Type 1 Diabetes
Carbohydrate Counting and
Insulin Adjustment
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Patient Information
About this workbook
Remember
Welcome to this workbook.
Never exercise if your blood glucose is more than 14 mmol/l and you have
ketones.
Some of the topics in the workbook are addressed using a question and
answer technique and these sections try to cover the most frequently asked
questions. You will also see symbols at various points and these are
designed to stimulate discussion or to encourage you to think about the way
you manage your diabetes.
What do the symbols mean?
This symbol indicates something for
you to think about, or a question
Websites
www.bda.uk.com
www.coeliac.org.uk
www.splenda.co.uk
www.runsweet.com
www.diabetes.org.uk
www.canderel.co.uk
www.infantandtoddlerforum.org
For further information or advice please contact the Paediatric Dietitians at
Ashford and St Peter’s Hospital NHS Foundation Trust:
Tel:
01932 723937
E Mail:
[email protected]
[email protected]
This symbol represents frequently asked
questions
Further Information
This is your own personal and private booklet; no one will ask to look at it, so
you can keep it private or share it as you wish.
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We endeavour to provide an excellent service at all times, but should you have
any concerns please, in the first instance, raise these with the Matron, Senior
Nurse or Manager on duty. If they cannot resolve your concern, please contact
our Patient Advice and Liaison Service (PALS) on 01932 723553 or email
[email protected]. If you remain concerned, PALS can also advise upon how
to make a formal complaint.
Author: Dietetics
Department: Dietetics Department
Version: 3
Published: September 2012
Review: September 2014
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o If the exercise is more intense and lasting more than 30 minutes have
some extra carbohydrate as advised above.
o If the exercise is going to last for more than 45 minutes and is within 2
hours of eating, you can try reducing your insulin dose at that meal by
30-50% instead of eating additional carbohydrate.
o If the exercise is going to last more than 45 minutes but is 3 hours or
more after eating, you do not need to adjust your insulin dose but should
have some additional carbohydrate.
General points
Introduction
As you know more than anyone else, having diabetes is difficult. The more
information you can gather about your diabetes, the easier it is to work out
what your blood glucose readings mean and to adjust your insulin. During
this course we will discuss how food and insulin in particular affect the sugar
levels in your blood and we will give you extra information about how to use
these things to help you get your control as normal as possible.
What we would like to do is:
• Help you to more closely match your insulin to your food and lifestyle
• Help you to manage your diabetes better
• Share your experiences with others like you
o Try not to exercise during the time your insulin action is at is peak.
o Don’t inject insulin into the muscle that is going to be working the
hardest.
It would be good to start by thinking about a couple of
things first:
o If you have a hypo after exercise, your stores of glucose will be lower
and therefore we recommend that you have 1 and a half times your
usual hypo treatment, such as 5 dextrose tablets of 1½ mini cans of
Coke.
What are your expectations of carbohydrate counting?
The things we will be going on to talk about are based on something called
DAFNE (Dose Adjustment For Normal Eating) which grown ups use a lot if
they have diabetes. We have changed a few things so that you too can now
start to use this as a way of managing your diabetes.
Some of the ideas also come from people who use insulin pumps because
you need to be able to count carbohydrate if you want to use one.
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So, these things that we are going to talk about are not really new, but we
are only just starting to use them for children.
Do remember that this way of doing things is not particularly easy.
Sometimes people find it too troublesome and difficult so they decide to stop
using it or maybe will only use parts of it. Don’t feel bad if this happens to
you. You can always go back to using it fully later on if you want to.
o Young children (up to 7 years old) don’t sweat and so don’t need
commercial isotonic sports drinks as they contain too much sodium. A
good home made version is simply normal (full sugar) squash.
o After exercise, remember you need to replenish your stores. Glycogen
will have been used and so you need to eat a good carbohydrate rich
snack within 15 minutes of exercising (you will need insulin with this) and
follow this up with a good carbohydrate portion at your next meal.
General points
o Check your blood glucose levels frequently as this is your only real way
of knowing how exercise affects you as an individual.
o Keep hydrated by drinking water alongside your isotonic sports drink and
also at frequent intervals through the sport and afterwards too.
Insulin and exercise
It is not possible to give precise guidelines for adjusting your insulin dose due
to each of us responding differently to exercise.
The only way to be more accurate is to measure your blood glucose before,
during and after your exercise so that you can see how exercise affects you.
