March 13, 2019 Carbohydrate counting
Interested in a different approach for meal planning to help manage your blood sugar levels? Learn all about carbohydrate (carb) counting, its advantages, and what you should discuss with your health-care team presented by nutritionist Meaghan Elger.
[00:00:00] Thank you very much for joining us. Today we're excited to have this presentation on carbohydrate counting. And we would like to thank Janssen for their sponsorship of this webinar. A presenter is Felicity Woolley. She is a Registered Dietitian and Certified Diabetes Educator with ten years of experience in the field of diabetes. She went to the University of Alberta to get her nutrition degree and she worked in a French hospital in New Brunswick where she graduated as the top student of her internship class. She has worked as a Registered Dietitian in the United States and in Canada related to diabetes work. She currently works at the University of Alberta Hospital in Mackay Edmonton clinic and the Outpatient Adult Diabetes Clinic and has been there for the past six years. She does a lot of work related to diabetes including nutrition assessments and counselling, teaching classes insulin pump therapy and providing education to individuals and their families, first year medical students, and as a preceptor for dietetic interns students at the University of Alberta. Felicity's favorite part of being a dietician is being able to help people help themselves and see the positive results of their health. So with that I'll turn it over to Felicity.
[00:01:22] Type 2 diabetes and carbohydrate counting. How to count carbohydrate using measuring cups and label reading and how to plan balanced meals. And before we start I'd like to just explain what diabetes is so that we're all on the same page. Diabetes is a condition that occurs when the body cannot use glucose. Diabetes is also associated with various long term complications involving damages due to complications. Diabetes is managed when food, activity and medication are in balance. Blood Glucose reflects this balance. And for today's presentation I'm going to be focusing on the food. Carbohydrate counting will first help you control your blood glucose and this will improve your A1C and often lowers insulin requirements and carbohydrate counting will also help you get better and also help you have a better quality of life. But what do you need to know to do carbohydrate counting? You need to know which foods contain carbohydrates and how to count the amount of carbohydrates in the food you eat. There are three main nutrients in our food that give us calories. Fat, protein and carbohydrates. These are the three nutrients in Canada's Food Guide. In fact, fat does not turn into blood glucose and it will not raise your blood glucose. However fat increases body weight. Small amount of fat, the healthy fats are acceptable and some example of some healthy fats include vegetable oil, nuts and seeds, avocados, olives, fish oil such as omega 3 oil, and then for details you can see eating well with Canada's Food Guide. It can give you more information on healthy fats and the portion sizes. Some less healthy fats include butter, lard, hard margarines, animal fat, animal skin, baked goods, deep fried foods. Healthy portions of protein does not raise your blood glucose. It's important to include healthy protein portions in your meals. At breakfast, at lunch and at supper. But if protein is eaten in large amounts it can turn into glucose in your blood several hours after eating it, about four to five hours later. And large amounts of protein is equal to over seven ounces of cooked meat. So if you go out to a steak house then you have an eight ounce steak or 10 ounce steak. That's excessive protein because it's a large amount of protein and will affect your sugars later. Protein does contain calories. So you need to watch your portion size because too much protein will also lead to increased body weight. Some healthy protein foods include extra lean or lean meat, poultry, fish, eggs, tofu, nuts and seeds, legumes such as lentils, maybe kidney and pinto beans, low fat cheese, low fat cottage cheese. And some less healthy protein foods include regular beef, baloney, Wiener sausages, regular cheese, bacon, regular luncheon meats, fried foods and