DIABETES NUTRITIONAL MANAGEMENT:
THE CARB COUNTING SYSTEM

by Martha Lee Palotta, RD
East Jefferson General Hospital, New Orleans

 

Ms. Palotta delivered the following as the keynote address at the annual seminar of the Diabetes Action Network, on July 1, 1997, part of the annual convention of the National Federation of the Blind, in New Orleans, Louisiana.

Nutrition is indeed the most challenging aspect of diabetes management. It is not only a challenge, we could consider it as the cornerstone of diabetes management. It doesn't really matter which medication you're on, you still have to make some attempt to follow some type of consistent meal plan.

A lot has happened in diabetes management, particularly in nutrition, in the past few years. I was at a conference in 1994, and was listening to some of the changes that were going to take place; I could hardly believe my ears. So I encourage you just to buckle your seat belts; we're going to cover some things about carbohydrates, and I hope they will be of interest to you.

It just so happens that the history of diabetes nutritional management goes back to 5 A.D. And, indeed there were some extremely strange diets, down through the ages.

Prior to the 1920s, even in this century, starvation diets for diabetes were the norm. Certainly, we know now that we have a lot more options available to us!

During the 1950s, the exchange lists were developed. Many of you are familiar with those from the past. They were somewhat a source of confusion to many people, and really a source of frustration for many who tried to get their blood sugars under control. Now, in recent years however, the carb-counting system, with the idea of consistent carbohydrate intake, has gained a lot of popularity. It is quickly becoming the meal-planning method of choice for many people who have type 1 or type 2 diabetes.

Why is carb counting important? There is a very close relationship between the amount of carb you eat and where your blood sugar is. In other words, if you eat a small amount of carbs, your blood sugar is going to rise a small amount. If you eat a large amount of carbs, your blood sugar is going to rise a large amount. So, if we can control somewhat the carbohydrate intake, we can control the blood sugar. This doesn't mean eliminating the carbs, it means controlling them.

Now carb counting isn't a magic solution, it's not for everybody; but, it does give you increased flexibility in meal planning. It gives you some other options and it helps you to prevent some of the troublesome highs and lows that you might experience. So where are the carbohydrates? What foods contain carbs? They're in your breads, your cereals, your pasta, and your grain products. Carbohydrate is found in fruit and milk, in vegetables and sweets.

So carbohydrate is very widespread in the food supply, and it is something that we do need to include in our meal planning. Certainly, if you are on any medication for diabetes, insulin or oral medication, you need a certain amount of carbs in your diet, or you'll have a low blood sugar reaction. We are not seeking to eliminate the carbs, simply to control them. Now, simply put, counting carbs means counting the grams of carbohydrates in the food you eat.

Grams are a weight, a measure of weight in the metric system. Foods have been assigned a particular gram level of a certain amount of carbohydrates. Again, the total quantity of carbohydrate in food products does predict how high the blood sugar will rise.

Now let's talk a little bit about carbs. There are two types, and this is very important to understand. There are the complex carbohydrates—what we commonly refer to as our starches. These derive their name from the fact that their chemical structure is very complex, very complicated. A complex carbohydrate, a "starch," may have as many as 1000 glucose units all hooked together. Likewise, the simple carbohydrates derive their name from their simple molecular structure.

Simple carbohydrates may only have one, or perhaps two glucose units joined together. What is confusing is that we call all the simple carbohydrates sugars. The complex carbs, the starches, are things like grains and cereals, pasta, and bread products. Simple sugars are found in our milk; the "milk sugar" being lactose. Our fruits contain simple carbohydrates as well, the simple sugar called fructose. And of course we are all familiar with "table sugar," a simple carb called sucrose.

So, anything that ends in -ose is a sugar. Basically we are talking about two kinds of carbohydrates here. We're talking very complex, our starches; and, we're talking very simple, our sugars.

Now, because of the simple nature of sugars, it was long assumed that they rapidly raised your blood sugar. And, because of the complex nature of starches, it was assumed that they must take a very long time to break down into blood sugar. Unfortunately, that was an erroneous assumption. Sometimes when we eat carbohydrates in the form of starches, "complex carbohydrates," the enzymes in our digestive system will rapidly separate those glucose molecules, making lots of little units that raise our blood sugar very, very quickly. The fact that something is a simple carbohydrate does not mean it is bad, yet for many years it was assumed that the simple carbs were actually much worse for you.

