Carbohydrate Counting at Different

Levels:
USA Management Guidelines

Suha Khoury, RD
 Purpose of Presentation

 To explain the carbohydrate counting approach and to

demonstrate ways for applying it in diabetes nutrition
management

1
 Topics of Discussion

1. Defining carbohydrate counting approach and

highlighting reasons behind popularity
2. Explaining the goals and objectives for the levels of
carbohydrate counting
3. Presenting recommended teaching aids
4. Discussing case studies

2
 1. Definition and Reasons Behind
Popularity
 Definition
• Carbohydrate Counting is a meal planning approach based
on the following ideas1 :
• Carbohydrates is the main nutrient affecting post-prandial glycemic
response
• Total amount of carbohydrates is more important than source of
carbohydrates
 Reasons behind popularity
• Effectiveness 2

• Flexibility 3

• Ease of implementation 4

1. Using Carbohydrate Counting in Clinical Practice, JADA

2,3,4. Practical Carbohydrate Counting, American Diabetes Association, 2001
3
 2. The Three Levels of Carbohydrate
Counting 1

 2.1. Level 1: Getting Started

 2.2. Level 2: Moving On
 2.3. Level 3: Using Insulin:Carbohydrate Ratios

1. Carbohydrate Counting: Getting Started, The American Diabetes Association and The American Dietetic Association, 1995.
4
 2.1. Level 1
2.1.1. Goals
 Goals of Level 1 of carbohydrate counting1,2,3
• Regulate blood glucose by balancing carbohydrate
intake with the diabetes medication and physical
activity
• Achieve and maintain consistency of carbohydrate
intake at meals and snacks at similar times each day

1. Carbohydrate Counting: Getting Started, The American Diabetes Association and The American Dietetic Association, 1995.
2. Practical Carbohydrate Counting, American Diabetes Association, 2001. 6
3. Using Carbohydrate Counting in Clinical Practice, JADA, 1988, v98, n8
 2.1. Level 1
2.1.2. Objectives
 Objectives of Level 1 of carbohydrate counting1,2,3
• Identify carbohydrate as the primary nutrient affecting blood glucose levels
• Determine what foods contain carbohydrates, protein, and fat
• Estimate accurately portion sizes
• Define 1 carbohydrate choice as 15 grams carbohydrate and as 1 bread, or 1 fruit, or 1
milk exchange
• Count carbohydrate in meal plan
• Determine time and carbohydrate goals for meals and snacks

1. Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 1995
2. Practical Carbohydrate Counting, American Diabetes Association, 2001
3. Using Carbohydrate Counting in Clinical Practice, JADA, v98, n8 7
 2.2. Level 2
2.2.1. Goals
 Goals of Level 2 of carbohydrate counting1,2,3
• Improve glycemic control through managing patterns of
blood glucose as they relate to food intake, diabetes
medication, and physical activity
• Increase flexibility in client’s lifestyle through advanced
carbohydrate counting skills
• For type 1 diabetes, introduce the concept of insulin
adjustment based on changes in usual carbohydrate intake

1. Carbohydrate Counting: Moving On, The American Diabetes Association, The American Dietetic Association, 1995
2. Practical Carbohydrate Counting, American Diabetes Association, 2001
3. Using Carbohydrate Counting in Clinical Practice, JADA, v98, n8 8
 2.2. Level 2
2.2.2. Objectives
 Objectives of Level 2 of carbohydrate counting1,2,3
• Apply concept of pattern management by
• Identifying patterns of blood glucose levels
• Determining relationships among food, diabetes medication, physical activity, and
glucose levels
• Establishing guidelines for managing these variables
• Identify impact of protein and fat on glucose
• Count carbohydrates in choices or grams for
• High fiber foods • Food labels • Recipes
• Combination foods • Restaurant meals
• Add 1 unit of short-acting or rapid-acting insulin for each
additional 10-15 grams carbohydrates

1. Carbohydrate Counting: Moving On, The American Diabetes Association, The American Dietetic Association, 1995
2. Practical Carbohydrate Counting, American Diabetes Association, 2001
3. Using Carbohydrate Counting in Clinical Practice, JADA, v98, n8 9
 2.3. Level 3
2.3.1. Goals
 Goals of Level 3 of carbohydrate counting1,2,3
• Improve BG control for people using intensive diabetes
management by matching the amount of insulin with
carbohydrate intake
• To offer greater flexibility in food choices and portion sizes