breaded meats. It's just important to remember that a healthy portion of protein does not raise your blood glucose. Nutrient number three: Carbohydrates. Carbohydrates are very important for the body. It also contains calories. Carbohydrates turn into glucose in your blood and therefore will raise your blood glucose. But remember that it is a healthy food. Foods high in carbohydrates raise blood glucose even higher and more quickly than foods that are higher in protein and fat. Carbohydrates include grains, starches, foods containing flours, vegetables, fruit, yogurt, milk, and the milk alternatives, sweet foods, and snacks. Let's look at the list of foods that will increase your blood glucose. You need to know your portions so you can see your sweet vegetables, all, will increase your blood glucose. They are healthy foods so your beets, carrots, corn, parsnips, peas, rutabaga, tomato juice, tomatoes, but only if you eat up to two cups of tomatoes. If you're eating less than two cups in one sitting you don't have to worry about it. It's not going to increase your blood sugar. But if you eat two cups or more it will have an effect on your blood sugar. Squash. So those are your starchy vegetables. You've got your fruits. All your fruits contain carbohydrates. That will increase your blood glucose so apples, apricots, bananas, blueberries, canned fruit. Even if it's an unsweetened juice or if it's in water, cherries, dried fruit, fruit juices even if it says 100 percent pure juice no sugar added it still contains carbohydrates because it comes from a fruit. You've got grapes, grapefruit, kiwi, mango, melon, nectarine, oranges, peaches, pears, pineapples, plums, prunes, raspberries, and strawberries. The list goes on. Just remember that your sweet vegetable, starchy vegetable and your fruit all contain carbohydrates that will increase your blood glucose. Grains. You've got your cookies and your bread and your cold cereals, hot cereals, muffins, bagels pancakes, pasta, popcorn, potatoes, sweet potatoes, rice crackers and tortilla. All those foods contain grains and contain flour. So they do contain carbohydrates. As well your legumes are both carbohydrates and protein and they're very healthy. So you've got your healthy hearty soups also containing carbohydrates. Milk and milk alternatives also contain carbohydrates, which come from lactose, and they will increase your blood glucose. Whether it's skim milk 1 percent or 2 percent they all contain carbohydrates. Chocolate milk, evaporated milk, your puddings, and soy beverages, your flavored almond beverages, your yogurt. And then you've got your sweet foods and snacks your honey and jam also contain carbohydrates and will increase your blood glucose even though honey is a natural food. Now we've got the foods that will not increase your blood sugar. Let's go back one slide. I've got foods that will not increase your blood glucose. We call these your free foods. The free vegetables. These contain very small amount of carbohydrates that will not increase your sugar. And these vegetables are high in water and fiber and they will fill you up when you are hungry. So we've got some vegetables such as artichokes, asparagus, bamboos, green and yellow beans, bok choy, broccoli, brussel sprouts, cabbage, cauliflower, celery, chard and then we've got our cucumbers, eggplant, garlic, kale, leeks, lettuce, mushrooms and then onions and the list goes on with your peppers. And tomatoes basically is a free food unless you eat two cups of tomatoes. Other free foods include your beverages such as the sugar free, crystal drinks, clear tea, clear coffee, sugar free soft drinks, your water. And then you've got your seasonings, spices, soy sauce, and then other spices that you use. You also have condiments if you stick to those portions that are listed such as your barbecue sauce, up to one tablespoon. It will not increase your blood sugar. You've got the no added sugar jelly, if you're having one tablespoon it's not going to increase your blood sugars. Your ketchup, if you have one tablespoon of ketchup it will not increase your blood sugar. And then the list goes on. You also have your salsa. But it's important for you to remember that these free foods are there and you do not have to worry as much about the free vegetables or their portion size.