When you eat carbohydrates, 90-100% of the carb breaks down into blood sugar. The portion that does not break down into blood sugar is called fiber. Fiber is non-digestible, so it doesn't cause our blood sugar to rise like starches or like the sugars do. It is important to have fiber in your diet. Fiber is good for us, and "higher fiber" carbs simply have more material in them that will not cause your blood sugar to rise.

Carbohydrates are just one of the three macronutrients in foods. Food contains fat. Fat does not raise your blood sugar directly, as very little of it actually breaks down into blood sugar.

Of course, protein is our other macronutrient. The conversion of protein to blood sugar is incomplete and much slower than the others. We don't see a lot of blood sugar rise from protein, unless of course, you eat a huge porterhouse steak or something like that. The bottom line is that we need to watch, first of all, the carbohydrate content of our meal.

But we still need to watch protein and fat! We know a high fat diet predisposes us to heart disease. We know a high protein diet might cause problems with our kidneys. So, just because these macronutrients don't significantly raise our blood sugar doesn't mean we should eat as much as we want of them. We watch the protein and the fat, but we zero in on the carbs to get better blood glucose control.

The goal of carbohydrate counting is to keep all meals or snacks from running too high in carbs. I describe it to my patients as if we were making house payments. In other words, you pay a little bit each month around the year—you don't save all your house payments until December and make a giant house payment. You pay a little bit at a time and pace yourselves, and that way you can handle making the payments.

It's the same way with carbs. Many of you are on medications for diabetes—medications that are timed throughout the day. What we like to see is carbohydrate intake match the timing of our medicine. And, in order to do that, we, as dietitian nutritionists, individualize meal plans to help accomplish good blood glucose control.

Most of you are familiar with the old Exchange Lists, the list of starches, fruits, vegetables, meat, fat, and milk that we have used as the basis for diabetes diet counseling over the years. You can take your knowledge of the exchange lists and transfer it all to the area of carbohydrate counting.

When the revisions and dietary guidelines came out (a project of the American Diabetes Association and the American Dietetic Association) the old "exchanges" were rearranged with all the carbohydrate foods grouped together. Portion sizes, for the starches, for the fruits, and for the milk, (those being your three carbohydrate-containing groups), were established with each "serving" as what we call a carbohydrate unit, containing 15 grams of carbohydrates.

If you don't remember anything else, that's probably the most important fact: One serving of carbohydrate, whether it be a serving of bread, or a serving of fruit, or a serving of milk, equals approximately 15 grams of carbs.

When we do meal planning for a person with diabetes, we try to take into consideration what they like, what are the things they want to eat? Also, we may say to have a certain number of carbohydrate units in a meal. For example, depending on the calories required, a woman might have three carbohydrates units at a meal, and a man may have four. It's a very individualized thing. And, again, it doesn't matter which carb is picked, not as far as new "1995 Exchange Lists for Meal Planning" guidelines are concerned. If your meal plan calls for a carbohydrate unit, you can have a starch, or you could have a fruit, or you could have a milk.

That's okay up to a point, but for persons who have problems with their kidneys, we have to remember that milk might have to be limited because of the protein in it, or because of phosphors in it. If you're following a "straight diabetic diet," with no other complicating factors, you may interchange the starches with the fruits and the milk. And that's the beauty of carb counting—it does allow some flexibility in meal planning.

The disadvantage to carbohydrate counting is that it only looks at the carbs, and doesn't focus on calories. So, if you were only counting carbs, and you had a big steak, you really wouldn't have a lot more carbohydrates. Yet, you might have consumed a lot of fat, or overdone it on the calories, and certainly we must look at all aspects of nutrition, for a good balanced diet.

You can take the old exchange list and think in terms of "a serving of carbohydrate" being 15 grams of carbohydrate. What does this mean? A slice of bread--15 grams of carbohydrates. An apple, the same thing. A half a banana, two tablespoons of raisins, a half a cup of cooked cereal, a cup of milk, all the same. How do you know how much carbohydrate is in something? Using your portion sizes from the exchange list, you can translate that over into carbohydrate counting. And, of course, we know that a given item's total carbs are listed on food labels.

Food labels list both total grams of carbohydrates and also grams of sugars. I am not concerned about the grams of sugars on the labels because they don't necessarily indicate just "table sugar." The "grams of sugar" on the labels are a total, which also includes any fruit sugar or milk sugar present. Total carbohydrate is what we are looking at here, not necessarily the source of the carbohydrate.

