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Gattullo, Barbara Ann APRN-BC, CDE

Feature: CE Connection: DIABETES SPECIAL

When it comes to diabetes, the topic of carbohydrates is one that most are quick to disagree about. Healthcare practitioners and patients with diabetes often have differing opinions about meal planning. Understanding what carbohydrates are and what they do is vital to the successful nutritional management of diabetes.

Understanding what carbohydrates are and what they do is vital to the successful nutritional management of diabetes.

Associate Professor • Department of Nursing • Kingsborough Community College • Brooklyn, N.Y.

The author has disclosed that she has no financial relationships related to this article.

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The great carbohydrate debate

“Carbs”—short for carbohydrates—are a commonplace part of the diet language, especially for people with diabetes. The first question your patient is likely to ask? What's a carbohydrate?

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All the food we eat, with the exception of meats and meat substitutes, fats, and oils, contains a mixture of carbohydrate, protein, and fat that the body converts to the energy that's essential for life. It's important to understand carbohydrates in order to manage diabetes because they're broken down into glucose—the sugar that people with type 2 diabetes have in excess in the bloodstream.

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The debate

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Everyone agrees that the body uses carbohydrates for energy as glucose, and that they're the main nutrient in foods that affect after-meal blood glucose levels. Knowing how much carbohydrates patients with diabetes should eat is a question that leaves healthcare practitioners and patients with differing points of view. Most healthcare practitioners will agree that blood glucose stays more stable when the intake of carbohydrates is limited, but remain aware that carbohydrate foods also tend to contain vitamins and minerals. Patients with diabetes wonder why they can't eat and enjoy the same foods as others. What we do understand, however, is that everyone involved may, in a sense, be right.

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The breakdown

Sugars, starches, and fibers are identified as carbohydrates, which are labeled as either simple or complex. Simple carbohydrates are sugars; complex carbohydrates are starches and fibers. The three basic sugars identified are glucose (or common table sugar), fructose, and galactose. After these sugars combine in a chain, larger sugars, such as sucrose, maltose, and lactose, are formed.

When sugars are formed together in a chain, they help develop starches and fibers. Starch sources, such as potatoes, bread, pasta, and white rice, are the main sources of dietary carbohydrates. Fiber, a structural component, isn't considered a nutrient. Fibers can be either soluble or insoluble. Soluble fibers, which can dissolve in water, are found in foods such as oat bran, barley, legumes, bananas, blueberries, carrots, and artichokes. These foods cause a slowed digestion, but can help lower a person's cholesterol count. Insoluble fibers are found in wheat, vegetables, and whole grains. Because these foods add bulk to the diet, food passes more quickly through the stomach and intestines. Fiber doesn't directly supply the body with energy, although eating fiber may indirectly affect blood glucose and provide benefits, such as effective waste elimination.

Glycogen, a complex carbohydrate, is the body's own glucose storage chest. Between meals when glucose levels aren't sufficient to satisfy the body's needs, small chunks of glucose are made available from glycogen. The liver addresses glucose levels, which can drop during intense exercise or periods of fasting.

Proteins have long been considered building blocks for the body. Diabetic nephropathy occurs in 20% to 40% of patients with diabetes and is the single leading cause of end-stage renal disease. This warrants early management to decrease risk and slow progression of the disease. A safe consideration for patients with diabetes is that protein should be approximately 20% to 40% of the total dietary intake. Although protein intake should be monitored, leaving out or severely limiting the intake of protein could lead to muscle cell disintegration.

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Fats typically provide more than half of the body's energy needs. Fat, which is formed into fatty acids, is stored in fat cells as triglycerides. Fat cells are very accommodating and store unlimited amounts of triglycerides. We do know that fat leaves the stomach more slowly and may delay the rise in blood glucose after a large meal for as long as 10 hours. With this in mind, patients with diabetes need to consider how a high-fat snack at bedtime affects early morning blood glucose readings.

Unsaturated fats are usually found in plant products, such as olive oil and corn oil, and remain liquid at room temperature. Saturated fats are found in animal products, such as butter, and are usually solid at room temperature. Trans fat may contain saturated or unsaturated fatty acids, which can be safely enjoyed when minimally included in the diet. Although fat has less of an effect on blood glucose, it's important to appreciate the negative effect fat intake has on the cholesterol level. Another accepted fact is that when eating low-fat diets, insulin sensitivity is improved, which will help to manage blood glucose.

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Low, moderate, or high?

Low-carbohydrate diets call for as little as 20 to 30 g of carbohydrates per day. Saturated fats are permitted, but trans fat is discouraged. Raw or cooked vegetables, popcorn, and milk could be suggested.

Moderate-carbohydrate diets are estimated at 40 to 50 g per day. Limited saturated fats found in red meats are permitted, but trans fat isn't.

High-carbohydrate diets are estimated to be 75% carbohydrate. No animal products, eggs, or dairy are eaten. Staples such as beans and lentils are permitted. The intake tends to focus on grains, fruits, and vegetables and an increased intake of fiber, white rice, pasta, bagels, and beans.

Knowing how many servings per day a person should consume depends on height, weight, age, sex, and activity level. A dietitian can help your patient construct a meal plan that's the right balance for him or her.

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What's the glycemic index?

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The glycemic index is a measure of how different foods containing the same amount of carbohydrates affect blood glucose levels. At one time, the glycemic index held promise as a meal-planning method, but responses proved quite variable. When low glycemic index diets have been compared with high glycemic index diets, some short-term studies showed benefits and some didn't. However, two 1-year studies reported that no benefit was seen in HbA1C results, which gives an average of 2- to 3-month blood glucose testing results.