[00:10:11] You have to remember as well that carbohydrates do affect your blood sugars. But it's important to know that not all carbohydrates affect blood glucose in the same way. The quality of carbohydrate food choice affects absorption. So you want to limit the simple sugar carbohydrates, you want to limit the process carbohydrates and then refined grain products. Please choose whole grains products more often because they have more fiber and the more fiber the better. You want to eat more fiber and fiber does not raise your blood glucose. Fiber, especially soluble fiber in food helps control blood glucose. Some examples of soluble fiber include your legumes such as dried beans and lentils, barley or bran, oatmeal, apples, pears, strawberries, and the list goes on. And these are so important because they help control your blood glucose. Insoluble fibre helps prevent constipation and some types of cancer. And some examples of insoluble fiber include wheat bran, whole grains and cereals, fruit and vegetables. And many foods contain both soluble and insoluble fiber and the higher fiber diet combined with lower fat diet can improve your blood glucose and reduce cholesterol levels. Recommended to aim for 25 to 50 grams of fiber per day. Because fiber has many benefits. It can control your blood glucose, it manages your blood pressure, it reduces blood cholesterol, it increases the feeling of being full so that way you won't overeat, and also controls weight, regulates bowel movement, and the list goes on. Eat more fiber because it will help you. And now we want to look at the blood glucose after meals. When you eat, your carbohydrates will raise your blood glucose and the more carbohydrate you eat the higher your blood glucose rises after eating and you may need insulin or other diabetes medication to help the blood glucose come back down to normal ranges. So as you can see with this graph, I've got the blood glucose on the left and then you see breakfast lunch supper and if you're having regular meals and regular snacks your sugars don't spike as high. But if someone's not having regular meals, it can lead to your blood sugars fluctuating. For example if someone woke up late and they had a granola bar for breakfast and tea, were really busy, no snack, and then they were hungry at lunch over-ate because they were super famished, their sugar spiked really high. And then because they were busy, no snack, what happens is their sugar is going to spike even higher because by the time they get to eat at suppertime, they're really hungry and they over-eat. And then this food amount, because it's more carbohydrate, and the blood sugar is going to be higher after eating. What can we do to help prevent the rise in your blood glucose after you eat? Well, you need to eat three balanced meals per day at regular times and this will be discussed when we do meal planning in a few minutes. You also need to space your meal four to six hours apart, no more than six hours. And healthy snacks can be included especially if meals are more than six hours apart. Healthy snack is needed because it can minimize fluctuation of blood glucose, it will help regulate hunger, and will help with you with portion control. And also the effect of irregular meals is that your sugars will spike after eating when you do eat later on.
[00:14:30] Okay so now let's move on to your blood glucose targets. I've got the general recommendations for adults and teens over 13 years. Before meals your blood sugar should be between four and seven and two hours after meals your sugar should be between five and 10. If you have a meal and you're wondering how that food is affecting your blood glucose just check your sugars two hours after you've eaten that meal and then you will see the effect on your blood glucose. Is it within target, which is between five and 10? If you are unsure of your blood glucose targets, talk to your diabetes health care provider.
[00:15:09] Carbohydrate counting. Carbohydrate counting is really important and the carbohydrate you eat can be broken into choices. And the choices are like a portion. Each carbohydrate choice contains about 15 grams of carbohydrates. And foods that increase your blood glucose if we go back you can see this slide. We saw it previously but here we're looking at it focusing on the portion size. One carbohydrate choice contains about 15 grams of carbohydrates. And when you look at this list what is one carbohydrate choice. It's the portion size that's indicated. So if you have a cup of beef that's one portion which is equal to one carbohydrate choice. Which is equal to 15 grams of carbohydrates. If you have two cups of tomatoes that's one carbohydrate choice but if you're eating less just a few slices of tomatoes on your sandwich that's a freebie does not count and will not affect your sugar. Look at your raspberries and strawberries. Two cups of raspberries and strawberries is equal to one portion one carbohydrate choice or 15 grams of carbohydrates when you move over to your grapes about half a cup of grapes, which is about 15 grapes, is equal to one carbohydrate choice which is the same as 15 grams of carbohydrates. So you can see all these sweet vegetables and your fruits. They come in different portions and those portions that are listed is equal to one carbohydrate choice. If you move down here to your starches. If you look at your bread. One slice of bread is one portion, one carbohydrate choice which is the same as 15 grams of carbohydrates which means if you have two slices of bread that's two carbohydrate choices or 30 grams of carbohydrates. If you look at your bagel this is a regular bagel. One quarter of a regular bagel is the same as one slice of bread is equal to one carb choice. So if you eat one regular entire bagel it's equal to four slices of bread, which is four carbohydrate choices. Which will equal to eventually 60 grams of carbohydrates. Now if you move down here to your milk and alternatives, approximately all are equal to one carbohydrate choice. Which is equal to again 15 grams of carbohydrates. Same thing if you have one tablespoon of jam or jelly or one tablespoon of honey. It's the same as one slice of bread. Which is equal to one carbohydrate choice. And that's important for you to use this hand out as a guide when you're wondering how much does this food contain in terms of the amount of carbohydrates.
