Diabetes: Counting Carbohydrates Meal Plan

What is the counting carbohydrates meal plan?

Counting carbohydrates is a food plan in which you adjust the insulin dose based on the amount of carbohydrates your child plans to eat.

How is this plan different from the exchange or constant carbohydrate meal plans?

This plan is different from the exchange meal or constant carbohydrate plan because the insulin dosage and carbohydrates are not always the same day to day. This plan is more flexible and is usually started after you have become familiar with food choices and insulin.

How does this plan work?

Carbohydrates affect your child's blood sugar more than any other kind of nutrient. Insulin your child takes works with carbohydrates to supply energy for the body. The main goal is to balance insulin with the carbohydrates your child eats throughout the day.

First, you and your diabetes care provider need to figure out how much insulin your child needs to take in relation to the amount of carbohydrate your child plans to eat. There are two approaches to take when figuring this out:

Units per carb choice (exchange): Count carbohydrates in portion sizes of 15 grams (this is called a "carb choice" or an exchange). Divide the number of grams of carbohydrate in a food by 15 to determine carb choices. For example, if a container of yogurt with fruit had 45 grams of carbohydrate in it, then it would contain 3 carb choices.

The units of rapid acting insulin (Humalog/NovoLog/Apidrazz) or Regular insulin are then adjusted at every meal to match the number of carb choices. To use this method, your provider needs to tell you how many units of insulin you need for every carb choice that you plan to eat. For example, if your child needs 1 unit of insulin for every carb choice, then for 3 carb choices, he would need 3 units of insulin (1 x 3 = 3).

units of insulin per carb choice X # of carb choices = units of insulin needed

I/C ratio: More commonly people use an Insulin to Carbohydrate ratio (I/C ratio) to calculate how much insulin to use. If you use a ratio, you do not need to convert the number of carbohydrates to carb choices. An example of an I/C ratio is 1 unit of insulin for every 10 grams of carbs eaten.

For example, if you plan to eat 60 grams of carbohydrate and your I/C ratio is 1/10 (.10), then you would need 6 units of insulin (60 X .10 = 6).

grams of carb X I/C ratio = units of insulin

Your dietitian will help you figure out your I/C ratio.

Adjustments to the insulin dose

After you calculate the number of units of insulin your child needs to take, you may need to make adjustments to the dose. Changes to the dose may be needed because of planned exercise, blood sugar levels, or other factors that may affect blood sugar (such as illness, stress, menstrual periods, etc.). For example, subtracting insulin if the blood sugar level is low (below 70 mg/dl) or adding insulin if the blood sugar is too high (above 200 mg/dl). Your dietitian and health care provider will give you guidelines for making these adjustments. The insulin dose calculated from the I/C ratio is usually reduced by half if it is given before strenuous exercise or at bedtime.

Which foods have carbohydrates?

Carbohydrates are found in many foods including:

• Starchy foods (such as breads, cereals, rice, starchy vegetables, and pasta)
• Fruits
• Milk and yogurt
• Sweets

Most vegetables do not have a lot of carbohydrate in them. Also, meats and fats do not have carbohydrates. These foods have less of an effect on blood sugar levels. Meats and fats affect the blood sugar in different ways than foods with carbohydrates do. If necessary, you can make slight adjustments to your child's insulin dose based on meats and fats once you have learned how to count carbohydrates.

To see a list of carb choices, you can order the Exchange List for Meal Planning from The American Diabetes Association and the American Dietetic Association (1-800-342-2383). Although this book is often used for the exchange diet, it lists the carbohydrate content for lots of foods and is very useful. Nutrition labels on food packages also list the grams of carbohydrate in a serving of food.

When should my child take insulin?

In general, your child should take his insulin so that the insulin starts working as the blood sugar begins to rise. Sugar is absorbed into the blood about 10 minutes after eating.

• Humalog/NovoLog/Apidra: Begins working in 10 minutes. The peak activity of this insulin is 30 to 90 minutes after taking. Take this insulin right before eating.
• Regular insulin: Begins working in 20 to 30 minutes. The peak activity is 2 to 4 hours after taking. Take this insulin 20 to 30 minutes before eating.

Sometimes insulin can be given after eating. Your child's doctor and dietitian will help you create a schedule for when to take insulin and when to eat.

How do I get started?

1. Keep a food, insulin, blood sugar level, and exercise record for at least 3 days. The more blood sugar tests you can do 2 hours before meals and 2 hours after meals, the better the advice your dietitian can give you. It is also important to record all doses of insulin or oral medicines you took.
2. The dietitian will analyze the report and work with your provider to decide what your child's Insulin to Carb (I/C) ratio is. Some people can use one unit of short acting insulin per 15 grams of carb for all meals and snacks (an I/C ration of 1/15). Your child may have a ratio that varies from one time of day to another such as a 1/15 ratio for breakfast, a 1/30 ratio for lunch, and a 1/10 ratio for dinner.
3. Start counting carbs and adjusting the insulin dose accordingly. You need to keep careful records for the first 1 to 2 weeks of:
   • number of carbohydrates your child eats at each meal or snack
   • insulin dose given
   • blood sugar levels (especially levels 2 hours after meals)
4. After a week or two, review your records with a dietitian to check if any adjustments need to be made. If the blood sugar values are not in the desired range, then your child's Insulin to Carb ratio will need to be changed. If the blood sugar value is consistently high 2 hours after a meal, more insulin is needed for the grams of carb in the I/C ratio. For example, your child would need to change from an I/C ratio of 1/15 to 1/10.