Notes:
1. The groups of people for whom these calorie ranges are appropriate generalizations.
2. The total grams of carbohydrate and servings of carbohydrate are from grains, beans, and starchy vegetables; fruits; and milk. Nonstarchy vegetables are not counted in the amount for carbohydrate servings, but are counted in the total grams of carbohydrate.
3. Based on fat-free milk (12 grams of carbohydrate and 8 grams of protein per 8 ounces). Children between 9 and 18 years old need 1300 milligrams of calcium per day. They should get at least three servings per day of milk. Adults from 19 to 50 need 1000 milligrams of calcium per day. This can be met with two servings of milk a day, plus another serving of a high-calcium food. Women over 51 years of age need 1200 milligrams of calcium per day. If milk or another excellent source of dairy is not regularly consumed, suggest the use of a calcium supplement to achieve the daily calcium goal. Then suggest adding another 24 grams of carbohydrate from either grains, beans, and starchy vegetables or fruit.
4. Calculated based on lean meat figures (7 grams of protein and 3 grams of fat per ounce). Use more or fewer grams or servings of fat based on the type of meats you tend to eat.
5. The calculation for the grams of fat is derived from the fat in meats plus the fat in the fat servings.
6. The servings of fat assume that each serving of fat provides 5 grams of fat.
Know how much carbohydrate to eat at meals and snacks
The number of meals and snacks a person eats should be based on two factors: current food habits and daily schedule. Understanding a person’s food habits and general daily schedule casts light on blood glucose results and control. Find out if the person is a three-meal-a-day eater, a person who finds it helpful to snack between meals, or a three-meal-a day eater and nighttime snacker. Learn about how and why a person divides his or her food between the number of meals and snacks he or she eats each day. Perhaps the person barely eats breakfast and eats a large evening meal. This might be why blood glucose levels after the evening meal are higher than at other times of the day. If the person eats snacks, find out why.
In addition, review the types and doses of blood glucose—lowering medications he or she has been prescribed. Overlay this information with their food intake and daily schedule. Then think about how well this routine works for them or whether a change in his or her medication and/or medication schedule may improve glycemic control. Keep in mind that it is easier for someone to change a medication or medication regimen than to change lifelong food habits.
After exploring and considering the above factors, divide the total amount of carbohydrate into meals and possibly one or more snacks. Strive for a balance of carbohydrate throughout the day and a similar amount of carbohydrate at meals and snacks from day to day. However, keep the person’s food habits in mind. Recognize that the average American eats a light breakfast, slightly heavier lunch, and the biggest meal at the evening meal.
Note that an eating plan for people with diabetes should no longer automatically include snacks. The rationale in years past for including snacks was to prevent hypoglycemia, a common risk from the then limited array of oral blood glucose—lowering medications and insulins (Polonsky and Jackson 2004). If hypoglycemia is occurring regularly, work with the person to determine the common reasons for their hypoglycemia and develop solutions that involve changes or timing adjustments with blood glucose—lowering medications and/or food intake. Include or eliminate snacks with the goal of achieving a balance between food habits and hypoglycemia prevention (if they take a medication that can cause hypoglycemia). If someone doesn’t want to include snacks and is not on blood glucose—lowering medication that can cause hypoglycemia, then snacks are unnecessary. If a person doesn’t want to include snacks and is on a multiple daily injection (MDI) insulin regimen or a continuous subcutaneous insulin infusion (CSII) pump, then snacks are unnecessary. An exception comes with young children. If a child has a small appetite at meals or difficult-to-control nighttime hypoglycemia, then snacks (generally three a day) are probably necessary to meet nutrition needs.
Table 3-2 provides a sample handout to help people learn how much carbohydrate to eat, how to divide the carbohydrate into meals and snacks, and space to work out or provide two sample meals.
Define a serving of a variety of common foods
People need to have a sense of how much food represents one, two, or three or more servings of a food that contains carbohydrate. They need to be able to translate the amount of carbohydrate (in either grams or servings) they should eat into real amounts of food. In the language of diabetes exchanges/choices, one serving of a starch, fruit, or milk serving equals about 15 grams of carbohydrate and one serving of nonstarchy vegetables equals about 5 grams of carbohydrate (Pastors, Arnold, et al. 2003). Table 3-3 provides a chart with the average macronutrients per serving in major food groups (Pastors, Arnold, et al. 2003).
The average amounts of carbohydrate in Table 3-3 can be used to teach generalities about the grams of carbohydrate per food group without mentioning the word “exchanges” or “choices.” Recognize that as the exchange/choice system is used less frequently to educate people with diabetes (particularly as more educators use carbohydrate counting), fewer people will be familiar with the exchange/choice system. Also recognize that there are different definitions of “servings.” Consider the definitions used herein as well as the definitions on the Nutrition Facts panels of foods set by the U.S. FDA. Table 3-4 provides examples of how these can be similar or different.
Even as counting grams of carbohydrate grows in popularity, many educators prefer to teach servings of carbohydrate. There is rationale for teaching one or the other or both. Some educators believe that if someone is familiar with the exchange/choice system and/or the fact that 15 grams of carbohydrate is a serving or one carbohydrate choice, then this knowledge should be used. The downside of only teaching servings (or choices) is that people have no base for translating the Nutrition Facts of food labels or other resources that only provide grams of carbohydrate.
Another downside of teaching exchanges/choices is that it introduces yet another term to a person’s carbohydrate counting lexicon. Some educators believe that teaching people to count grams of carbohydrate is more precise and makes it easier to use the variety of carbohydrate counting resources available. For people learning and using Basic Carbohydrate Counting, providing both a count of carbohydrate grams as well as servings (total and per meal) may be most helpful, as shown in Table 3-2. People who progress to using Advanced Carbohydrate Counting should be trained use the more precise practice of counting grams of carbohydrate. Averaging based on servings will not match medication as precisely.
Know how to plan meals
Converting the recommended servings and grams of carbohydrate into palatable meals is often the most challenging aspect of meal planning for many people with diabetes. People need to have a sense of what and how much they should eat at their meals to gain confidence that this is a plan they can follow. Use a form, such as the one in Table 3-2, to work out two sample meals. In a group setting, this is a form that people can complete and review with an educator. In a one-on-one setting, this is a form that can be completed together. Various teaching tools, such as those in the list on page 13 in chapter 2, can