1. Carbohydrate Counting: Carbohydrate/Insulin Ratios, The American Diabetes Association, The American Dietetic Association, 1995
2. Practical Carbohydrate Counting, American Diabetes Association, 2001
3. Using Carbohydrate Counting in Clinical Practice, JADA, v98, n8 10
 2.3.Level 3
2.3.2. Objectives
 Objectives of Level 3 of carbohydrate counting1,2,3
• Explain insulin action; basal and bolus
• Count carbohydrates using Carbohydrate Gram Method or
Carbohydrate Choices Method
• Calculate insulin:carbohydrate ratio and ISF
• Adjust insulin for
• Varying amounts of carbohydrates • Vacations and holidays
• High-protein and/or high-fat meals • Alcohol use
• Foods containing fiber • Sick days and stress
• Physical activity and exercise • Restaurant meals

• Correct hypoglycemia and hyperglycemia

1. Carbohydrate Counting: Carbohydrate/Insulin Ratios, The American Diabetes Association, The American Dietetic Association, 1995
2. Practical Carbohydrate Counting, American Diabetes Association, 2001
3. Using Carbohydrate Counting in Clinical Practice, JADA, v98, n8 11
 3. Recommended Teaching Aids
3.1. The Exchange Lists
3.2. Carbohydrate Choices
3.3. Estimating Portion Sizes and Carbohydrate Choices
3.4. How Much Carbohydrate is Needed
3.5. Factors Influencing Glycemic Control
3.6. Carbohydrate Counting for Foods Containing Sugar
Alcohols
3.7. The Actions of Insulin
3.8. Insulin:Carbohydrate Ratio
3.9. Calculating Carbohydrates in Recipes
3.10. Exchanges for Alcoholic Beverages
3.11. Treating Hypoglycemia
3.12. Exercise Guidelines
3.13. Guidelines for Illness 12
 3.1. The Exchange Lists1
Groups/ Lists Carb. Protein Fat Calories
Carbohydrate Group
Starch 15 3 1 or less 80
Fruit 15 ___ ___ 60
Milk
Skim 12 8 0-3 90
Low-fat 12 8 5 120
Whole 12 8 8 150
Other carbohydrates 15 varies varies varies
Vegetables 5 2 ___ 25
Meat and Substitute Group
Very lean ___ 7 0-1 35
Lean ___ 7 3 55
Medium-fat ___ 7 5 75
High-fat ___ 7 8 100
Fat Group ___ ___ 5 45

1. Exchange Lists for Meal Planning, The American Diabetes Association, The American Dietetic Association, 1995
13
 3.2. Carbohydrate Choices

Foods that Contain One Carbohydrate Choice2

Carbohydrates1 15 grams of carbohydrate
Bread, cereals, pasta, and grains 1 slice of bread
Rice, beans, and starchy ½ cup pasta
vegetables: potatoes, corn, peas 1 small potato
Fruit and fruit juices ½ cup legumes
Milk and yogurt ½ cup cereal
Sugars foods: regular soda, fruit 1 fruit
drinks, jelly beans
1 cup yogurt
Sweets: cake, cookies, chocolate
candy 1 cup milk

1. Practical Carbohydrate Counting, American Diabetes Association, 2001. 14

2. Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 1995
 3.3. Estimating Portion Sizes1 and
Carbohydrate Choices2
Hand Guide Example
Thumb = 1 oz 1 serving cheese
Palm = 3 oz 1 serving cooked meat
Tight fist = ½ cup 1 serving frozen yogurt
Loose fist or handful = 1 cup 1 serving pasta

Carbohydrate Target Total Grams Range of Total Grams

Choices of Carbohydrate of Carbohydrate
1 15 8-22 grams
2 30 23-37 grams
3 45 38-52 grams
4 60 53-65 grams

1. Practical Carbohydrate Counting, American Diabetes Association, 2001. 15

2.Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 1995
 3.4. How Much Carbohydrate is Needed1

