CARBOHYDRATE COUNTING AND THE EXCHANGE LIST

by Ann Smith, RD, CDE

Ms. Smith, a dietitian and diabetes educator with the Diabetes Management Program at Clark Memorial Hospital, in Jeffersonville, Indiana, gave the following as the keynote address at the 2003 annual conference of the Diabetes Action Network of the National Federation of the Blind. This took place on June 30, 2003, at the annual convention of the National Federation of the Blind, in Louisville, Kentucky.

Good afternoon everyone. I'm going to hand out several items that I often use when teaching folks with diabetes. What you’re getting is a tennis ball, and a paper plate, and we’re going to talk about those, and about how you can use something as simple as that -- even using your hand, and portions of your hand, to identify food portion sizes.

But first, let's cover a bit of background about basic nutrition. Our topic today is carb counting and the diabetes exchange list, and you probably are hearing a lot about these carbs. What I’d like to do today is give you some valid information -- some sound nutritional information you can use with the diabetes exchange list, or if you’re a person who does carb counting through other methods, to show you how you can do that. But let's get back to that background in basic nutrition.

What I like to do is begin by saying your body is like a car, and in order for that car to go anywhere, it has to have fuel. The body is like that in that, but we have to fuel it every day, not like you might do with your car, like I do with mine, where you go once a week to the gas station. In the body, we need to actually fuel that "car" a few times a day.

Several things (your lifestyle, how your medications work, and whether you sleep in the nighttime or the daytime, etc.) determine how often and how much you need to eat. We know the energy in our food (measured in "calories") comes from three sources. Those three nutrients are: carbohydrates, protein and fats. The only other place that we get any caloric value at all would be in alcohol. And alcohol I usually talk about separately, and although I can field questions on that today, I mainly want to talk about these foods.

The carbohydrates are your first main category of nutrients. What is their role? Carbohydrates are your body’s number one fuel base. If someone’s telling you not to eat carbohydrates, please don’t listen to that. Please don’t be an advocate of the Atkins diet. That is not the safest way, or the healthiest way of getting your nutritional needs met. Carbohydrates play a very important role for us. When we look at how they affect the blood sugars, we can see that a carbohydrate in the food has a very quick conversion into sugar in your bloodstream.

Two different types of carbohydrates make up most of the foods we eat. First, the "simple" carbohydrates -- we sometimes just call these the sugars. With these we see a very quick conversion to sugar, and all of them have a 100% conversion into glucose in the bloodstream. That isn’t bad, however, as you need them. Remember, this is your body’s number one nutrient source for fuel.

In planning a diabetic diet, I usually set the carbohydrate level at about 50% of your estimated caloric needs. For instance, for someone on a 1200 calorie per day diet, with about 50% of their calories coming from carbohydrates, I’d plan on about 150 grams of carbohydrates a day.

The other type of carbohydrates are the "complex" carbohydrates -- the ones we sometimes call the "starches." You hear all that bad stuff in the news about starch being bad for you, that you should never eat potatoes, you should always leave off bread, etc., but again, the starches, the complex carbohydrates, can actually be very much a part of a well-balanced and very nutritious diet.

But here’s where we begin to look at what would be your best types of complex carbohydrates. Those would be the ones where you see some fiber coming on board with them. Where do we find fiber? In cereals. What kind of cereals? Whole grains. Where else? In fruits, and in vegetables. Does anyone in here like beans? Yes! Beans are a very good high fiber carbohydrate.

Beans can be a very economical source of both starch and protein. When we look at the conversion of these high-fiber complex carbohydrates into sugar, we see these high-fiber carbohydrates are much slower than those without fiber. This means they break down anywhere from about an hour to an hour and a half after your meal. So, that bowl of beans gives a much slower rise in your blood sugar than if, for instance, you'd had a bowl of fruit, a piece of candy, or even a piece of white bread instead. That’s why the complex carbs are the ones we like to recommend as part of any given meal.

What happens if your meal consists mostly of carbohydrates? We know even very complex carbs will break down maybe an hour to an hour and a half after your meal. And what’s a typical breakfast for many of us: cereal, fruit, milk, and maybe toast? What category do all of those foods fit in? Carbohydrates. Does anybody ever notice they’re hungry again an hour or two later -- if that’s what breakfast consisted of? Yes! And the reason that happens -- is because such a breakfast consists of quick fuel, that is giving your brain the fuel you’ll be needing, and giving your body a lot of essential nutrients that come on board with those carbohydrates.

