CLINICAL NUTRITION

Katelyn Yzquierdo, MS, RD, CSP, LD

PRACTICAL METHODS AND APPLICATIONS OF CARB COUNTING IN THE SCHOOL SETTING

Diabetes Management of the School-Aged ChildProvided by Texas Children’s Hospital Provider #18-267764-A

February 2nd, 2019 | The Woodlands, TX | 8:00-5:00 pm

CONTINUING NURSING EDUCATIONTexas Children's Hospital is an approved provider with commendation of continuing nursing education by the Texas Nurses Association - Approver, an accreditedapprover with distinction, by the American Nurses Credentialing Center’s Commission on Accreditation.

REQUIREMENTS FOR SUCCESSFUL COMPLETIONTo receive contact hours for this continuing education activity, the participant must: • Attend activity the entire activity• Sign the attendance sheet• Complete post survey evaluation online

Once successful completion has been verified, a “Certificate of Successful Completion” will be awarded for 4.8 contact hour(s). For web link issues, email cne@texaschildrens.org

LEARNING OUTCOME: At the conclusion of this course, the nurse will be able to provide improved care for the school age child as a result of increased knowledge about diabetes, ways to treat them, and the appropriate management of identified barriers.

CONFLICTS OF INTERESTExplanation: A conflict of interest occurs when an individual has an opportunity to affect or impact educational content with which he or she may have a commercial interest or a potentially biasing relationship of a financial nature. All planners and presenters/authors/content reviewers must disclose the presence or absence of a conflict of interest relative to this activity. All potential conflicts are resolved prior to the planning, implementation, or evaluation of the continuing nursing education activity. All activity planning committee members and presenters/authors/content reviewers have submitted Conflict of Interest Disclosure forms.

The activity’s Nurse Planner has determined that the following presenter, Dr. Siripoom McKay, have a conflict of interest. Those conflicts of interest have been appropriately resolved. No other planning committee member, presenter, or content reviewer has a conflict of interest.

JOINT PROVIDER STATEMENTThis CME/CNE activity has been jointly provided by Texas Children’s Hospital collaboratively with Baylor College of Medicine.

CLINICAL NUTRITION

• Learn how to carb count for meals and snacks

• Understand label reading and other methods to calculate carb counts

• Apply carb counting to manage blood glucose levels

• Learn how to prepare the student for physical activity/sports

OBJECTIVES

CLINICAL NUTRITION

• Follow age appropriate meal plan and portion sizes (MyPlate)

• Make your carbs count by choosing whole grains, fruit and vegetables

• Eat less saturated fat and focus on healthy fat sources

• Limit foods high in added sugar.

EATING HEALTHY WITH DIABETES

CLINICAL NUTRITION

• No! • Individuals with diabetes must be mindful

of how many carbs they eat, they don't need to avoid it altogether. Carbs are the body's main source of fuel and are necessary to maintain proper function.

• The type of carb and portion size are what matter most.

• Think of your carb intake like rain:• We don’t want a drought or a flood but a nice even sprinkling

throughout the day!

ARE CARBOHYDRATES BAD?

CLINICAL NUTRITION

• Starches • Made from grains: pasta, bread, rice, corn,

potatoes, beans

• Sugars• Fruit, sweets, dairy

• Fiber• Fruits, vegetables, whole grains

WHAT ARE CARBOHYDRATES?

CLINICAL NUTRITION

• Foods high in starch include:• Starchy vegetables:

• corn, green peas, potatoes, beats

• Dried beans, lentils and peas • pinto beans, kidney beans, black eyed peas and split peas

• Grains like wheat, oats, barley and rice• Crackers, tortillas, breads, pasta

STARCHES

CLINICAL NUTRITION

• Simple or “fast-acting” carbohydrate.• There are two main types of sugar:

• naturally occurring sugars - milk (lactose) or fruit (fructose)

• added sugars - added in processing such as fruit canned in heavy syrup or sugar added to make a cookie (sucrose)• Examples of common names are table sugar, brown sugar, molasses, honey, beet

sugar, cane sugar, confectioner's sugar, powdered sugar, raw sugar, turbinado, maple syrup, high-fructose corn syrup, agave nectar and sugar cane syrup.

SUGAR

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• Fruits, vegetables, whole grains, nuts and legumes.

• Beneficial for digestive health, management of cholesterol levels, and aids in satiety

FIBER

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Glucose = type of sugar = your bodies form of energy!

Glucose → ENERGY

• The carbohydrates we eat are turned into glucose by the body.• Glucose provides energy for:

• Cells

• Brain• Every function in the body!

WHAT IS GLUCOSE?

CLINICAL NUTRITION

HOW DOES FOOD AFFECT BLOOD SUGAR?

CLINICAL NUTRITION

Insulin = Hormone made by the pancreas

• Insulin is the key that unlocks the cell and allows glucose be used as energy!

• We need to pair glucose (or carbs) with insulin in order to get energy from the foods we eat!

WHAT IS INSULIN?

glucose

CLINICAL NUTRITION

• Eating consistent amounts of carbohydrates at meals and snacks keeps your blood glucose in a healthy range

• The goal is consistency:• Too many carbs make blood glucose ↑

(hyperglycemia)

• Too little carbs make blood glucose ↓ (hypoglycemia)

WHY IS CARB COUNTING IMPORTANT?

