Carbohydrate counting 1, 2, 3 - Some practical tips for adapting carb counting to literacy levels utilising the LFAC/ISPAD carbohydrate counting books
Dear colleagues,
Life for a Child, in partnership with ISPAD, has developed a series of carbohydrate counting resources, ‘Healthy eating and carbohydrate counting for children and adults with type 1 diabetes’. We are excited to let you know that we have expanded the series of the books to Spanish, featuring Mexican and Ecuadorian foods, following the initial resource in English with Indian foods. This resource is a versatile tool that can cater to different audiences such as children, teens, laypersons, and healthcare professionals and varied literacy and numeracy levels (also known as health literacy). A version for Pakistan in both English and Urdu is currently being developed.
If you are interested in developing a carb counting bookfor your country, language or culture, please contact us via email ([email protected] or [email protected]). Or, if we can help you develop a resource that is more suitable and practical for your centre, please let us know.
In this article, we will show you how to make the best use of this resource in delivering diabetes education and supporting diabetes self-management. We will discuss how to teach carbohydrate counting (also referred to as carb counting) from Level 1 and building up to Level 3, to tailor to the health literacy of a person with diabetes and/or their carers.
The image was sourced from the internet.
What is carb counting?
It is a method that focuses on the quantity (or amounts) of carbs in a meal.
It is a way to estimate the amount of total carbs in a meal or snack.
Why is it important to count carbs?
There is evidence that carb counting is an effective way to manage postprandial (after meal) blood glucose levels. It allows the insulin dose to be adjusted to the amount of carbs a child/person with diabetes consumes. A recent systematic review and meta-analysis examined 10 randomised controlled trials with 1,026 patients with type 1 diabetes and showed that carb counting could significantly reduce HbA1c as compared to other dietary methods or usual care (mean difference -0.32%, 95% CI -0.49 to -0.15, p < 0.001) (Fu et al., 2016). Furthermore, another systematic review and meta-analysis of 11 studies with 899 patients found that carb counting was associated with a significant reduction in HbA1c compared to other forms of dietary advice (mean difference -0.29%, 95% CI -0.45 to -0.13, p < 0.001) demonstrating the efficacy and safety of carb counting in type 1 diabetes as compared to other forms of dietary advice (Builes‐Montaño et al., 2022). Therefore, carb counting is an essential skill for parents/carers and people with diabetes who use insulin, especially those with type 1 diabetes.
How to choose the right level of teaching carb counting?
There are different levels of carb counting depending on the diabetes health literacy level of a person, no matter what their age is. Table 1 shows the key learning outcomes for each level of carb counting. It is crucial for the person with diabetes and their support network (e.g., family and carers) to work closely with their diabetes team, especially the dietitian, to develop and acquire the skills.
Table 1: Three levels of carb counting skills for people with diabetes when using the LFAC/ISPAD series of the carb counting resource.
Levels
Key learning outcomes
Suggested target audience
The key content from the carb counting resource
Level 1
Understand and follow the general healthy eating guide of the country.
Identify the sources of carbs in different types of foods and drinks.
The audience has low diabetes health literacy and numeracy skills and/or is newly diagnosed with diabetes.
Use Chapter 1 to teach the general healthy eating of the country. Then, point out the typical sources of carbs from the healthy eating guide.
Level 2
Maintain a consistent carb intake for each meal and snack.
Use standard portions or measuring tools (e.g., a household measuring cup or tablespoon) to estimate the amount of the most common carbs in meals consumed in a typical day.
The audience has successfully acquired Level 1 skills with fair diabetes health literacy and numeracy skills and uses a pre-mixed or self-mixed intermediate and short-acting human twice-daily insulin regimens.
Continue to use Chapter 1, to consolidate the understanding of carb counting.
Select foods from Chapter 2 and Chapter 3 that are applicable to the person’s dietary intake, to show and add up the amount of carbs in the person’s meal and snack.
Level 3
Count the exact amount of carbs for each meal and snack using food labels, scales, apps and measuring tools.
Adjust the insulin dose for each meal and snack based on the carbohydrate-to-insulin ratio (CIR) with guidance from the diabetes team.
The audience has successfully acquired Level 2 skills, has adequate diabetes health literacy and numeracy skills and wants to have more flexible insulin regimens, e.g., long-acting analog once daily and short-acting human or rapid acting analog insulin before each main meal.