[00:18:23] And then the next slide will show us foods that do not increase your blood glucose. So this is the carbohydrate that will not increase your blood glucose. You can see here that there is no portions listed on this side because there is very very little. So if you like broccoli, sure you can have as much broccoli as you want. And I want you to use these foods to fill you up when you are hungry. You can see the other free foods beverages and seasonings down here. There is no portions on the side and we're just focusing on the carbohydrate amount. So your clear tea will not affect your blood sugar. If you have your condiments, we do have portion size on the side such as your ketchup. If you have up to one tablespoon of ketchup, it won't affect your blood sugar. But if you're having half a cup of it or a cup of ketchup that is more than is listed here. So it will affect your blood glucose. It's important for you to use these slides and this handout as a reference. Use It as a guide. One point I want to mention is this little symbol next to the food just means that the food choice may be high in salt so use it in moderation.
[00:19:43] Let's move on to the next slide and we're going to look at the label reading. So if you have a food that contains a label you can find the carbohydrate value using the nutrition label. If it doesn't have a label then you can go back to this list and then you look at these foods such as your fruits and some of the vegetables they don't have a label on it. So use this list as a guide. But if the food has a label on it please look at the label. So how to find carbohydrate values using the nutrition label. Amount of carbohydrates in food is listed on the nutrition facts table. And this is the nutrition facts table. Amount listed is for the serving size given. Here we have one muffin. Are you eating more or less or the same. Really what I'm wanting to know is are you eating half a muffin or are you eating one muffin or are you eating two muffins and you compare your serving size to figure out the amount of carbohydrates you're eating so your total carbohydrates in grams is listed first. This number includes starch, sugar and fiber. Starch is not listed separately. Fiber does not raise your blood glucose and therefore should be subtracted from the total carbohydrates. So you're one muffin contains 34 grams of carbohydrates. We're going to minus two grams of fiber because fiber will not increase your blood glucose and that total is going to be 32 grams of carbohydrates. So this is the 32 grams is the available carbohydrates that will affect your blood glucose. So just to review and make sure we're all on the same page. You need to remember the three things you need to look at when you look at your label. Here is your muffin. You need to look at the three things which is your serving size. Are you having one muffin half a muffin or two muffins or three muffins? And then you want to look at the carbohydrate amount. And we want to know the total grams of carbohydrates you minus the fiber. And then you get the available carbohydrates, which is 34 grams of carbohydrate minus two grams. this gives the available carbohydrate that will affect your blood glucose. So serving size, total carbohydrates minus fiber.
[00:22:36] Now you need to know the portion size when you're going to be having your meals in total. We based the recommendation and the recommended serving size off Canada's Food Guide and simply by using a measuring cup and also using your hands. So when you use the list that I've provided you can actually use a measuring cup and measure out your food to know ahead. Your hands are very handy. Two ways to estimate portions. So a small fist is about one cup. One cup of grains, cereal, pasta, potatoes and then a small palm minus your fingers is equal to three ounce servings of meat fish or poultry. And that's a healthy portion size for your protein with your meals. Two hands full is about equal to one to one and a half cup of vegetables and especially your free vegetables. Have as much as you want such as your salads. And then your thumb is equal an ounce of cheese and that's your portion size there and your thumb tip is equal to a teaspoon of fat. So if you choose to put some margarine on your bun or your toast that's a teaspoon of fat. So portion size basically is a fist of your grains and then your meat will be three ounces of meat, which is approximately your small palm of minus your fingers. And this is going to be very handy.