But how long does that fuel stay with you? What happens if your meal is only carbohydrate-based foods? What would be a solution, giving us a longer-extending fuel, one that’s not going to continue to spike our blood sugar? Protein! If we look at the breakdown on protein, we see a much slower conversion, of protein to glucose, than we do for carbohydrate in the body. The conversion begins about 30 to 45 minutes after the time you actually start eating something with protein, and at its peak, in the two-to-four hour range that protein has only made about a 50% conversion to sugar. That conversion, that glucose level we see, is not a level that continues to spike the blood sugar -- it’s your ongoing fuel source. So to give you more satisfaction in a meal, and some longer-lasting fuel that does not continue to spike the blood sugar, always add some protein with your meal -- and typically, breakfast is the meal where we miss that. Usually lunch and dinner are going to have some protein on board, just because that’s usually the way we in our culture eat. But at breakfast it is very important to put some protein on board.

The last nutrient that I want to talk about is fat. Fat often gets a very bad label. You've heard it, like, "It makes us gain weight and causes us to clog arteries and, you know, it’s just not the good stuff." Well, folks, there’s some good news on the horizon about fats. There are some very good fats to put into your daily intake of healthy foods. Some of my favorite fats now are nuts and natural peanut butter. I eat olives, I use olive oil, and I love avocados. Those are some of the healthiest kinds of good fat.

When we look at how fat breaks down and turns into glucose in the bloodstream, we learn that it is a very slow-converting nutrient. Fat breaks down very slowly, over the course of several hours. But when you look at the amount of fat that actually turns into sugar, it’s only about 10%! So, very little of the fat actually turns into glucose at all. The healthiest fats are nuts, avocados, and olives, and the three best types of oils (those richer in the mono-unsaturated type of fat) are canola, olive and peanut oils. Those are the top-of-the-line, absolutely very best kinds of fat.

What about nuts? Any kind of nuts. We’ll talk about portion size on those nuts in just a minute.

Remember, when we’re looking at how fat affects the blood sugar, very little of that fat ever actually turns into sugar. So fat, by itself, does not greatly affect your blood sugar. But it breaks down so slowly, and if we look at the energy fat provides, one gram of fat gives you nine calories, so we get a lot of calories with those fat grams. The newer guidelines for healthier eating actually see a benefit of making about 30% of your calories to be from fat grams. That is because fats actually give your meal what I call the “satiety factor.” Any of you ever hear that word? Satiety means satisfaction. So, even if you add a piece of really lean chicken to a meal that already has the correct number of carbs, you may still find that you’re hungry three to four hours later. Then ask yourself, did that last meal have some fat? Here is where we get the combination fuel that can give you a five-hour span between meals.

Now let’s look at how to put this fuel together, so you’re getting the immediate energy source you need, you’re getting some protein on board (which will not only give you a little hold-over on that fuel, but also will give your body those building and repairing nutrients you get from protein), and then we add some fat to that meal to give it staying power -- the satiety factor to help you to last anywhere from five to six hours, before you need to eat again.

The three nutrients (carbohydrates, protein, and fats), then, are your key fuels. When we look at the Exchange List, we see our carbohydrate foods are made up of several food groups. Fruits are one, and there is the Starch group, the Low Carb Vegetables (the higher carbohydrate vegetables, the "starchy vegetables," are going to be in the Starch category), and the fourth group is Dairy, which includes only milk and yogurt. We do not include cheese or cottage cheese in Dairy, because they contain so much protein, so they go in the "protein" group. We see cheese and cottage cheese as "protein-based foods, with a little carbohydrate in them."

We have the Milk/Dairy group, we have Fruits, we have Starch, and we have Vegetables. And if you see most of the exchange book guidelines, they have another category they call Other Carbohydrates. That’s a group with foods that don’t fit in any of the other categories, like ice cream, angel food cake, jam, jelly, honey, tortilla shells and Tostitos chips, even hummus. Hummus has a little bit of protein, and some fat, but mostly complex carbs from the chickpeas used to make it.

