Using Carbohydrate Counting in Diabetes Clinical Practice

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Abstract

Carbohydrate counting is a meal planning approach used with clients who have diabetes that focuses on carbohydrate as the primary nutrient affecting postprandial glycemic response. The concept of carbohydrate counting has been around since the 1920s, but it received renewed interest after being used as 1 of 4 meal planning approaches in the Diabetes Control and Complications Trial. In the trial, carbohydrate counting was found to be effective in meeting outcome goals and allowed flexibility in food choices. Recent practice pattern surveys have shown an increasing interest in and use of carbohydrate counting for medical nutrition therapy for persons with diabetes. Carbohydrate counting can be used by clients with type 1, type 2, and gestational diabetes. Three levels of carbohydrate counting have been identified based on increasing levels of complexity. Level 1, or basic, introduces clients to the concept of carbohydrate counting and focuses on carbohydrate consistency. Level 2, or intermediate, focuses on the relationships among food, diabetes medications, physical activity, and blood glucose level and introduces the steps needed to manage these variables based on patterns of blood glucose levels. Level 3, or advanced, is designed to teach clients with type 1 diabetes who are using multiple daily injections or insulin infusion pumps how to match short-acting insulin to carbohydrate using carbohydrate-to-insulin ratios. All 3 levels emphasize portion control and offer opportunities for using creative teaching methods, such as “food labs,” and use of a variety of carbohydrate resource tools and publications. In this article, glycemic effects of protein, fat, and fiber intake are discussed for persons with type 1 and type 2 diabetes. Decision trees are introduced for each level of carbohydrate counting and show the usual progression through each level. Carbohydrate counting as a meal planning approach offers variability of food choices with the potential for improving glycemic control. Research opportunities are available for those interested in comparing carbohydrate counting with other meal planning approaches for clients with diabetes and the effects on clinical outcomes. J Am Diet Assoc. 1998;98: 897-905.

Section snippets

Historical Background

Carbohydrate counting is not a new concept. Soon after the discovery of insulin in 1921, references appeared in the literature (6), (7), (8) that indicate that carbohydrate counting was used in meal planning for persons with diabetes in the United States and in Europe. Joslin et al (6), (7) reported tests in which they administered similar amounts of different carbohydrate-containing foods to compare dextrose to starches. No statistical differences were found in glycosuria or blood glucose

Practice Patterns and Meal Planning Approaches

Practice patterns of dietitians in the United States are changing as a variety of meal planning approaches for persons with diabetes are available and are being used (9). During the past decade, several surveys of dietitians who provide medical nutrition therapy for persons with diabetes have been conducted to determine current practice patterns as well as to assess the needs of dietitians (11), (12), (13). These surveys identified the need for a variety of meal planning approaches to be used

Why Count Carbohydrates?

Carbohydrate counting is based on 2 tenets. First, scientific evidence gathered using modern research methods (2), (3), (4), (5) and clinical observations have shown that carbohydrate is the main factor affecting postprandial blood glucose excursions and, thus, insulin requirements. Second, carbohydrate is converted to glucose within the first 2 hours after eating (3), (4) and appears in the systemic circulation within the first 15 minutes (4). The 1994 American Diabetes Association nutrition

Levels of Carbohydrate Counting

Three levels of carbohydrate counting have been identified: level 1, or basic; level 2, or intermediate; and level 3, or advanced. Level 1 introduces the concept of carbohydrate counting and encourages inclusion of consistent amounts of carbohydrate at meals and snacks. Level 2 focuses on relationships among food, medication, activity, and blood glucose level and introduces the concept of how to make adjustments based on blood glucose patterns. Level 3 is designed to teach clients who use

Summary and Future Directions

Carbohydrate counting is a meal planning approach that is being used more frequently for persons with diabetes. The graduated approach that includes 3 levels with progressive complexity has been helpful to clients and health care providers. A variety of content areas need to be covered at all levels and multiple visits by the client are highly useful (Table 1). Progress is being made nationally to secure third-party reimbursement for medical nutrition therapy, which should help with coverage

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