The first step in carb counting is to zero in on the actual carbohydrate that you are eating, your food. The second step in carbohydrate counting is to look at your medication (oral meds or insulin). There are actually ways to adjust your insulin dose, based on the carb content of the meal you are going to enjoy. For example, if you know that you are going to have 45 grams of carbohydrates, there are ratios of insulin sensitivity that you and your physician can establish. For everyone who takes insulin by injection, there is a specific number of units of insulin to match the grams of carbohydrates that you eat. There are formulas, and your physician or health professional can help you with them. (EDITOR'S NOTE: Many physicians are unfamiliar with meal planning, so it is always advisable to have a dietitian familiar with diabetes on your health care team.)

So, there are ways to balance your medication with the amount of carb you are eating. Of course, for people taking oral diabetes medications, you really can't adjust the medication as easily as you can units of insulin. For people who are on pills, the most important thing is to have consistent carbohydrate intake day-to-day. In other words, don't have a high-carb breakfast one day, and hardly any the next day. Be consistent on a day-to-day basis! This will help you and your health care team regulate your blood sugar.

For years, people believed that the world was flat. Why? It was so obvious the world was flat, you could see it. For years people believed that consuming table sugar was the absolute worst thing you could do. Why? Because it was so obvious. I had a patient one time, and I was talking about consuming a little bit of sugar, and the fact that the new guidelines allowed that. She was so frustrated she said, "how do you expect me to control my blood sugar if you are giving me sugar?" And, I understood her frustration. To be honest with you, when I heard it for the first time, I almost fell of my chair, too. It was something that was just totally against everything that we had been taught. For all we knew, there was a stone tablet inscribed somewhere that said, "Thou shalt not eat sugar." This was perhaps the only thing people carried away from diet instructions we gave them.

I am here to tell you today that when the new guidelines came out in 1995 they included a statement that said "scientific evidence has shown that the use of sucrose, or table sugar, as part of the meal plan does not impair blood glucose control in individuals with Type 1 or Type 2 diabetes". The problem was that diabetics were adding the sugar and sweets on top of the other carbohydrates, rather than counting them. The idea that you could have angel-food cake, perhaps, or graham crackers led some people to eat the whole box or the whole cake at times, because, after all, they could have it. ("The dietitian said I could.")

The idea here is that we need to control the total carbohydrates. In the new diabetes guidelines, if you can account for carbohydrate in the candy, or in the cookie, or whatever (balance it in as part of your allowed total for that day), then you can have it. But it has to be "paid for" on a gram-per-gram basis.

In other words, if you eat 15 grams of carb from M&Ms, you have to give up 15 grams of carb from fruit or bread. "The guidelines are not "recommending" that you have sugar—merely telling you how to account for it". As a matter of fact, we know that most of the foods high in sugar are very low in nutritional value, may be high in fat, and are not going to be very good food choices. None the less, if you choose to have something with sugar, you must account for it as part of your total carbs. What the new guidelines say is that gram-per-gram, 15 grams of carb is 15 grams of carb.

The new guidelines allow persons with diabetes to make food choices. It is not unusual for people with diabetes to crave sweets. Many never stop craving them. The idea is that if you can control the craving, limit the amount consumed, and allow for it in your total, you can have it. But, it needs to be controlled! I talked to a gentleman yesterday whose family member told me that he was getting up in the middle of the night and eating a box of cookies. That is not appropriate—to give up all your carbohydrates for cookies!

Now, that brings us to the subject of sugar-free cookies. Just because something says it's "sugar-free," does not mean it is carbohydrate-free. You must count the carbs, even in sugar-free cookies. The same thing goes for juice. The same patient yesterday said, "I don't understand why my blood sugars are so high—but I just drink unsweetened grapefruit juice."

My question was, "How much?"

He said, "48 ounces".

That's a good reason why your blood sugars are so high. It matters how much carbohydrate you have. The fact that it didn't have sugar added to it, he thought it was okay. Now that brings us to say, just because it has "no added sugar" doesn't mean it doesn't contain carbohydrates. Many people avoided sugar or sweets, yet gave no attention to how much bread they ate, no attention to how much pasta, and their blood sugars were out of sight. It does matter in controlling carbs.

Where did this "no sugar" thing originate? It started in the 1920s. Laboratory dogs, that had their pancreases removed, were given glucose. When tested, glucose showed up in the dogs' urine. The researchers assumed from their findings that all sugars must be bad. In the 1970s they began to question whether this was really true or not. After years of research they came to the conclusion that it was not the table sugar specifically, but the quantity of total carbohydrates—both starches and sugars.