These, then, are the five categories we call the Carbohydrate group of foods in the Diabetes Exchange List. Now, when you put together a meal plan, generally your dietitian or diabetes educator will give you either a certain number of carbs or, as I sometimes do, give you a certain number of carbohydrate choices. For instance, on a 1200-calorie meal plan, you would generally have about three carbohydrate choices per meal. Or if you had a 1500-calorie meal plan, you might have four carbohydrate choices per meal, or with an 1800 calorie meal plan, you might have four to five, depending on whether or not you have planned-in snacks in between meals.

Why is it important to space those carbohydrates out from meal to meal, and not do the Weight Watchers concept where it doesn’t matter when you have them as long as you have the same number of points at the end of the day? Why would you not want to do that with your carbohydrate foods? Why would you not want to have them all in dinner? What’s going to happen to that blood sugar if you have all your carbohydrates in your evening meal? It’s going to skyrocket, and it will still be high at bedtime and more than likely it will still be high the next day. Your doctor puts together your medication to accommodate and treat your diabetes. Then we match that with a meal plan to correspond to the way your medication is going to affect the timing of when you eat, and how many carbohydrates you should have in that meal plan at that particular meal.

That’s why it’s important for you, since you have diabetes (and Weight Watchers wasn't set up for people with diabetes) to, more or less, have “constant carbs.” Have any of you heard of that term? That’s where you have a consistent, constant amount from one meal to the next. For instance, if your educator has told you to have 50 to 60 grams of carbs, or four carb choices per meal, then that would mean making some food choices within your carbohydrate category. As an example, let’s put a breakfast together -- I have a few samples of food models up here that we can do some meal planning with. Let’s put together a breakfast with four carb choices and see how we do. Orange juice? Well, let’s see. I forgot to bring my juice, but I brought an apple -- we will consider that our fruit. And let me tell you something, which one would be a better choice based on what we said earlier about the fiber? Yes, the apple, or a whole orange -- more fiber than the juice has.

And now we’re going to talk about portion size with this. You know the tennis ball I gave you? Hold that in your hand. Hold that tennis ball and actually cup your fingers around it. Now do you feel how that feels? That is what we call "an average portion of fresh fruit." That would be "one fruit choice" or "one fruit exchange," a tennis-ball-sized piece of fruit.

One fruit choice generally has about 15 grams of carbohydrate in it. We said our goal was to have about 60 in this meal, or four carb choices. So what else could we have in our breakfast? Cereal, yes, how about some oatmeal? "Oatmeal warms the heart," have you ever heard that? We know that among of the complications of diabetes are heart disease and high cholesterol. And what do we know about oatmeal? The soluble fiber in that oatmeal actually clinically lowers your LDL (bad) cholesterol. So it very much "warms the heart," and it helps keep that cholesterol down. Now I’ve got actually a bowl of oatmeal with me, a one-cup portion. One cup of cooked oatmeal would be how many carb choices? Two. A half-cup of cooked oatmeal is one carb choice in the Starch category. That’s one starch -- a half a cup of cooked oatmeal. And if you eat the whole cup of cooked oatmeal, those carbs also double.

To make oatmeal, start with a half-cup dry oats, add one cup of water, and that makes a whole cup of cooked oatmeal. So that’s about two of your carb choices in the starch category, and now we’ve got that partnered with the apple we're going to eat. So we need one more carb choice, since we have three now; how about milk? Okay, we can do milk, or you can have a light or plain yogurt. That would be your choice in the milk category. One cup of light or plain yogurt has about the same amount of carbs, about 15, as you would find in an eight-ounce glass of milk. An eight-ounce glass of milk only has about 12 grams of carbs, but in our carb choices we would still call that one carb choice. That, then is the fourth carb choice in this breakfast meal.

Okay, so we have our carb choices, what are we missing? Protein. Remember I said earlier that nuts are a really good type of fat, but they also have protein in them. When we know we want some good fat in a meal and we also need some protein, then cup your hand with those fingers closed -- and you have a small handful of nuts. That would give you an equivalent to the amount of protein in one egg, or one ounce of meat. So if you add nuts, either with your oatmeal or on the side, you have now satisfied your needs both for protein and for some of that good fat, in our sample breakfast.

Now I’ll share with you one of my favorite breakfasts. That’s two pieces of whole grain bread, toasted, and by the way, when we look at the nutritional information on that reduced calorie bread, we find even more fiber in the reduced calorie bread than in the same amount of whole grain bread, and you get two slices for the same fuel value as one slice of regular bread. Generally there are about five grams of dietary fiber in a two-slice portion of reduced calorie bread. So, if you use reduced calorie bread, just think, it’s a two for one. It’s a two for one in your starch category, so you would get two slices for one carb choice.