[00:24:18] Now if you go back to your list of the carbohydrate foods that will affect your blood glucose. If you're having a cup of rice you want to know how many carbohydrate choices is that or how many grams of carbohydrates. You can look here. Cooked rice one third of a cup is equal to one carbohydrate choice or 15 grams of carbohydrates. So if you have a cup of rice that's three carbohydrate choices or forty five grams of carbohydrates. When you look at your pasta, we know that half a cup of pasta, cooked pasta, is equal to one carbohydrate choice. So a cup of pasta, which is a small fist, is equal to two carbohydrate choices or 30 grams of carbohydrate. Now we want to know how much can we have at meals. But when you look at your free food you can have as much as you want. If you want to bring salad where you put your lettuce or a spinach and onions and mushrooms and tomatoes you don't have to worry about the portion size there. If you're having foods that increase your blood glucose, those carbohydrates, the general recommendation is for women: three to four carbohydrate choices per meal. So that's about equal to 45 to 60 grams of carbohydrates per meal at a breakfast, lunch or at supper. For a snack: 1 to 2 carbohydrates choice. For males, 4 to 5 carbohydrate choices per meal at breakfast lunch supper and then that's equal to 60 to seventy five grams of carbohydrates per meal. So you can choose whether you want to use choices. But if the food has label on it or if you're going to a restaurant and they have grams of carbohydrates, now you know what your meal should be approximately within these carbohydrate grams of 60 to 75 for men and then 45 to 60 for women. As you can see it's both for men and women. It's approximately the same amount. The key is consistency. If you're not sure you can always talk to your dietitian and they can provide more detail suggestions to meet your personal needs.
[00:27:00] Now balanced meals. You know your portions. Your plate should look like this: half of your plate should be your vegetables the free vegetables you can have as much as you want and simply fill your plate with these healthy foods. You can see I have a few carrots in there, your broccoli, free, your cauliflower, free. If you're having less than a cup of carrots it's free as well too. So half of the plate should be a vegetable. And here we have one quarter of your plate should be your protein. We do want your protein with breakfast, lunch and supper. And then one quarter of your plate should be your grains and starches and you can always include a glass of milk or yogurt. This is what a balanced meal looks like. You've got your vegetable your protein and then your grains and starches.
[00:28:01] And now we're going to have more specific examples. How to make a balanced meal at home when you're making breakfast. You're probably wondering how can I make a balanced meal and have my carbohydrates. You want to have at least a fruit, grain and the milk and protein. And this is going to provide balanced meals because you get all the vitamins that your body needs. We want to watch the portions. For example this individual they have one fruit. That's one carbohydrate choice. One slice of whole wheat bread or 1 cup of high fiber cereal. One choice. And then your milk or yogurt. One cup is one choice. So here we have three carbohydrate choices for this breakfast meal and their protein will not increase their blood glucose. So we're not going to account for it. And then of course you're fat, if it's the appropriate portion, is not going to affect your sugars. And then for snack you can have one to two carbohydrate choices. And this individual chose to have a fruit or they can choose to have a cup of yogurt. And then for lunch again a balanced meal includes fruit and vegetable. Pick the ones that you like. And then if they choose to have a sandwich two slices of bread is two carbohydrate choices which is the same as 30 grams of carbohydrates. And then when they have their yogurt or milk that's another choice. So here for lunch they have: one choice comes from the fruits. One cup of fruit vegetables does not count because it's free vegetables. Two slices of bread. It adds up to three. And then if they have their yogurt or milk it adds up to four carbohydrate choices which is the same as 60 grams of carbohydrates. Now if you move on to supper time. Exactly the same pattern. Fruit and Vegetable or you can just have a larger portion of your starchy vegetables. So if they choose to have half a cup of starchy vegetables such as half a cup of corn or half a cup of peas, that's equal to one carbohydrate choice. And then they're free vegetable, like a big salad, that will not count. If they choose to have a cup of brown rice or a cup of quinoa or pasta, that is also your carbohydrate choice there. If rice it's three carbohydrate choice if it's your pasta than it's two carbohydrate choice for one cup. And remember one cup is equal to a small fist. Here they have their protein. Three ounces of meat. That's about the palm of your hand minus your finger. And that will not increase your blood sugar. Beans, they account for both carbohydrates and protein. If you like beans and you choose to have chili for supper it's an excellent choice. And your beans and your chili will count as your carbohydrates. Evening snack of course, you can have one to two carbohydrate choices. A whole grain of toast, with peanut butter, or, a half a cup or a quarter cup of cottage cheese with a small fruit. And so you can see only the stuff that will increase your blood glucose is your starches which is your grain or your fruit. So that's the sample there. And then of course we're going to practice.