This will sound like I'm contradicting myself, but hang with me. All carbohydrates are not created equal. I just told you "15 grams of carbs is 15 grams of carbs," but what I am talking about now is a little bit different. We do know that certain carbs affect your blood sugar differently. For example, if you eat potatoes, a certain amount, or the same amount of rice, or the same amount of carbohydrate from spaghetti, your blood sugar might rise to different points, even though you had consumed the same total grams of carbs.

In the 1970s and 1980s, researchers testing specific carbohydrate foods, to determine the effect each had on blood sugar. They called the results of their work the glycemic index of foods—"glycemic" meaning how high your blood sugar went up. They compared each food to a standard food item—pure glucose. In other words, how high your blood sugar rose after consuming pure glucose, they established as "one hundred percent." Every other food was ranked in relation to that.

For example, some of the foods that raised blood sugar the quickest were things like mashed potatoes. They were almost as high on the glycemic index as pure glucose. Flaked corn cereals were also very, very high. They raise blood sugar almost as high as the mashed potatoes.

Other foods very high on the glycemic index are things like carrots and bananas. Actually, bread came in at about number 69. In other words, the impact of bread on your blood sugar was about 69% of what eating pure glucose was. And lo and behold, here we have sucrose, "table sugar." It was in the 60th percentile, as far as the actual impact on your blood sugar—it wasn't as bad as once thought. However, it still has to be counted as part of the total carbohydrate.

For those of you who have a low blood sugar reaction, please go ahead with your orange juice; don't eat mashed potatoes to stave off a crisis! One of my patients asked me the other day, "Well, why don't we treat low blood sugars with a mashed potato?" Yes, mashed potatoes will probably do about as good, but orange juice is easier to obtain. Often it is right there in the refrigerator.

If you really want to fine tune your blood glucose control, eating foods that are lower on the glycemic scale would be helpful. For example, things like beans, because they have fiber, are lower on the glycemic index. What affects how quickly the blood sugar rises after eating certain foods? Often times it is particle size. Note the potatoes are pulverized and mashed. Things like corn flakes are made from pulverized corn.

Whether the food is raw or cooked makes a difference. Carrots that are cooked to mush are going to be converted quicker to blood sugar than are raw carrots.

It's not that we eliminate foods just because they are high on the glycemic scale, or eat only those that are low, because the glycemic index is only useful in a limited fashion. Why? Because we don't ever just eat mashed potatoes. We put fat gravy on them or we eat them with meat, or we do this, that, or the other. When you mix things in a meal, the glycemic effects of the individual foods are changed.

By the way, for those of you who thought: "Honey is good," honey is right up there with those mashed potatoes. All carbohydrates are not created equal. But, you can have a variety of carbohydrates provided that you account for it.

Much of the dietary advice of the past was based on theories and assumptions. Now we have shifted to actual facts. We have shifted our focus from sugar consumption to carb consumption, where it should be.

How much carbohydrate should you have in a day? About half of our daily calories should come from carbs, and it should be spaced throughout the day. Don't save all your carbs for the night meal. Your registered dietitian and your physicians can help you to regulate your medicine with your carb intake. Remember, don't overdo the sugar-free products. Watch not only the carbohydrate, but watch the calories and the fat content. Emphasize foods that are good quality nutrition, and by all means check your blood sugar.

This is what I tell my patients to do: If your blood sugar is unusually high, right then and there, think back, what happened? Was I at the convention in New Orleans, or was I at a birthday party? Make a note as to why your blood sugar might have been so high. You can take the information and do something about it. Make some adjustments next time.

Does anybody have any questions?

Q: What about protein restrictions, if you're going into kidney failure?

A: Actually, that is a very complicated subject. In general, the protein restriction in renal disease depends on whether a person is on dialysis or not. If a person has not started dialysis yet, or if the physicians are trying to prevent a person going on a dialysis machine, they will often times place some limitations on the protein content of the meal. New guidelines give the requirements for protein as 0.8 grams of protein per kilogram of body weight. That is not an extreme reduction, but actually what is recommended for all Americans.

We in the U.S. eat way more meat than we are supposed to eat. That's one reason we have some the health problems we have in this country. The guidelines say to bring it back down to what is appropriate for all Americans. Once a person is on dialysis, those protein guidelines are relaxed some, because you need a little bit more protein. It is a very complicated issue. We have dietitians who specialize in that!

Q: What about bloating or swelling in the late afternoons and evenings?