Now let’s go back to that breakfast -- if we do two pieces of regular whole grain bread, that is one starch for each slice, so we have two starch choices, and we put some natural peanut butter (the kind that has only "peanuts and salt" on the ingredients list) onto that sandwich. Toast your bread, put natural peanut butter on it, and you can put, in our carb counting system, a small amount of regular jam or jelly -- as a teaspoon of regular jam or jelly has five grams of carbohydrates.

Regular peanut butter, by the way, like Jif or Skippy or your store brand, has a whole multitude of ingredients, including sugar, but the number-one ingredient that’s not good for you is the hydrogenated oil. Those partially or fully hydrogenated oils are what we know now as the worst substance in our fuel system. And Congress is asking for more information on products containing those. So I suggest you try to use the natural peanut butter instead.

Natural peanut butter is separated when you open the jar (the oil separates from the solids) and here’s the trick -- you put it in your refrigerator upside down overnight. By the next day, it will actually already have started distributing and mixing for you. When you take it out and open the jar, take a knife and stir it, all the way to the bottom. And remember, it has no preservatives. When you take that hydrogenated oil out of it, it will not stay on your pantry shelf forever, like regular peanut butter. Store it in the refrigerator to keep it well preserved. And, if you need it to spread easier, set it out a few minutes before you make your sandwich, so it can warm, and it will spread much better. You have to prepare yourself for it, by saying "this isn’t going to taste like my old peanut butter" because it’s not going to be as smooth as shortening, and it’s not going to taste sweet. It’s going to taste like ground up, salted peanuts, which is what it is. But I can tell you from my own experience, once you make that switch to natural peanut butter, you will not go back to the other. I buy the store brand, the Kroger’s natural peanut butter -- it’s also made by Smucker’s -- but the store brand is about a dollar cheaper per jar.

So, if we put that sandwich together, we now have two carb choices, and you can make the other two to once again be a serving of fruit and a glass of milk. What goes better with a peanut butter sandwich than a glass of milk? That breakfast will stay with you a good five hours. This is one of the main breakfasts I’ve found will stay with me through a whole morning of teaching, and my stomach not growl. When I’m teaching people about what to eat, about how to eat, I don’t need to have my stomach growling in the middle of it. I’ve found the fat in the peanut butter was my satiety factor for that meal.

How many calories per gram are there in each of the different nutrients? Carbohydrates and Protein both have four calories per gram, and fat, as I mentioned earlier, has nine calories per gram. When you break down a nutrition label, and you actually see the serving size on that particular food, the calories in that serving come from the protein, the carbohydrates, and the fat. There are no other sources of calories in that food. So you can actually do your math, and multiply the total grams of carbohydrate and protein each by four, and the total fat grams by nine.

One thing I would mention to you, though -- don’t get bogged down in those percentages of daily calories -- you know, the percentage column over to the right side. Please just ignore that. Those percentages are based on this bogus 2,000 calorie a day diet, which is just kind of a token number they chose to represent an average American diet.

When we’re looking at carbohydrates, the serving portion is very, very important! Someone may tell you, "there’s only 90 calories in this," but not if what you have on your plate is the whole can, versus the one half-cup portion listed as the serving size. If the serving you have on your plate is more, or less than what the serving size listed on the container, then you do some math. If there’s 90 calories in a serving, and you have three times that serving, your total calories would be 270. If there are 14 grams of carbohydrate in the recommended serving, and you doubled your serving, you now have 28 grams of your carbohydrates, or, using Exchanges, that would be two carb exchanges. Each one of those carb choices in the categories I mentioned, approximately 15 grams of carbohydrate. So one starch, one fruit, one milk, and if you look at your vegetables, that actually multiplies. A serving of a vegetable, for instance, like broccoli or green beans or a tossed salad, has very small amounts of carbohydrate in a serving as well. I usually tell people that unless you’re eating a whole lot of them, don’t even consider those low carb vegetables in your meal plan. Number one, most people aren’t going to eat more than what they really could enjoy in that meal, and it won’t be a problem for their blood sugar. Number two, we know there’s a lot of fiber in those vegetables, and if we actually look at the glycemic effect of those vegetables on the blood sugar, it’s very low. Even carrots -- even if you snack on some baby carrots, you’re not going to get into a problem with your blood sugar. So the low carb vegetables, they’re your freebies.