CLINICAL NUTRITION

• The average 2000 calorie diet may eat ~45-60g carbs per meal

• Carb consistent diets are usually used at first diagnosis

• Pts may then transition to insulin-to-carb ratio (ICR) for insulin injections or use with an insulin pump (ex. 1:10)

CARB COUNTING BASICS

CLINICAL NUTRITION

• A carbohydrate prescription will give you a goal amount of carbs to eat at each meal or snack time

• 1 serving of carbohydrates = 15gA dietitian can help determine a carb prescription that is appropriate for the age and activity level

of the child

CARB COUNTING: THE BASICS

7:00am 5:30pm3:00pm12:00pm10:00am 8:00pm

45 g 60 g60 g 0-15 g0-15 g 0-15 g

CLINICAL NUTRITION

Girls/Ages

(years)

Grams of

Carbs

Calories

(approx).Breakfast Snack Lunch Snack Dinner Snack

1-3 129 1000 30 8 30 8 45 8

4-5 166 1300 45 8 45 15 45 8

6-8 150 1300 45 0/15 45 0/15 45 0/15

9-11 180 1700 45 0/15 60 0/15 60 0/15

12-13 180 1700 45 0/15 60 0/15 60 0/15

14-16 195 1900 45 0/15 60 0/15 75 0/15

17-18 180 1700 45 0/15 60 0/15 60 0/15

SAMPLE CARB CONSISTENT DIETS

CLINICAL NUTRITION

1. Pt is prescribed a carb consistent diet or ICR

2. Pt calculates the amount of carbohydrate in their meal

3. Carb count is used to ensure compliance with carb consistent diet OR to determine amount of insulin needed with ICR OR is entered into an insulin pump which calculates automatically.

UTILIZING THE CARB COUNT

CLINICAL NUTRITION

• Methods of Carb Counting:1. Based on serving size (Food List

Handout)

2. Reading food labels

3. Utilizing restaurant or food company websites and/or smart phone apps

4. “Guesstimating”

CARB COUNTING: THE BASICS

CLINICAL NUTRITION

• Use as general guide to learn food groups and portion sizes

• Not always as accurate as food label

• Encourage pt to refer to list when struggling to carb count

• Take a picture of the list and keep it in your phone for quick reference

CARB FOODS LIST

CLINICAL NUTRITION

• AKA “free foods”

• Carb count non-starchy vegetables only when eating 3+ cups raw or 1.5 cups cooked at a time

• Limit fat intake; choose low-fat when possible

NON-CARB FOODS LIST

CLINICAL NUTRITION

READING FOOD LABELS

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LETS

PRA

CTIC

E • How many servings in this product?

• What is the serving size of this product?

• How many grams of carbohydrates in this product?

• How many grams would be in 2 cups of this product?

2 servings

1 cup

31g (2 servings carbs)

62g (4 servings carbs)

CLINICAL NUTRITION

• Apps• My Fitness Pal

• Calorie King • ShopWell

• Websites • https://www.myfitnesspal.com/

• http://www.lillydiabetes.com/

USEFUL TOOLS

CLINICAL NUTRITION

SWEETS & SNACKS

CLINICAL NUTRITION

• Mini cupcake (15g CHO) vs regular (35-40g)

• Lofthouse cookie (~25g) vs mini Lofthouse cookie (~10)

• Small slice of birthday cake (~40g)

CARB COUNTING FOR TREATS AND SWEETS

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PREPARING FOR ACTIVITY

CLINICAL NUTRITION

• Regular physical activity is important for overall health and wellness• Its important to balance insulin doses with the food you eat and

activity you do (even if just house or yard work)• Planning ahead and knowing your body’s typical blood glucose

response to exercise can help you keep your blood glucose from going too low or too high.

• If blood glucose is less than 100 mg/dL or greater than 300 mg/dL, no strenuous exercise until blood glucose levels are within range.

PREPARING FOR ACTIVITY

CLINICAL NUTRITION

• Your blood glucose response to exercise will vary depending on:• your blood glucose level before starting activity,

• the intensity of the activity,

• the length of time you are active,

• and changes you’ve made to insulin doses.

PREPARING FOR ACTIVITY

CLINICAL NUTRITION

• Sometimes people experience a drop in blood glucose during or after exercise, so it is very important to monitoryour blood glucose, take proper precautions, and be prepared to treat hypoglycemia (low blood glucose).

• To learn how different types of activity affect you, you should frequently check your blood glucose before, during, and after an exercise session

• Physical activity can lower your blood glucose up to 24 hours or more after your workout by making your body more sensitive to insulin.

HYPOGLYCEMIA

CLINICAL NUTRITION

• Blood glucose can also run high temporarily during or after exercise, especially with high-intensity exercise that increases stress hormone (i.e., glucose-raising hormone) levels.

• If your blood glucose is high before starting exercise, check your blood or urine for ketones. If you test positive for ketones, avoid vigorous activity.

• If you do not have ketones in your blood or urine and you feel well, it should be fine to exercise.

HYPERGLYCEMIA

CLINICAL NUTRITION

1. Check your blood glucose.

2. If your reading is 100 mg/dL or lower, have 15-20 grams of carbohydrate to raise your blood glucose.

3. Check your blood glucose again after 15 minutes. If it is still below 100 mg/dL, have another serving of 15 grams of carbohydrate.

4. Repeat these steps every 15 minutes until your blood glucose is at least 100 mg/dL.

PRIOR TO ACTIVITYFOLLOW THE 15-15 RULE:

CLINICAL NUTRITION

MAN

AGIN

G EX

ERCI

SE

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COMMENTS/QUESTIONS?