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Now you understand the concepts from level 1, Getting Started. You have a better idea of the foods that contain carbohydrate and how to count carbohydrate using portion sizes, food labels, and carbohydrate resource books.
Level 1 encouraged you
In level 2, you will develop your record-keeping skills and learn to identify patterns in your blood glucose levels that are related to the food you eat, any diabetes medications you use, and the physical activity you do. Finding these patterns, interpreting them, and taking action is called pattern management. The goal of level 2 is for you to have increased flexibility in your lifestyle, as well as improved Bg control. As your carbohydrate counting skills improve, you will find a greater variety of foods to fit your meal plan. Your health care team will help you determine your target BG range. For example , your premeal BG target may be 70-50. If you check your post meal BG, you may also have a postmeal BG target zone. If you take insulin, you will begin to learn how to make adjustments in insulin based on larger or smaller than usual amounts of carbohydrate foods. Once you have mastered Level 2, you may choose to progress to Level 3. Level 3 offers even greater flexibility and will help you fine tune your diabetes management. Write it down Ideally, careful record keeping should include at least 7 days of recording:
Many things can affect your BG level. If you record the most important ones, you'll begin to see how your body works and what your BG level is going to do. This information helps you and your health care team identify your BG patterns. Pattern management helps you learn how to balance your food, medication, and exercise wherever you are. Be Consistent Weighing and Measuring Food for Carbohydrate Counting Practice Exercises To weight (oz): bread, roll, bagel, various fruits, crackers, baked potato. To measure (measuring cup): mashed potato, popcorn, cereal, plain pasta, rice, vegetables (raw or cooked), fruit juice.
Combination (mixed ) foods are more complex to figure portions and carbohydrate. If not adjust the carbohydrate grams for the portion in the book to your portions. Example: Au Gratin Potatoes Carbohydrate reference book says: Your portion was: 1 cup When a reference book or food label is not available, or the information does not seem to match the food you've chosen, here's how you can figure carbohydrate. Start by separating the ingredients of the mixed foods. Then weigh or measure each one and calculate the grams of carbohydrate in each. Next, add up the grams of carbohydrate in each food item to get the total grams of carbohydrate in the combination food. Using the following example of beef stew, look up the carbohydrate grams and figure the total for one serving.
Practice will help you develop your skills until you can estimate the carbohydrate levels of mixed foods accurately. Choose one of your favorite combination foods and take it apart to figure carbohydrate, using the method above.
Don't Give Up!!! Food Labels and Carbohydrate Counting If you eat the same serving size as listed on the label, you know the total grams of carbohydrate that you're eating. Be sure you are looking at the correct line on the label. The gram weight of food is not the same as grams of carbohydrate. Notice that the grams of sugar are on the nutrition factspanel and are part of the total grams of carbohydrate. In fact, the carbohydrate in fiber and sugars as well as other carbohydrate is included in the total grams of carbohydrate. Let's review: One carbohydrate choice = 15g of carbohydrate
How many grams of carbohydrate are in a 1/2 cup of apple juice? To figure total number of carbohydrate choices, divide the grams by 15. Eating out A practice session with the dietitian might include obtaining actual foods from a restaurant, taking the food apart and weighing or measuring the food items, and deciding how much carbohydrate is in the meal. This is a useful exercise if you eat out often. Fast foods. If printed material is not available, you can use a standard reference book on carbohydrate values of foods and write down the information for future use. The example below shows how to figure the grams of carbohydrate in a pizza meal, using information from a fast foods reference book.
Other factors to consider Fat. A meal that's high in fat can slow down the time your stomach takes to empty. This can delay the after-meal rise in your Bg levels. This means for example, that if your evening meal consists of mainly fried foods, your bedtime blood glucose may be higher than usual. The BG rise that usually occurs soon after dinner was slowed by the fatty foods. You may be following a low-fat meal plan with an occasional high fat meal, such as a bacon cheeseburger with french fries. If you take insulin, your health care team will show you how to make adjustments in the dose and/or timing of your insulin injection for that high-fat meal. Protein. The protein in the foods that you eat has little effect on your BG. Your diabetes medications have most likely been adjusted for your usual amount of protein. When you eat quite a bit more protein than usual at one meal, you usually get much more fat as well. This protein and fat combination can delay the after-meal rise in your BG. For example, eating a 10-ounce piece of prime rib, instead of your usual serving of 3 ounces of cooked lean meat, may require an insulin adjustment in the dosage and/or timing of the injection. Food and BG records will help you to compare BG responses between your usual meals and those unusual high-fat and high-protein meals. A Word About Weight Gain and Hypoglycemia There are several reasons for this possible weight gain. Fats have more calories. For example, 1 pat of butter or margarine = 45 calories, about the same as 2 cups raw vegetables! At the same time that you and your dietitian check how much carbohydrate you are eating, set up guidelines about protein and fat. If you are not eating enough carbohydrate, it may be because you are eating too much protein and fat and they are satisfying your appetite. Remember eat at least 3-5 servings of vegetables and 2 fruit servings as part of your carbohydrate choices each day. Also, discuss your calcium needs with your RD. Another reason for weight gain is that the flexibility of carbohydrate counting may