ratio can be used to calculate the
appropriate dose for any meal or snack. Keep in mind that your ratio could change from
meal to meal, day to day, or under special circumstances, such as active or inactive days,
illness or stress.
Changes in appetite, eating new foods or
drinking alcohol can also affect your blood
sugar levels. In these cases, you may need
to change your ratio(s). Your dietician will
help you work out the correct insulin:
carbohydrate ratios that are appropriate
for you.
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Why is it essential to keep detailed records?
Keeping a record of the times that you eat and inject, what and how much you eat and
drink, blood glucose levels, insulin doses as well as the time and duration of exercise, will
give you an indication of whether your insulin:carbohydrate ratio is working and where
adjustments are needed.
Insulin sensitivity factor (ISF)
Your ISF is the amount (in mmol/l) that your blood glucose level is reduced by one unit of
rapid-acting insulin. The ISF helps you decide how much insulin you need to get elevated
blood glucose levels back into target range. Because everyone is different, your ISF should
be tailored for your specific needs. Trial-and-error and keeping detailed records, will help
you and your diabetes team, work out your ISF.
Correction dose (CD)
Extra insulin can be given to correct high blood glucose levels that are above the target
level, in addition to that needed for the carbohydrate eaten. If frequent corrective doses are
given, the insulin: carbohydrate ratio may need to be changed. Once you know your ISF,
you can use it to calculate your correction dose of insulin.
Your doctor, dietician or educator will provide you
with specific guidelines and formulas to work out
your ISF and CD.
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Steps to successful carbohydrate counting
1. Identify foods containing carbohydrates
2. Calculate the total carbohydrate content of the meal or snack
3. Consider factors (such as fat & alcohol) that influence the blood glucose response
4. Consider time and duration of activity
5. Consider pre-meal blood glucose level (i.e. is a correction dose required?)
6. Calculate insulin dose required based on the above factors
7. Give insulin dose
8. Record blood glucose response before and 2 - 4 hours after the meal
Summary
Carbohydrate counting can be a successful meal planning method to help you manage your
diabetes. It allows you to match your insulin doses to the different types and amounts of
carbohydrates you eat.
It offers the most precise and flexible approach
available today, is relatively easy to learn and use,
and can add a lot of freedom to food choices.
It takes some time and practice, but if you are
persistent, you will become an expert and see the
results you want over time.
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The Carbohydrate Exchange System
STARCH: 1 Starch exchange ± 15g carbohydrate
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MILK: 1 Milk exchange ± 15g carbohydrate
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FRUIT: 1 Fruit exchange ± 15g carbohydrate
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VEGETABLES: 1 Vegetable exchange ± 15g carbohydrate
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SNACKS & TREATS: 1 Snack & Treat exchange ± 15g carbohydrate
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Carbohydrate Counting
Order further Accu-Chek guides:
Accu-Chek offers a complete programme of information for
people with diabetes. We are pleased to provide you with
further guides on “Living with Diabetes”.
To order:
Call our toll free Diabetes Care Line:
080-DIABETES (Dial: 080-34-22-38-37)
Important Information:
Accu-Chek wants to emphasize that the information supplied in this guide,
does not replace the opinion and recommendations of your healthcare
team.
Roche Products (Pty) LTD
Diagnostic Division
PO Box 1927, Randburg
Toll free: 080-Diabetes (Dial 080-34-22-38-37)
www.accu-chek.co.za / www.diabetes.co.za
Ref: SUP110810
NDG P52968 011 803 6200
Reference:
1. Mandy Marcus, Registered Dietician, Centre for Diabetes and Endocrinology, Houghton, Johannesburg.