How many of you have problems with blood pressure? And blood pressure is something that, especially with diabetes, is important to keep under good control. Another reason those low carb vegetables are so beneficial to you is because they actually help give you better blood pressure. The natural potassium, magnesium, and the fiber that’s in there -- those are important natural nutrients in our food. This information came from a really good study a few years back called the DASH Diet. It stands for the Dietary Approaches to Stopping Hypertension. Part of the approach was to eat lots of those vegetables and fruits every day as part of your overall basic meal plan. They recommended five to nine servings a day.

Now we know that you can’t have all of those five to nine servings in fruit, because that’s going to be a whole lot of your carb choices. For people with diabetes, I generally recommend two to three servings a day. Some people may go as high as three to four, but the Fruit category of carbohydrates can get some people in trouble with high blood sugars. Here we also often tend to have problems with portion control. That’s why I gave you the tennis ball today, as a reminder on your portion of fruit. The low carb vegetables, then, are very very healthy -- include a lot of those in your meal plan.

With the starchy vegetables, you watch portions. Make a fist with your hand, and that fist is like a one-cup portion of food. That would also be about the size of a medium baked potato. A medium baked potato is about two starches, so how many carbohydrates in that medium baked potato? Thirty. So we roughly round it off to say it’s about 30 carbs, or two of your carb choices in the starch category. So potatoes aren’t bad, and if you know it's scrubbed well, eat the peeling with it because you’re getting some fiber in that peeling. The baked potato serves well.

Your portion of meat, especially at the main meal of the day, is about three ounces. If you hold up the palm of your hand, don't count the fingers, and stop at the wrist, that’s about three ounces of cooked lean meat. Now that’s just the lean portion of the meat, fat removed and with no skin or bones. In your other meals, you can have about one to two ounces, though, and that’s a much smaller portion. Remember meat has no carbs, unless there has been a breading or something added to that meat or protein food, so we do not count the meats as carb-based foods. And most of the time your fats would not be considered carbohydrate food choices. But here’s an exception -- some people automatically choose fat-free salad dressings, but some of those fat-free salad dressings have a lot of sugar added to them. The carbohydrates in those fat-free dressings may actually be as high as one of your carb choices. They may have 15 to 16 grams of sugar, or total carbohydrates, in maybe two tablespoons of salad dressing. So beware of those dressings. Even if a dressing is identified as fat-free and sugar-free, look at the label! See if there are any total carbohydrates listed. Don’t be deceived by words like "sugar-free," "dietetic," or "no sugar added." They are not necessarily carbohydrate free. The automatic assumption is that because it’s "sugar-free" I can eat all I want of it. Not true.

Dextrose, corn syrup, and fructose? These are sugars. Fructose is actually fruit sugar in a syrup form. High fructose corn syrup is one of the more common ingredients you will see. Sorbitol is a sugar alcohol that is something a little bit different, actually, than your other forms of sugar. Generally, the forms of sugar that will be in a product will generally end in “-ose” like dextrose, sucrose, fructose, maltose, levulose. There are also some other names like corn syrup and maltodextrin. But when I teach carb counting, I really don’t even have you worry about the detail of where those sugars are coming from. You simply go to the nutrition facts label, and you see how many total carbohydrates there are in one serving of food. Don’t even go down to the sugars -- you look at the total carbohydrates because it is the total carbohydrates in a meal that affects what your 2-hour blood sugar will look like. That’s why we have a more liberalized approach to diabetes meal-planning now, and we even say you could have a teaspoon of honey or something with regular sugar in your meal, if you have counted that as part of the total carbohydrates in your meal. We now know it is the total carbohydrate in your meal that matters -- it’s not that you have to avoid all sugars, or those simple sugars -- it is the total carbohydrates. So when you’re looking at a product, even ice cream, it can be part of your carbohydrates within a meal -- in a portion allotted that meets your guidelines. It’s the total carbohydrates in that meal that makes a difference on what that 2-hour blood sugar will look like.

What about the "diet foods" that have all the fake stuff in them, like Olestra?