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Estimating portion sizes

How does your patient know how much is enough? Estimating the volume of a serving of food by comparing it with an object such as a fist, which equals about 1 cup; the palm of the hand, which equals about 3 oz; or the thumb tip, which equals about 1 teaspoon helps a person develop a practical approach to portion sizing. A food list may be used to determine the amount of carbohydrates in a particular food. Remind your patient to measure only the portion of the food to be eaten, which will provide more accurate information.

A less practical method of monitoring carbohydrate intake is to weigh foods on a scale. Your patient must identify the amount of carbohydrate in the food to be eaten, estimate the portion size based on one of the common measuring devices, and do the math of the number of grams of carbohydrate multiplied by the portion size. However, the steps may become burdensome to your patient. Knowing which plan works best for your patient depends on caloric needs, blood glucose goals, food preferences, daily schedules, medications, exercise plans, monitoring schedules, and his or her desire for flexibility.

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Labels tell all

The U.S. FDA requires that all packaged and processed foods list key nutrient information and ingredients on labels. In the United States, the label must contain the grams of total carbohydrates, as well as the grams of sugar and dietary fiber in a single serving. The carbohydrate listing includes everything in the food that's carbohydrate: starch, fiber, sugar, and sugar alcohols. The percentage listed identifies how much of the daily recommended food intake is in each serving. It's important that your patient pays attention to the portion size listed because it may not be the amount normally eaten and an adjustment may be needed.

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Don't be mislead by free foods

Free foods are foods that have little or no effect on blood glucose levels. They're defined as having fewer than 20 cal or 5 g of carbohydrates per serving. When eating multiple servings of free foods, calories and carbohydrates can still mount up and must be counted as part of the food plan.

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The impact of diabetes self-management

Diabetes self-management education is the cornerstone of care for all patients with diabetes who wish to achieve successful health-related outcomes. Patients should interact with the multidisciplinary team that includes nurses, physicians, and dietitians who may also be certified diabetes educators.

Medical nutrition therapy (MNT) is an integral component of diabetes prevention and management. The American Diabetes Association recognizes the impact that nutritional management therapy plays in the maintenance of an overall healthy lifestyle. Because nutrition issues must be individualized and can be complex in diabetes management, it's recommended that a registered dietitian who has diabetes management experience be the one who provides MNT.

Carb counting for patients with diabetes takes practice, and it can be discouraging when blood glucose testing doesn't produce a normal result. Eating well with carbohydrates has been addressed over and over again, but the debate still exists as to whether patients with diabetes should focus primarily on carbohydrates or not. Some of the following tips may prove helpful to your patient who's beginning to count carbohydrates:

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* Accept that you have diabetes.

* Allow yourself to become smart about diabetes.

* Start your carbohydrate management plan by eating at home.

* Test your blood glucose levels frequently and keep records for review.

* Be a label reader.

* Simple is comfortable.

* Figure out what foods work positively for you. Be consistent, but not boring with food choices.

* Plan ahead and know how foods affect blood glucose readings.

* Know portion size estimates.

* Avoid senseless munching.

* Don't worry about being an expert; welcome support.

* Allow for setbacks to serve as a guide for future successes.

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The power of education

Diabetes is common, costly, and complex, and may seem frustrating for your patient at times. Proper patient education can result in less distress, better outcomes, and greater adherence to recommended treatments. Adherence, a voluntary, collaborative involvement of the patient in a mutually designed plan of action, gives your patient a choice and makes him or her an active participant in care. Teaching carb counting takes patience and time for both the patient and the teacher. Start by asking your patients what they feel they need to know.

The following tips may prove helpful as you embark on diabetes education:

* Take the time to get to know your patient. Don't stereotype patients, such as all patients with diabetes are likely to be “cheating on the diet.”

* Ask your patient how he or she likes to learn. Uncover hidden information about your patient, such as cooking skills. Striking a familiar note may help with the implementation of the plan.

* Keep it simple. Begin first with what a carbohydrate is and then progress to making food choices and meal plan selections.

* Stop and ask your patient if he or she has any questions. Remember to be a partner in your patient's care. Ask open-ended questions such as: “What would you do if a certain situation arose?” Build on life experiences.

* Let your patient play. Experience with choosing the right foods to eat and setting up a satisfying meal plan will translate into effective learning.

* Never forget to follow up. Patients should never be expected to have 100% recall. Keep your education patient-focused. Tap into your patient's thoughts and feelings about how the plan is going. Can anything be changed? Give feedback. Thinking in a “one size fits all way” will have your patient coming up short.

* Always reinforce.

To help patients overcome barriers, practitioners must understand that patients adhere to chronic disease recommendations when the treatment regimen makes sense and seems effective and when they think that the benefits exceed costs, believe it's important, have confidence they can succeed in the regimen, and when they have support.

Remember: Be a coach, be a mentor, and reinforce that the best diet is the healthy diet that the patient will follow.

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Learn more about it

American Diabetes Association. Carbohydrate counting.
American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care. 2011;34(suppl 1):S11-S61.
Gebel E. The science of carbs: sugar, starches, and fiber, from molecule to meal.
Neithercott T. Back to basics: carb-counting tips.
Neithercott T. Are carbs the enemy?
Overgaard PM. Patient teaching in five easy steps. Nursing made Incredibly Easy! 2009;7(3):56.
Scheiner G. Counting carbohydrates like a pro: practical tips for accurate counts.
© 2012 Lippincott Williams & Wilkins, Inc.