Use Chapter 2 and Chapter 3 to teach the person to calculate the carbs with more than one carb source in a meal and in different serving sizes. Also, refer them to additional resources, like food labels and apps, to calculate carbs in different scenarios.
Work with the diabetes team to teach the family/person how to adjust insulin doses for flexible eating and carb counting.
What else is important for carb counting?
Besides the quantity of carbs, another important aspect is their quality. The nutritious carbs are high in fibre, lower in fat and based on wholefoods or wholegrains. Often, these carbs have a lower ‘Glycemic Index’ (GI), which is a measure of how quickly a carbohydrate food raises blood glucose levels. Therefore, GI has been widely used to indicate the quality of carbs. Backed by more than 40 years of science, a healthy low GI lifestyle is a sustainable way to improve overall good health across all stages of life. The Glycemic Index Foundation website, gisymbol.com, has useful information including diabetes friendly recipes, meal plans and a food database to search the GI value of a food. These resources are for both healthcare professionals and people with diabetes and their support network.
The Glycemic Index Foundation Low GI certified symbol is the only independent global certification program. The GI Symbol guarantees that the GI value has been tested by an accredited laboratory and is accurate. Foods that carry the GI Symbol have been assessed against a range of strict nutrient criteria in line with International Dietary Guidelines making them among the healthiest choices in their category. The GI Symbol can be found in Australia, New Zealand, USA and parts of Europe and Asia.
Where to find helpful materials for carb counting?
You can find the English version with Indian foods and dishes under ‘other resources / carbohydrate counting books and resources’ on the LFAC English language page, while the Mexican version is here and the Ecuadorian version here under ‘for parents and carers’ on the Spanish language page.
Below are some practical examples from the book in Spanish showing the carb amount from the Mexican and Ecuadorian cultures:
Some practice tips for teaching carbohydrate counting:
Show young people and/or their carers the portion sizes and carb content of different foods using food models, such as plastic replicas or pictures. You can also use everyday objects, such as a tennis ball or a deck of cards, to help them estimate the carb content of foods that do not have labels. For example, a tennis ball is roughly the same size as a medium apple, which has about 15 grams of carbs.
Help young people and/or their carers measure and calculate the carb content of cooked meals using food labels, scales, or apps. For example, a cup of spaghetti with meat sauce has about 45 grams of carbs. One useful website is ‘calorieking’, or My Fitness Pal, which is available in different countries and languages with local food databases.
Demonstrate to young people and/or their carers how to count carbs from mixed dishes and sauces using cooked meals, such as those from a cafeteria or a restaurant.
Encourage young people and/or their carers to keep a food diary, where they record the food they eat, the carb content, the insulin dose, the blood glucose level before and after each meal, activity level, illness and others. This can be an effective tool to learn how to adjust insulin doses to the amount and types of carbs eaten. It can also identify other factors that affect their blood glucose levels. For example, they can see how exercise, stress, illness or hormonal changes influence their blood glucose levels.
Seek other opportunities besides the clinics, such as teaching carb counting at camps or other group settings, where you can provide hands-on practice and feedback in a more relaxed and fun environment. You can also have a dietitian attend the camp if available, to provide more guidance and support. For example, one popular activity during a camp is the ‘carb counting challenge’ where a quiz or competition can be set up at mealtimes. The camp lead or dietitian can ask the ‘campers’ to estimate the carb content on their plate. The one closed to the actual amount is the winner.
To improve the quality of carbs eaten, talk to young people and/or their carers about swapping to low GI carbohydrates for health benefits. Going low GI does not mean giving up favourite carbs. It is all about swapping – swapping high GI carbohydrates for lower GI options. You can use the searchable database to know what foods are low GI and the swap it tool are all available on the Glycemic Index Foundation Website.
If you have any other suggestions for teaching carb counting that have worked well for young people and/or their carers, please share them with us by email to: [email protected] and we will share them in our future bulletins.
References
Builes‐Montaño, C. E., Ortiz‐Cano, N. A., Ramirez‐Rincón, A., & Rojas‐Henao, N. A. (2022). Efficacy and safety of carbohydrate counting versus other forms of dietary advice in patients with type 1 diabetes mellitus: a systematic review and meta‐analysis of randomised clinical trials. Journal of Human Nutrition and Dietetics, 35(6), 1030-1042.
Fu, S., Li, L., Deng, S., Zan, L., & Liu, Z. (2016). Effectiveness of advanced carbohydrate counting in type 1 diabetes mellitus: a systematic review and meta-analysis. Scientific reports, 6(1), 37067.