lead you to treat yourself to high calorie desserts or pastries ( or larger portions of your favorite foods) that you may not have eaten in the past. A final reason for weight gain may be the foods that you use to treat low BG (hypoglycemia), such as candy bars or ice cream. If you have frequent hypoglycemia (several times per week) and you use high calorie foods to treat those episodes, you may gain weight or be unable to lose weight if that is your goal. Discuss with your RD and health care team how to prevent low BG episodes and which foods and glucose products to use to treat them. When treating low BG's , first try 15 grams of carbohydrate Fiber. Foods high in fiber are a healthy addition to a meal plan. Fiber is not digested and absorbed like other carbohydrates, such as starches and sugars. It does not become blood glucose. When you read food labels, check how much fiber is in the total carbohydrate. A very high fiber meal would not release as much carbohydrate as a lower fiber meal of the same total carbohydrate. You may notice a difference in your BG tests when you eat a high fiber meal and compare it to your BG after a lower fiber meal. That is, your BG may be lower after the high fiber meal than after the low fiber meal. If you always eat a high fiber meal at a particular time of day, your diabetes medications should be adjusted for that. When there are 5 or more grams of fiber per serving, subtract them from the total grams of carbohydrate to determine how much carbohydrate is available. In the example on the next page, breakfast A may require less insulin or diabetes pills than breakfast B because a larger part of the carbohydrate in breakfast A comes from fiber. The amount of carbohydrate that becomes blood glucose is greater in B. Pattern Management Step 1. Study the records collected. Look for BG levels outside the target range. Different colored highlighted pens are useful to mark BG levels above and below target range. Example: Your premeal BG target range is 70-150, Note how often BG levels are within target range. Look for possible explanations for BG levels outside target range. Possible explanations for high BG levels might be:
Step 2. Find and Interpret BG Patterns Example: BG level out of range 2,3 or more times per week.Look for possible reasons to explain relationships between BG levels and other data - food, physical activity, and medication. Step 3. Decide what to do based on your pattern reading. List possible strategies to be tried. Select the best strategy to try first. Discuss with your health care team. Common adjustments include:
Practice Exercises Example#1
Pattern Management Step 1. Study the records collected. Note how often BG levels are within target range.Look for possible explanations for BG levels outside target range. Possible explanations for high BG levels might be:extra carbohydrate at previous meal or snack, not taking diabetes medication as directed or medication needs adjustment, less activity than usual high fat foods at previous meals or snacks, illness or stress Possible explanations for BG levels below target range: meals and/or snacks delayed or omitted, less carbohydrate than usual at previous meal or snack extra physical activity,
Circle prelunch BG over 120mg/dl (premeal target range). Step 2. Interpret the data. Step 3. Determine possible actions or strategies. Mrs. Smith will discuss with her health-care team which of the above strategies she chooses to try. Example #2
Mr. Jones has a pattern of low midafternoon BG's following moderate to heavy physical activity. He is close to or within his carbohydrate targets for lunch. He uses 60-70 g of carbohydrate to treat the afternoon low BG. This is much more than necessary and the foods used are not the best choices. His pre-supper BG's are high following afternoon hypoglycemia. This shows that he is not treating the afternoon hypoglycemia correctly.His pre-supper BG was within target range on the day an afternoon snack was eaten, and he prevented hypoglycemia. Step 3. Determine possible actions or strategies. Adjust activity: because Mr. Jone's job and lifestyle include moderate to heavy physical activity, he most likely can't or prefers not to change his physical activity pattern. Adjust food: to prevent midafternoon hypoglycemia, Mr. Jones needs to eat a planned snack before his afternoon activity (27 g carbohydrate worked well on at least one occasion). Adjust Insulin: The prebreakfast NPH insulin may need to be lowered on days of usual afternoon activity, if planned snack does not prevent hypoglycemia. If low BG (hypoglycemia) later by using less carbohydrate. Try 15g carbohydrate instead (such as glucose tablets or milk). Wait 15 minutes, retest, and repeat if necessary. Example #3
Step 1. Study the data. Identify patterns. Step 2. Interpret the data. Step 3. Determine possible actions or strategies. How can you adjust your mealtime insulin What should you expect from a registered dietitian (RD) The time it will take you to learn level 2 skills depends on your interest and goals for your BG control.For example, your highest BG levels may occur at bedtime. This would probably lead to a discussion of which foods you eat in the evening whether you have any insulin or medication acting at that time, and what strategies you might try to bring those BG's closer to your target. Once you agree on a plan, you will need to schedule a follow-up appointment to see how your strategies worked. As part of this process, you will learn about other factors that may affect your BG. Some factors include fat, fiber, protein, and physical activity. The number of visits you spend on these topics will depend on your interest and goals for your BG control.In summary, level 2 expands your level 1 skills and, if you are taking insulin, prepares you to go on to level 3. Level 2 helps you identify patterns in your BG levels that are related to food, physical activity, and any diabetes medication you take. As you develop skills in carbohydrate counting and pattern management, you will enjoy a greater variety off foods and more flexible lifestyle. If you are taking insulin and are ready to try intensive diabetes management using carbohydrate/insulin ratios, you may choose to proceed to level 3. Your RD can provide guidance about which level of carbohydrate counting is best for you. |
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