Calorie level ~ 1200 ~1400 ~1600 ~1800 ~2400 ~2800

Calorie range 1200- 1300- 1400- 1600- 1800- 2200-
1500 1600 1700 1900 2300 2800
Carbohydrate grams 180 180 195 210 240 300
Carbohydrate choices 12 12 12-13 13-14 15-16 18-20
Grains, beans, &
6 6 6 7 9 11
starchy vegetables
Vegetables 3 3 3 4 4 5
Fruits 3 3 3 3 3 4
Milk 2 2 2-3 2-3 2-3 2-3
Meats 2 (4oz) 2 (4oz) 2 (5oz) 2 (5oz) 2 (6oz) 3 (70z)
Fats g/servings 40/4 47/5 54/6 60/7 74/9 93/12
1. Practical Carbohydrate Counting, American Diabetes Association, 2001.
16
 3.5. Factors Influencing Glycemic
Control1,2
High-fiber Meal
Subtract from total carbohydrate content the amount of fiber in foods and
meals containing more than 5 grams of carbohydrate
High-protein and/or High-fat Meal
 Take rapid-acting insulin after, rather than before, the meal
 Split the dose of rapid-acting insulin and take half before the meal and half
after the meal

1.Carbohydrate Counting: Moving On, The American Diabetes Association, The American Dietetic Association, 1995
2. Practical Carbohydrate Counting, American Diabetes Association, 2001 17
 3.6. Carbohydrate Counting for Foods
Containing Sugar Alcohols (Polyols)1
Conditions Recommendation
 Total carbohydrate comes from polyols  Do not count if three or less
 There are less than 10 grams of servings are eaten per day
carbohydrates per serving
 Total carbohydrate comes from polyols  Divide total carbohydrate in
 There are more than 10 grams of half then count it
carbohydrates per serving
 Polyols are just one source of  Divide grams of polyols in
carbohydrates half and subtract the amount
from total carbohydrate

18
1. Practical Carbohydrate Counting, American Diabetes Association, 2001
 3.7. The Actions of Insulins1
Insulin Onset Peak Duration
 Rapid acting
Lispro (Humalg) <15 minutes 0.5-1.5 hours 2-4 hours
Aspart (Novolog) <15 minutes 0.5-1.0 hour 1-3 hours
 Short acting
Regular 0.5- 1 hour 2-3 hours 3-6 hours
 Intermediate
NPH 2-4 hours 4-10 hours 10-16 hours
lente 3-4 hours 4-12 hours 12-18 hours
 Long acting
Ultralente 6-10 hours 10-16 hours 18-20 hours
Glargine (Lantus) 2-4 hours peakless 24 hours

1. Practical Carbohydrate Counting, American Diabetes Association, 2001

19
 3.8. Insulin:Carbohydrate Ratio

3.8.1. Method #1: Food dairy, insulin dose, and SMBG

information
3.8.2. Method#2: The rule of 450 or 5001
3.8.3. Method#3: Using the insulin sensitivity factor (ISF)
 3.8.1. Method #1

Food dairy, insulin dose, and SMBG information1,2

 Insulin:Carbohydrate ratio = Grams of carbohydrate at a given meal ÷
number of units of insulin taken at that meal

Example
 Client needs 4 units of insulin to cover 45 grams of carbohydrates
 Insulin:Carbohydrate ratio = 45 ÷ 4 = 11.25
Ratio = 1:11

1. Carbohydrate Counting:: Using Carbohydrate/Insulin Ratios, The American Diabetes Association, The American Dietetic Association, 1995
2. Practical Carbohydrate Counting, American Diabetes Association, 2001 21
 3.8.2. Method #2

The rule of 450 or 5001

 Insulin:Carbohydrate ratio = 450 or 500 ÷ total daily insulin dose
(TDD)

Example
 TDD = 36 units
 Glucose levels are within target range
 Insulin:Carbohydrate ratio = 500 ÷ 36 = 13.8 (rpund up to 14)
Ratio = 1:14

2. Practical Carbohydrate Counting, American Diabetes Association, 2001 22

 3.8.3. Method #3

Method # 3: Using the insulin sensitivity factor (ISF)1

 ISF = 1500 or 1800 ÷ TDD
 Insulin:Carbohydrate ratio = ISF× 0.33

Example
 TDD = 25 units
 ISF = 1800 ÷ 25 = 72 mg/dl
 Insulin:Carbohydrate ratio = 72 × 0.33= 23.8 (round up to 24)
Ratio = 1:24

2. Practical Carbohydrate Counting, American Diabetes Association, 2001 23

 3.9. Calculating Carbohydrates in
Recipes1
Food Amount Weight Carb. Exch.
White flour 1 cup 113 g 87 g 6
Whole wheat flour 1 cup 111 g 77.7 g 5
Oatmeal 1 cup 84 55.2 4
White sugar 1 cup 200 g 199 g 13
Honey 1 cup 336 g 277 g 17
Raisins 2/3 cup 100 g 79.1 g 5
Cocoa 1/3 cup 28 g 12.8 g 1
Chocolate chips ¼ cup 43 g 31.3 2