[00:31:45] Let's practice with Mrs. Snow. So Mrs. Snow here wakes up in the morning she checks her sugar and her sugars 5.3. She takes her diabetes medication and she chooses to have two toasts with peanut butter an apple and a cup of milk. How many carbohydrates choices for breakfast. If you look at the list that we had previously, you'll remember that one slice of bread is one carbohydrate choice or 15 grams of carbohydrates. So two slices of bread there gives us two carbohydrate choices which is the same as 30 grams of carbohydrates. For peanut butter, it's her protein, so doesn't count. And her apple is another carbohydrate choice. And her cup of milk is another carbohydrate choice. So how many carbohydrate choices is she having for breakfast? Four, which is the toast the apple and the milk. And if you want to know how many grams of carbohydrates at breakfast it's the four carbohydrate choices times 15. Gives us 60 grams of carbohydrates. And then two hours later she wanted to know how well her food or how her food was affecting her blood sugar so she checked it two hours later it was 7.9 And that's good. It's within target. She walked her dog for 30 minutes and ate a pair and a quarter cup of nuts. That pair is one carbohydrate choice. Her nuts, that's a protein. At lunch time, she decides to have a cup of hearty vegetable soup. And that one carbohydrate choice which is the same as 15 grams of carbohydrates. And then she had a turkey sandwich and the two slices of bread is what will count as carbohydrate. Her turkey will not count, her tomatoes and mayo will not count. And she chooses to have a cup of carrots and that will count. If she was only eating three baby carrots that would not count. But a cup of carrots is enough to be equal to a portion size. So how much carbohydrate choices is she having at lunchtime? We have one here, two from the bread and then a cup of carrots. So again four carbohydrate choices, which is equal to 60 grams of carbohydrates. Mrs. Snow wants to know why her blood glucose is elevated at supper. Well two hours after lunch she checked her blood glucose and it was 10.1, which is within the normal glucose target range. She chose to have a bagel for snack with cheese and with tea and a sweetener. Remember for snacks how many grams of carbohydrate or how many carbohydrate choices. We said it was 1 to 2 carb choices. Remember the bagel. A whole bagel is equal to four carbohydrate choices, which is the same as four slices of bread and that's too much for snack. So that is what made her sugars go high by supper time and you can see the bagel would be a good choice for breakfast because she can have three to four choices for a meal but it's too much for a snack. And that's why her sugar rose at supper time. She had three ounces of chicken. That's fine. The chicken will not affect your sugars. A cup of brown rice. A cup of rice is about three carbohydrate choices. If you look at your list which is the same as forty five grams of carbohydrates. She has one cup of broccoli and a cup of cauliflower. Those are free food. We're not counting it. A cup of green salad with low fat salad dressing. That's also free food. We don't count it. And then she included a cup of yogurt. How many carbohydrate choices does she have at this meal? Well we've got a cup of yogurt so there is approximately one and then we have a cup of rice. There's three right here. So three plus one gives for carbohydrate choices which is equal to 60 grams of carbohydrates.
[00:36:04] Now we need to make the connection by doing record keeping. Keeping record of food activity and medication and blood glucose may show how well diabetes is managed and how different foods affect blood glucose. It also shows what needs to be adjusted. Is it the food or insulin or other diabetes medications? Also it shows what behaviors to keep. So record keeping is important. And if you eat a meal and you're not sure how it affected your blood glucose, then you wanted to know, just check your sugars two hours after that meal and you will see if your sugars went high or they're within target. So if your sugars are high that means there's too much carbohydrates. If your sugars are low, there was not enough carbohydrates in that meal. In conclusion, carbohydrate counting is very important and it will help you improve your blood glucose. Please remember that healthy portions of protein and fat will not increase your blood glucose and fiber will not increase your blood glucose. So eat more fiber. Carbohydrates will increase your blood glucose. So you need to be careful of your portion size and you need to know your portion size. And please use the resources provided. And when you're using the nutrition labels to find carbohydrate values of food you need to remember that total carbohydrates minus fiber will give you available carbohydrates and then balanced meals include appropriate portions of carbohydrates, protein and fat. Just do your very best. And then if you're ever wondering or having questions just make sure you contact your diabetes health care team and they can help you more.