To minimise the risk of exercise related hypos you can try the following:
o If the exercise is low intensity such as a walk or playing at school you
don’t need to have additional carbohydrate or adjust your insulin dose.
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o Your normal diet should contain enough carbohydrate for normal daily
activity such as playing at school or going for a walk.
Food and Exercise
These rules apply to intense sports and exercise only:
o Have a carbohydrate based meal such as pasta 2 hours before
exercising for optimum performance.
o Additional carbohydrate prior to exercise is only needed if you are
exercising for more than 30 minutes.
o A good rule of thumb for how much carbohydrate you need for exercise
is 1gram of carbohydrate per kilo of body weight per hour of exercise, up
to a maximum of 30g.
o Don’t use chocolate for carbohydrate! Chocolate contains too much fat
and so it is digested far too slowly for the muscles to actually use. Avoid
low GI slow release carbohydrates. A much better carbohydrate is an
isotonic sports drink.
Food and Carbohydrate Counting
Food is made up of 3 nutrients:
• Protein
• Fat
• Carbohydrate
The main type of nutrient in food that affects your blood glucose level is
called carbohydrate. Most foods contain a mixture of all 3 nutrients, but foods
which contain mainly protein and / or fat will have a minimal effect on your
blood glucose levels.
Carbohydrates are found in mainly starchy and sugary foods. All
carbohydrates are digested into glucose and appear in your bloodstream
between 10 minutes and 2 hours after eating.
Carbohydrate counting is a system of assessing the quantity of carbohydrate
in each meal or snack and injecting the right amount of insulin to match the
food you have eaten.
Why do people use carbohydrate counting?
Food
15g Carbohydrate
30g Carbohydrate
Sports drinks
Jelly babies
Fruit juice
Full sugar
squash
Jaffa Cakes
250ml
20g
125ml + 125ml water
500ml
40g
250ml + 250ml water
125ml + 500ml water
2
4
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Carbohydrate counting gives you more choice and flexibility in both the type
of food you eat and in the timings of your meals. It can also help you
maintain your blood glucose levels closer to normal levels.
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Exercise management
Which foods contain carbohydrate?
What is aerobic exercise?
Aerobic exercise is when muscles are used at a steady
pace over a long period of time in a rhythmic way. During
aerobic exercise plenty of oxygen is available to the
muscles, allowing them to use glucose to provide energy.
Examples of aerobic exercise include running, cycling,
swimming, playing basketball, roller-skating and dancing.
Many foods contain a mixture of all 3 nutrients and the main sources are
shown in the table below.
Nutrient
Examples of foods
Protein
Meat, poultry, fish, eggs, nuts, cheese
Fat
Butter, oil, margarine, cream
Carbohydrate
Starchy foods, sugary foods, fruit, milk
Protein foods alone will have little effect on your blood glucose levels, but
some protein foods have carbohydrate added during processing. This may
be flour or a cereal; examples of these are sausages, fish fingers, chicken
nuggets or pastry goods such as quiches, pies and sausage rolls. You can
check the food label for more information. We will cover this later on.
Fat has little effect on glucose levels after eating, but a large amount of fat
can slow down the digestion of a meal and make your blood glucose levels
rise more slowly. Examples of high fat foods which have this effect are fish
and chips, burger and fries, Chinese or Indian meals from a takeaway or
restaurant.
You are more likely to have lower blood sugars after
aerobic exercise as glucose has been used for energy.
What is anaerobic exercise?
Anaerobic exercise is short lasting high intensity activity. There is no oxygen
available to the muscles in anaerobic exercise so glucose cannot be used for
energy. Examples of anaerobic exercise include sprinting and weight lifting.
Often certain positions in team sports such as football can be anaerobic as
short sprints occur infrequently.
You are more likely to have high blood sugars after anaerobic exercise.
Why can hypo’s be more difficult to detect during exercise?
Many of the recognised symptoms of a hypo are often experienced during
normal exercise, for instance feeling hot and sweaty and noticing an
increased heart rate. Checking your blood glucose will help you to make the
necessary adjustments. A previous hypo within the last 24 hours may
increase your risk of further hypo’s and this risk is further increased by
exercise.
Activity
Carbohydrate foods will have the greatest effect on your blood glucose levels
after eating. They include all starchy and sugary foods.
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o Are you truly exercising or just being active? Often PE lessons at school
are not intense enough to count as exercise.