Olestra is a fake fat. It doesn’t absorb as a fat, but is supposed to make the food taste like it has fat in it. But it hasn’t been a very popular item, because it has a very detrimental side-effect for many people, and that side-effect is diarrhea. Personally, I choose instead to use baked chips and baked items rather than Olestra fat-free products, like the WOW chips. You can use baked chips (and you still count your carbohydrates in those), but they’re baked, without having oils added to them, and they actually have some pretty good tasting items on the market now, and you can use those as part of your carbohydrates in a meal.

What about the sugar alcohols? Sugar alcohols are ingredients many manufacturers use in sugar-free or no-sugar-added foods. The way they can legally say a food is sugar-free or no-sugar-added is to simply take the sucrose out of that product, so that opens up a whole can of worms on what that food can contain. Lots of times they put sugar alcohols into that food, as a substitute sweetener. Let me tell you just a little about the sugar alcohols. They are still considered a carbohydrate, and the FDA now requires them to be so listed.

Remember I told you earlier your regular carbs have four calories per gram? Well, your sugar alcohols have two calories per gram. If they are present in a food (as part of the sweetening), then manufacturers must list them now under the total carbohydrates. It should either say “so many grams of sugar alcohol.” The FDA now requires this listing. Lots of manufacturers actually list that actual ingredient: sorbitol, maltolol, zylitol, manitol, you hear that -ol ending in the ingredient? Those are the sugar alcohols. If they are in there, they will show up in the total carbohydrates of that food.

Let me give you a forewarning about sugar alcohols -- if it's in there, greater than five grams in a serving, which it very often is in a lot of your sugar-free desserts, your sugar-free ice creams, sugar-free cookies, sugar-free syrup, sometimes you may see as much as 25 to 28 grams of sugar alcohol in one serving. That sugar alcohol, like the Olestra I mentioned earlier, can have a very detrimental side-effect, for many folks. It causes a great amount of gas, stomach distension, and diarrhea. I have heard some very funny stories in my practice - one of the funniest was a truck driver who was on the road, and he had diabetes, he'd had diabetes for years, but no one ever told him about the sugar alcohols. So he stops at this restaurant, and the waitress is taking his order, and he finishes his meal, and she comes along and says well, would you like dessert? And he said well I have diabetes, so I can’t really have any of that dessert, and she’s like, oh, but we have this sugar-free pie -- you can have that, can’t you? It’s sugar-free. And so he says, yeah I’ll take a piece. She brings him a large piece of this sugar-free pie, and he eats it, then gets back in his truck, and about 30 minutes down the road, it hits, and he had to find a rest stop, and there was no rest stop to be found, and he finally was in this little small town somewhere in middle USA, stopped at an extension office in this little small town, and he rushed in and says to the lady, I have to go the bathroom right now, and so he had this major case of diarrhea, and did not know until he came to our diabetes class back several months ago that it was the sugar-free pie that had caused his problem. He thought it was his medicine. And his eyes got as big as golf balls when I was telling about the sugar alcohols, and he’s like, "That’s what happened to me that day!"

So just beware, your sugar-free gums and mints have a little bit of this in them, but it’s usually only about two or three grams in a portion or a serving, so it’s not a whole lot and it probably won’t affect you, unless you eat a whole package at one time. So that’s the case of the sugar alcohols. In small amounts they're fine; but if you’re counting carbs, and it’s something that has 25 or 30 grams of sugar alcohol, don’t waste your carbs, don’t spend your carbs on that stuff, spend it on something that tastes better in a smaller amount with the real stuff in it. That’s the beauty of counting carbs.

We talked about cereals; what about cereals other than oatmeal? Any time you try out a new cereal, look at the portion they give you as the serving size, whether it be a half-cup, three-fourths of a cup, one cup -- this is a time to get your measuring cups out, get the feel for that estimated portion, measure that serving in the bowl, to know what your serving of that cereal would be, and how many of your carbohydrates it would account for. Here it’s very important to look at that serving size, at how many carbohydrates are in each serving, because your cereals can vary widely, and in some of those cereals that really taste good, the carbs go up tremendously from the added sugar. But even something like Raisin Bran -- one cup of raisin bran has about 43 grams of carbohydrates. Not only do you have carbohydrates in the flakes -- the whole wheat flakes in the raisin bran -- you’ve also got raisins in there -- and they coat those raisins with sugar, so one cup of raisin bran would be three of your carb choices in that meal. And then your milk would be your fourth carb choice, if you’re on 60 per meal.

