Diabetes: Carbohydrate (Carb) Counting Meal Plan

What is the carb counting meal plan?

Counting carbohydrates is a food plan that adjusts the insulin dose based on the amount of carbs your child plans to eat.

How is this plan different from other carbohydrate meal plans?

In this plan, the insulin dosage and carbohydrates are not always the same day to day. This plan is more flexible and is usually started after you are familiar with food choices and insulin.

How does this plan work?

Carbs affect your child's blood sugar more than any other kind of nutrient. Insulin works with carbs to supply energy for the body. The main goal is to balance insulin with the carbs your child eats all through 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 2 ways to figure this out:

Units per carb choice (exchange): Count carbs in portion sizes of 15 grams. This is called a "carb choice" or an exchange. Divide the number of grams of carbs in a food by 15 to figure out carb choices. For example, if a container of yogurt with fruit has 45 grams of carbs, it equals 3 carb choices.

Units of 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 each carb choice. 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: Most people use an Insulin to Carbohydrate ratio (I/C ratio) to figure out how much insulin to use. If you use a ratio, you do not need to convert the number of carbs 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 carbs and your I/C ratio is 1/10, then you would need 6 units of insulin (60 ÷ 10 = 6 units).

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

Adjusting the insulin dose

Your child may need to change the dose based on planned exercise, illness, stress, or menstrual periods that affect blood sugar levels. For example, your child may need less insulin if the blood sugar level is low (below 70 mg/dl or 3.9 mmol/L) or more insulin if the blood sugar is too high (above 200 mg/dl or 11.1 mmol/L). Your dietitian and healthcare provider can show you how to figure out these adjustments.

Which foods have carbohydrates?

Carbs are found in foods such as:

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

Non-starchy vegetables, meats, and fats contain very little or no carb. They have less of an effect on blood sugar levels. You should still pay attention to meats and fats.

Your child should eat little or no butter, milk based salad dressing, bacon, cream, sour cream, stick margarines and shortening. These contain saturated fats.

Your child should limit soft margarines, light mayonnaise, oil based salad dressing, nuts, seeds, olive, canola, peanut, flaxseed oil and oily fish. These are healthier fats, but should be eaten in moderation.

You can also use the booklet Choose Your Foods: Exchange Lists for Diabetes to check how many carb choices are in different items. The Complete Guide to Carb Counting 3rd edition gives more detailed information and more carbs to choose from. You can order these publications from http://www.shopdiabetes.org/Categories/8-Diabetes-Books.aspx or by calling the American Diabetic Assocation at 1-800-232-6455.

When should my child take insulin?

In general, your child should take insulin so that it starts working as the blood sugar starts to rise. Most carbs are absorbed as sugar into the blood about 10 minutes after eating. The peak in blood sugar from food is usually about 60 minutes after eating.

• Humalog/NovoLog/Apidra: Starts working in 10 minutes. The peak activity of this insulin is 100 minutes after it is taken. Take this insulin 15 to 20 minutes before eating (if blood sugar is above 80 mg/dl or 4.5 mmol/L).
• Regular insulin: Starts working in 20 to 30 minutes. The peak activity is 2 to 4 hours after taking. Take this insulin 30 to 60 minutes before eating.

Sometimes insulin can be given after eating. (For example, toddlers who may not eat consistently, or children with blood sugar levels less than 70 mg/dl or less than 3.9 mmol/L.) 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 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 taken.
2. The dietitian will review the report and work with your provider to decide what your child's Insulin to Carb (I/C) ratio is. Some people can use 1 unit of short acting insulin per 15 grams of carb for all meals and snacks (an I/C ratio of 1/15). Your child's ratio may vary from one time of day to another. For example, 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 as needed. You need to keep careful records for the first 1 to 2 weeks of:
   • grams of carbohydrates your child eats at each meal or snack
   • insulin dose given
   • when the insulin was given (10 minutes before eating, 15 minutes before eating, etc.)
   • blood sugar levels (especially levels 2 hours after meals when levels should be less than 180 mg/dl or less than 10 mmol/L)
4. After a week or two, review your records with a dietitian to check if any changes need to be made. If the blood sugar values are not in the desired range, then your child's I/C ratio needs to be changed. If the blood sugar value is always high 2 hours after a meal, more insulin is needed for the grams of carb in the I/C ratio. For example, your child might need to change from an I/C ratio of 1/15 to 1/10.