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Snacks
If your snack contains less than 20grams of carbohydrate you may not need
any extra insulin. However if want to have a larger snack you may need to
give yourself some insulin.
Let’s practice:
My insulin to carbohydrate ratio is……………..
I want to eat a sandwich after school
How much carbohydrate does it contain?.............................
Starchy foods
All starchy foods contain carbohydrate. Examples of these include:
• rice
• pasta
• noodles
• bread
• breakfast cereals
• grains such as cous-cous and bulgar wheat
• flour and foods made from flour such as pastry, pizza bases, sauces
• plain biscuits, crackers
• starchy vegetables such as potatoes, yam, sweet potato, lentils,
beans and dried peas
Will I need to give extra insulin?.............................
If yes, how much will I need to give?..……………………
Before you give yourself insulin consider the
answers to the following questions as these may
alter your insulin dose:
o Is my blood glucose within the target range or do I need to give myself a
correction dose?
o Have I eaten any carbohydrate within the last two hours as this may be
why my blood glucose is a bit high?
o Have I injected any insulin in the last two hours? Remember fast acting
insulin may still be in your body for up to 6 hours after injecting.
o Am I planning to do any exercise?
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Sugary foods
There are 3 main categories of sugary foods and all will raise blood glucose
levels after eating:
Any food made with ordinary sugar called sucrose contains carbohydrate.
These foods include cakes:
• biscuits
• chocolate
• sweets
• jam, honey, marmalade
• puddings, desserts
• squashes, fizzy drinks
Fruit contains natural sugar called fructose which is also a form of
carbohydrate:
• fresh fruit
• dried fruit
• frozen fruit
• fruit juices and smoothies
Blood Glucose Monitoring
Measuring blood Glucose is a way of checking your diabetes. By using the
blood test results you can learn how different things can affect you, such as
the food you eat, the exercise you take, or illness or if you are worried or
upset about something.
Blood Glucose monitoring will help you see what’s working and what is not
working. Try not to worry about them too much. Instead, try to see them as
information that you can use to help you change things if you need to.
Correction Doses
Your Paediatric Diabetes Consultant or Diabetes Specialist Nurse will have
given you a correction dose of insulin that you need to give if your blood
sugars are not within the normal range. You still need to apply this to your
total insulin that you have calculated you need to give.
Milk and milk products contain natural sugar called lactose. All milk contains
carbohydrate including:
• full cream, semi skimmed and skimmed milk
• long life, pasteurised, homogenised
• custard
• ice cream
• yoghurt and fromage frais
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Applying the insulin to carbohydrate ratio to food
Go back to page 10/11 to where you calculated the amount of carbohydrate
in rice, breakfast cereal and the pepperoni pizza.
How do I work out the carbohydrate content of my
food?
There are different ways to do this and we will learn
more and practice each of these in turn.
Let’s practice!
200g cooked rice contains ……………………. g carbohydrate
Weighing food
If I eat this I need to bolus ………………………... units insulin
My bowl of breakfast cereal weighs …………………………. g
This contains……………………….................... g carbohydrate
If I eat this I need to bolus…………………………. units insulin
You can weigh your food using digital kitchen scales
and work out the amount of carbohydrate in your portion by using food charts
or food tables. This system is useful for foods like breakfast cereals,
potatoes, pasta and rice as portion sizes can vary quite a lot between
different people. You need to weigh food in grams (g) rather than ounces (oz)
as most food tables will give you the amount of carbohydrate per 100g. You
can work out the amount of carbohydrate by doing the following:
•
•
The whole pepperoni pizza contained………… g carbohydrate
If I eat this I need to bolus …………………………..units insulin
•
•
weigh the food in grams and note the weight
Look up the amount of carbohydrate per 100g in your food table for
the food you are eating and make a note of it
Divide the amount of food you have weighed by 100
Multiply the result by the amount of carbohydrate per 100g from the
food table
Or you can use the following formula:
Weight of food in grams x amount of carbohydrate per 100g
100
Let’s practice!
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Take out your food tables and scales, and use the rice and breakfast cereal
to complete the following exercise:
Let’s practice!
Have a go at calculating your own insulin to carbohydrate ratio using the 500
rule:
A portion of cooked rice weighs 200g
My total daily dose is……………………………..