If you’re making oatmeal at home in the microwave, what will make a one-cup portion? If you’re making regular oatmeal at home, 1/2 cup of dry oats mixed with one cup of water, and then microwaved, will make a one-cup portion. That one-cup of cooked oatmeal would be two of your carbohydrate choices. Your exchange book lists 1/2 cup of COOKED oatmeal as one carb choice, NOT 1/2-cup of dry oatmeal -- that makes one cup cooked, and is two carb choices. It will take 1/4 cup dry oatmeal to make 1/2 cup cooked, which is one carb choice.

What about sugar substitutes? If you’re baking cookies at home, what kind of sugar substitute can you use? There are some recipe books out there for making cookies, and you can actually use any recipe, if it has your carbs per serving in the nutritional breakdown. They don’t have to be sugar-free. But when you’re using the sugar substitute, my favorite is Splenda, and that’s what I actually use at home. It is made from sugar, and it tastes like sugar, but it is a non-nutritive sweetener. If you buy it in the large pourable containers, you pour it out measure for measure. It measures exactly like sugar for a recipe. That’s my favorite, because it doesn’t have an aftertaste. You can still use Equal or Sweet'N'Low, but I can tell you the taste is not going to be as true, and it’s not going to be as good, and sometimes cooking alters what happens to that sweetener -- it does not on Splenda. There are very good studies and research on using that sweetener, and it has stood up to the test. The price is also coming down, and we’re finding it in more and more products. It’s a plus, because those products taste a lot better.

How do raisins stack up as a snack? I always caution people with diabetes about how often and what they’re having for snacks. How your meal plan is structured will determine what those snacks can consist of. If you are using insulin, but your insulin regimen is only covering the carbohydrates in your planned meals, and you’re not on any additional insulin (to "reduce excursions"), You're probably using a very quick, rapid-acting insulin, like Novolog or Humalog. Those insulins cover and process what you’re eating anywhere from 30 minutes to about two hours. That’s the in-and-out time of that quick form of insulin. It will cover the carbohydrates in that given meal. But if you snack three hours later, and you add on a handful of raisins, or other dried fruits, the portion size must go much smaller, or you'll blow your control. A quarter cup of raisins has about the same amount of carbohydrates as that tennis ball-sized piece of fresh fruit does -- the sugar is still there, you just took out the water. I would suggest you be very careful about using raisins as snacks unless you have carbohydrate snacks worked into your meal plan. And, if you use carbohydrates for snacks, you should, test your blood sugar, two hours after a meal. If you’re not in the really good recovery zone in the two hours after that meal, that means the blood sugar we’re looking for is less than 140, two hours after the meal, if you’re not below that, and then if you’re having a carbohydrate snack in two and one half to three hours, and your blood sugar is still 200, what’s going to happen to that blood sugar? It's going to go way back up. So, snacks can be part of your meal plan, but this is where you really should work with your educator to plan those snacks appropriately in your meal plan, based on you doing some checking of those blood sugars and seeing how many carbs you can have in your meal, if you want to have a snack in three to four hours.

What about cashews as a snack? Cashews are wonderful, but we must remember portion control. Remember the palmful. Any of the nuts are actually very good combinations, some are a little higher in the mono-unsaturated fats, some a little higher in the polyunsaturated, but any of the nuts are good. There was an excellent study done in Salt Lake City by the Mormons, because of their vegetarian way of eating. They did a study on the health value of nuts, and they report any kind of nuts can be used as part of a healthy meal plan. So cashews can be part -- but just remember the portion size, a palmful.

A good question: What size banana is one carb choice? We would say a small banana, or half of a large banana, is one fruit choice. And a small banana is only about five to six inches long. By the time you peel it, you’ve got four to four and a half inches on that banana.

Some of you are hearing statements like, "there's no such thing as a diabetic diet." I know this is confusing -- but what we mean is there are not separate foods, rather, a person with diabetes can simply eat a healthy meal plan. A diabetic meal should not be much different from a regular meal at a particular occasion. You can make wise substitutions, like choosing fruit instead of the regular dessert, or grilled chicken when others get fried chicken. In the big scope of diabetes meal planning, I always teach people you can take any given meal, and you can modify it to make it fit into your meal plan.