1. Food Composition Tables, Israeli Ministry of Health, 1996 24

 3.10. Exchanges for Alcoholic
Beverages1
Carb. Exchanges for
Beverage Serving (gms) Calories Type 2 DM
 Beer
Regular beer 12 oz. 13.7 151 1 bread + 2 fat
Light beer 12 oz. 6 90 2 fat
Nonalcoholic beer 12 oz. 9.7 50 1 bread
 Distilled spirits
86 proof 1 ½ oz. Trace 107 2 fat
 Table wines
Red or Rose 4 oz. 1.0 85 2 fat
Dry white 4 oz. 0.4 80 2 fat
Sweet wine 4 oz. 4.9 102 1/3 bread + 2 fat
Wine coolers 12 oz. 22.0 192 1 fat
 Sparkling wines
Champagne 4 oz 1.5 73 2 fat

1. Exchanges For All Occasions, Marion Franz, RD, MS, 1987

25
 3.12. Treating Hypoglycemia1

Blood Glucose Amount of Carbohydrate Recommended

51-70 mg/dl 15 grams
41-50 mg/dl 20 grams
<40 mg/dl 30 grams

Amount of Apple or Grape Cola/

Carbohydrates Orange Juice juice Milk Sprite
15 grams 120 cc 90 cc 300 cc 125 cc
20 grams 180 cc 120 cc 420 cc 190 cc
30 grams 240 cc 180 cc 600 cc 250 cc

1. Exchanges For All Occasions, Marion Franz, RD, MS, 1987 26

 3.13. Exercise Guidelines1
Increase Carb. Suggested
Type of Exercise If Blood Sugar Is: Intake by: Food
 Short Duration or Less than 80-100 mg/dl 10-15 grams. 1 fruit or 1 bread
Moderate intensity 100 mg/dl or above Not necessary ___
 Moderate intensity Less than 80-100 mg/dl 25-50 grams before ½ meat sandwich
exercise then 10-15 + milk or fruit
grams/hr, if necessary

80-170 mg/dl 10-15 grams 1 fruit or 1 bread

180-300 mg/dl Not necessary ___

300 mg/dl or greater Don’t exercise ___

 Strenuous activity Less than 80-100 mg/dl 50 grams 1 meat sandwich +

or exercise milk or fruit
180-300 mg/dl 10-15 grams/hr 1 fruit or 1 bread
300 mg/dl or greater Don’t exercise ___

1. Exchanges For All Occasions, Marion Franz, RD, MS, 1987

27
 3.14. Guidelines for Illness1
 To replace 10 grams of carbohydrates
Food Quantity
Carbonated beverage containing sugar ½ cup (4 oz.)
Popsicle ½ twin bar
Corn syrup or honey 2 tsp
Sweetened gelatin (Jell-O) ¼ cup

 To replace 15 grams of carbohydrates

Food Quantity Food Quantity
Ice cream ½ cup Saltine crackers 6
Cooked cereal ½ cup Toast 1 slice
Milk shake ¼ cup Sherbet ¼ cup
Orange or grapefruit juice ½ cup Jell-O 1/3 cup
Grape juice 1/3 cup Cream soups or broth based 1 cup
Custard ½ cup Yogurt, plain 1 cup

1. Exchanges For All Occasions, Marion Franz, RD, MS, 1987 28

 4. Case Studies

 4.1. Setting Carbohydrate Goals

 4.2. Impact of Fiber
 4.3. Applying Pattern Management
 4.4. Applying Insulin:Carbohydrate Ratio
 4.5. Determining Premeal Insulin Dose
 4.6. Correcting Premeal Hypoglycemia
 4.7. Correcting or Supplementing Insulin Dose

29
 4.1. Setting Carbohydrate Goals1

Example: 1300 Kcal/day diet

1300 Calories ÷ 8 (½ calories as carbohydrates and ¼ gram per calorie) =
162 grams carbohydrates

Meal Grams of Carbohydrates Carbohydrate Choices

Breakfast 30 grams 2 choices
Snack 15 grams 1 choice
Lunch 45 grams 3 choices
Snack 15 grams 1 choice
Dinner 45 grams 3 choices
Snack 15 grams 1 choice
Total 165 grams 11 choices

1. Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 1995
30
 4.2. Impact of Fiber1
Total Available
Carbohydrate Fiber Carbohydrate
Breakfast Meal (grams) (grams) (grams)
Breakfast A
½ grapefruit 15 1.7 15
1 oz bran cereal (1/2 cup) 22 10.0 12
1 oz slice whole-wheat bread 15 1.5 15
Total 52 13.2 42
Breakfast B
½ c orange juice 15 0.4 15
1 oz corn flakes (1 cup) 24 1.0 24
1 oz slice white bread 15 0.5 15
Total 54 1.9 54

1. Carbohydrate Counting: Getting Started, The American Diabetes Association, The American Dietetic Association, 1995 31
 4.3. Applying Pattern Management1
Day/Date Time BG Food Serving Size Carbohydrate Activity
Sun 18:00 99 steak 4 oz 0g Watch TV
6/10 baked potato 8 oz 43g
corn 1 cup 30g
Total 73g
20:00 201
Mon 18:30 105 Spaghetti 2 cups 60g Read
6/11 Marinara sauce ½ cup 10g
Total 70g
20:30 221
Tues 18:20 117 Grilled chicken 3 oz 0g Computer
6/12 Bun 2 oz 30g work
French fries 9 oz 45g
Diet drink 12 oz 0g
Total 75g
20:30 215

1. Carbohydrate Counting: Moving On, The American Diabetes Association, The American Dietetic Association, 1995 32
 4.4. Applying Carbohydrate:Insulin
Ratio1
Carbohydrate Carbohydrate
Food Gram Method Choices Method
3.5 oz broiled hamburger 0g 0
2 oz hamburger bun 30g 2
½ cup low-fat cottage cheese 4g 0
4 oz sliced tomato 5g 0
1 cup homemade coleslaw 15g 1
Totals 54g 3 choices or 45g

Example: Insulin:carbohydrate ratio = 1:9

Method Amount of Insulin
Carbohydrate Gram Method 54 grams ÷ 9 = 6 units R
Carbohydrate Choices Method 45 grams ÷ 9 = 5 units R
1. Carbohydrate Counting: Using Carbohydrate/Insulin Ratios, The American Diabetes Association, The American Dietetic Association, 1995 33
 4.5. Correcting or Supplementing Insulin
Dose1
Example
 Glucose = 264mg/dl
 Target glucose level is 100 mg/dl
 ISF = 53 mg/dl

Answer
 Difference between target and actual glucose levels = 264 – 100 = 164 mg/dl
 ISF= 164 mg/dl ÷ 53 mg/dl = 3.1 units
The correction dose of insulin is 3 units

1. Practical Carbohydrate Counting, American Diabetes Association, 2001

34
 4.6. Determining Premeal Insulin Dose1
Example
 TDD= 34 units
 Target glucose levels = 100 mg/dl
 Premeal glucose level = 226 mg/dl
 60 grams of carbohydrates are to be consumed

Answer
 ISF = 1800 34 = 52.9 (round up to 53)
 Difference between target and actual glucose levels = 226 – 100 =126 mg/dl
 Units of insulin to decrease high preprandial glucose levels= 126 ÷ 53 = 2.3 units
 Insulin:carbohydrate ratio
• 500 ÷ 34 = 14.7
• Ratio= 1:15
 Units of insulin to cover carbohydrates = 60 ÷ 15 = 4 units
Premeal insulin = 2.3 units + 4 units = 6.3 units

1. Practical Carbohydrate Counting, American Diabetes Association, 2001 35

 4.7. Correcting Premeal Hypoglycemia1

Example
 Insulin:carbohydrate ratio = 1:13, ISF = 35
 40 grams of carbohydrate will be consumed
 Actual glucose level = 57 mg/dl
 Target glucose level= 110 mg/dl

Answer #1: Increase amount of carbohydrate

 13 grams of carbohydrate will raise blood glucose by 35mg/dl
Answer # 2: Decrease preameal insulin dose
• Amount of insulin to cover carbohydrates= 40 ÷ 13 = 3 units of insulin
• Amount of insulin to be subtracted= Difference between target and actual blood
glucose levels ÷ ISF = 53 mg/dl ÷ 35 = 1.5 units insulin
• Premeal insulin = 3 units – 1.5 units = 1.5 units
Answer # 3: Delay premeal insulin

1. Practical Carbohydrate Counting, American Diabetes Association, 2001

36