Use your food tables to find out how much carbohydrate it contains per 100g
Divide 500 by this
……………………………
My insulin to carbohydrate ratio is 1 unit of insulin for every
How much carbohydrate is there in the 200g portion?
………………………….…………….. grams of carbohydrate
……………………………
A portion of your usual breakfast cereal weighs:
A second and more accurate way to calculate your insulin to carbohydrate
ratio is to keep a food diary (see separate food diary).
…………………………….
Use the food tables to find out how much carbohydrate it contains per 100g
……………………………
The 500 rule is a good starting point but you may want to use both methods
and take the mid point for a more accurate ratio.
How much carbohydrate is there in your portion?
…………………………..
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The way you can check to see if your meal insulin dose is right for you is to
see if your blood glucose is between 4 and 9 mmol/l l 2 hours after you have
eaten. If it is higher than this you may need more insulin with your food.
Calculating your insulin to carbohydrate ratio
The amount of insulin you need with food is called your ‘insulin to
carbohydrate ratio’. This ratio is different for each person.
There are two ways of calculating this ratio:
One way is to use the 500 rule to estimate how many grams of carbohydrate
one unit of insulin will cover.
To calculate this you will need to add up your total daily insulin dose and
divide it into 500.
For example:
Total daily dose
20 units
50 units
Calculation
500 / 20
500 / 50
Insulin to carbohydrate ratio
25
10
If your total daily dose varies a lot you will need to look back over the last 5 to
7 days and add them together to take an average. The average number is
what you divide into 500.
Remember you will need to recalculate your insulin to carbohydrate ratio
every time your total daily dose changes significantly. If the new insulin to
carbohydrate ratio is very different you may feel happier to make the change
in stages rather than all at once.
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Food labels
Many food manufacturers now supply nutritional information on the label
about the carbohydrate content of that food. Remember that you have to
count the total carbohydrate and not just the sugars.
The information can be shown as either per 100g or per portion. If you use
the value per 100g then you will need to know the weight of the portion you
are eating and you can use the formula above to work out the carbohydrate
content. You may find the information per portion more useful, but remember
that your portion size may not match that recommended by the manufacturer.
Let’s practice!
Pepperoni Pizza 300g
Per 100g
275kcal
25.3g
3.4g
12.4g
Energy
Carbohydrate
(of which sugars)
Fat
Per 150g serving
412kcal
38g
5.1g
18.6g
This is an example of a label with nutritional information for a pepperoni
pizza. It gives you the information both per 100g and for a 150g serving
(which is half the pizza).
If you ate the whole pizza how much carbohydrate
would you have eaten?
…………………………………..
.
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Helpful information
Keeping a record
Once you have weighed your usual portion sizes and calculated how much
carbohydrate each food contains, it may be worth keeping this information in
an index file or A-Z index book so that you can refer to the information each
time without having to re-weigh foods. However as you grow and your
appetite changes your portion size may vary, so it’s worth double checking
that your figures are still up to date every now and again.
Insulin Dose Adjustment
The background insulin is usually injected once a day at bedtime and is
called:
•
•
Eating out
Can you remember what your background insulin is
called?
Many people find it a challenge to try and calculate the amount of
carbohydrate in foods and meals eaten away from home. As you become
more practiced at working out the carbohydrate content of the foods you
normally eat, you will find it easier to estimate just by looking at how much
carbohydrate is in the foods order.
Snacks
Carbohydrate counting means you can decide to have snacks based on your
personal choice. If your snack contains more than 20g carbohydrate you
may need to take extra insulin with it, or if you don’t want to have an extra
injection you may decide to wait until the next meal.
You can have as much carbohydrate free food as you wish without the need
for an extra injection as this won’t affect your blood glucose levels. Some
examples include:
• Lean meat e.g. ham, turkey, beef
• Fish e.g. tuna, mackerel, smoked salmon, prawns
• Eggs
• Hard cheeses e.g. cheddar, Cheshire, edam
• Vegetables e.g. carrot sticks, celery, tomato, cucumber
LANTUS (also called glargine)
or
LEVEMIR (also called Detemir)
……………………………………………………
The way you would check to see if your background insulin dose is right for
you is to see if your blood glucose is between 4 and 9 mmol/l at breakfast
time. If it is consistently higher or lower than this it may need adjusting.
The insulin usually injected with each of your meals is very fast acting and is
called:
•
•
NOVORAPID
or
HUMALOG LISPRO
What is your fast acting insulin called?
……………………………………………………
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