One of the other visuals I gave you was the paper plate. If you have a plate in front of you, the choices in that meal are going to be a serving of meat, a starch of some kind, be it potato, rice, pasta, whatever, and you’re also likely to have some sort of a brightly colored vegetable, like green beans or broccoli or carrots or summer squash, zucchini, greens. Those kinds of brightly colored vegetables are generally your non-starchy vegetables. What I usually suggest in making up that plate, is that if you want to have a healthier meal plan, make about half of that plate be those non-starchy vegetables. About a fourth of that plate, or a fistful, would be your starch, and then your meat should be the other fourth of that plate. This is just the healthiest way of eating -- that’s why we say there’s no such thing as a "diabetic diet" any more. You're eating the same things the non-diabetics are, just in appropriate, balanced moderation.

When people come to see me, they think I’m going to give them a diet sheet, and the first thing I tell them is, "you are not here to get a diet." I teach you how to eat healthier, so don’t even call what you’re doing a "diet." You'll instead be eating healthy, in the healthiest way for a person with diabetes, and you don’t need "special foods" to do that. You don’t have to go out and buy all those "sugar-free products." Our goal is healthy eating, so everyone should be broiling and grilling and sautéing with a non-stick skillet, with a little olive oil pan spray, stir frying with lots of vegetables and lean meats, and limiting those starchy foods, because too many of those get us in trouble with our blood sugar two hours later. So, more of those vegetables, less of the starch, and then round out that meal -- if you have saved some of your carbohydrates from that meal, kept the portions down, that will allow you to have a small portion of that regular dessert. And that way you’re not singled out because you have diabetes.

Some have even said that if everybody ate the “diabetic diet” nobody would be diabetic. There’s a certain amount of truth to that (for people with type 2 diabetes), but you’d also have to consider lifestyle. It really is a partnership: what we eat, and how active our lifestyle. And yes, a sensible diet would be a very good start to preventing diabetes, but in diabetes prevention program that came out published last year, what was the key element? It was exercise. Five times a week, thirty minutes of walking, to walk about two miles in that 30 minutes. But exercise, five times a week prevented overt diabetes in the folks who had the genetic predisposition for type 2. They modified their lifestyle, and they ate healthier, so it was a partnership.

One last question; what about pizza? This is where I suggest to people that you modify your previous thinking. Pizza is a "combination food" -- we know it has a lot of carbohydrates, from the starch in the crust, and from the tomato sauce. And if you’re having a meat topping, you’re going to have a lot of protein but also a lot of fat. Lots of fat partnering with those carbs. If your pizza is the only thing you have in that meal, then your portion is probably going to be way above what you need, in order to satisfy your stomach for quantity of food. And what’s going to happen to that blood sugar later? It’s going to be high. And that’s one where people very typically report the next morning blood sugars are still very high. Here’s part of the problem with pizza. It’s not just the amount of carbohydrates, but also the amount of fat partnered with those carbs. I said earlier some fat in your meal is always a good idea, but too much fat in your meal, partnered with your carbs, will actually delay the breakdown, the converting those carbs to sugar, and that will keep that blood sugar higher at the two hour mark, and those sugars are on for the ride. Those are the ones that get held over until the next morning, and they affect that A1c, so what I would say about pizza is change your thinking about pizza a little bit. Always have a nice big salad before you start eating the pizza. And have that salad be with some light dressing, or just do the fork dipping on the dressing so you’re actually not adding a lot of fat in the dressing, and then an average up to a couple of pieces would be your max to keep you in good control.

What about using olive and lemon juice as a salad dressing? Is that good? Yes. Lemon juice is a freebie, it’s rich in ascorbic acid, citric acid, so that’s a freebie in the diabetes realm. Your olive oil, you’ve got to use in very small amounts, because one teaspoon of olive oil has five grams of fat, so here is where you’d want to use not a whole lot, max one tablespoon of the olive oil. But when you add herbs and spices to that olive oil, they are actually enhancing the flavor without giving any more carbs or fats or anything. Those are free, in the realm of your meal plan. If you add sodium, or salt, you’ll want to be very minimal with that, but use your spices, garlic, onion, basil, thyme, all of those kinds of herbs and spices are wonderful for enhancing the flavor -- and they do not add any more caloric value. Vinegar is also a freebie. I think we’ve got to close. Thank you very much.