A: Are you speaking of edema? Normally, dietary salt acts like a sponge, it holds in a lot of fluids, and that could cause problems for you. Here in the city of New Orleans we have a very high salt content in our food. Pay close attention to the sodium content of your meals!

Q: What about swelling in your ankles?

A: Same thing. You gotta watch that salt. The salt content of your diet is very complicated because literally everything, especially if it is a packaged food, has a great deal of sodium in it. Fast foods are high in sodium. Anytime you eat out, and the food is prepared in a large quantity, you're going to be getting more salt or sodium than you need. For example, if you eat our gumbo here, or our crawfish ettouffee, that is prepared in large quantities. If you have a piece of grilled chicken, or fish with a baked potato, there may not be as much salt content. You can request it be prepared to your specifications.

The recommendation for sodium intake, for a person with diabetes, is no more than 2400 milligrams a day. Anywhere below 3000 is recommended for the general public. Most people probably get about 6000 milligrams of sodium. Here in New Orleans we may get 8000.

But salt is only one part of the puzzle. Any kind of packaged foods, for example, canned soup, contains maybe 1000 milligrams of sodium right there. Chinese food—very high sodium. A lot of people tell me, "I don't cook with salt."

I question them, and they tell me:

"I cook with pickled pork, and kitchen bouquet, and Worcester sauce and stuff like that."

Those condiments are all very high in sodium. A lot of times it's not that you use salt but that sodium gets into your food through all these seasonings and things. However, salt is an acquired taste. We are not born liking salt. We learn to like it. The more we use, the more we want. Along with that I might tell you that human beings are born with a sweet tooth. But, you are not born craving salt. You learn to like it. Again, I would watch the hidden sources of sodium that might be getting in. If you have a low-salt diet, great, that's wonderful. Keep it up.

Q: If a person weighs 100 pounds, how much protein should that person be eating?

A: The standard formula is: .8 gram of protein per kilogram of body weight. A hundred pounds would be 45 kilograms, and you multiply 45 times .8, which would give about 36 grams of protein. Now an ounce of meat has about 7 grams of protein in it. A cup of milk has about 8 grams of protein in it. So that 36 grams adds up very quickly. As you can see, the average American really overeats protein.

Our ancestors, way back in times past, when there were no refrigerators, probably did not consume the amount of meat protein that we do. They probably ate more grains, more fruit, more vegetables. They may have had meat every couple of days, when they killed something. Now, some people feel like a meal is not a meal unless we have meat. And that is a problem.

Q: Could you say something about honey?

A: Honey is an excellent food. It is thought to have some natural things in it that are beneficial to us. But honey is very, very high on the glycemic index. It is a carbohydrate. If that's the carbohydrate you choose to have then you can have it, but you must count it as part of your total carbohydrates. A lot of people say, "But, it's natural." Well, it's naturally going to make your blood sugars go high, too. It is a very quick-acting carbohydrate, but you just have to work it in.

Q: Some packages are labelled "sugar-free," and then on the back of the package it says sorbitol and mannitol. I wondered if that was the sugar?

A: Sorbitol and mannitol and xylitol are what we call "sugar alcohols." They do raise the blood sugar, but gradually. They are used primarily in "sugar-free" cookies and candies. The problem with sugar alcohols is that in excess quantities they will produce a laxative-like effect. I have a patient who said, " When I have a problem with constipation, I use those."

Q: I work with a lot of people who are transplant patients and are trying to manage their diabetes with that. One of the things that happens a lot of times with transplant patients is they gain weight, and one of the things they say is, "that's because of my Prednisone." I consistently respond to them that it is not really their Prednisone, it is because of the food they eat. My question: Is it the Prednisone that makes people gain weight or is it the increased appetite?

A: Well, we certainly see a number of different things with the use of Prednisone. We see fluid retention and that could cause some weight gain. We see tremendous increase in the amount of appetite, and that could cause a person to eat more than they need. When you get your diabetes in good control, which you have to do with those transplants, you may see weight gain. Think about it: If your blood sugar it running high, and all of that glucose is spilling over into your urine and out of your body, you are not really getting the benefit of the food you eat, until you start getting your blood sugar under tight control.

If you then start giving yourself insulin to match your carbohydrates, you are going to see all that food you're eating now utilized by the body. Many times, a big complaint when people start getting their diabetes under control is that all of that food they were getting away with eating before now shows up as weight gain, even though they may not be eating any more food than they were. The body is now utilizing it more efficiently. Your question is hard to answer, but I would say it is probably a combination of both, the tremendous appetite, and the fluid retention. It is really very difficult for them.