Meal planning and controlling carbohydrate consumption

If you have diabetes, an important part of your overall treatment will be to design or select a healthy eating plan that will help you control your blood glucose, lose weight (if you are overweight or obese), reduce your risk for complications associated with diabetes, and provide balanced nutrition to maintain general health. Remember, in addition to your diabetes care goals, another important consideration in putting together a healthy eating plan will be how well it will work within your family, among the people with whom you share most of your meals.

Your registered dietitian

Your best resource for guidance in formulating a healthy eating plan is a registered dietitian (in many cases a registered dietitian with experience helping people with diabetes will also be a certified diabetes educator). This important health professional has valuable experience in assessing the nutritional needs of people with diabetes and will have many useful tips and advice about healthy eating. In case you think you don’t need to consult with a dietitian, remember, your eating plan is one of the most important parts of your overall treatment plan. It is also a plan that you will need to stick with for the long term (for many years), so you can use all the expertise and support you can get in putting together a plan that will work.

Changing eating habits and behaviors

When it comes to adopting a healthy eating plan, knowing what changes you want to make is only half the battle. Changing the behaviors that have been reinforced and practiced over a lifetime is the other half and the more difficult challenge. Your certified diabetes educator and dietitian can be very helpful in giving guidance when it comes to changing behaviors. They have many tools they can use to help you change your behaviors, including cognitive-behavior approaches aimed at getting you to identify, explore, and analyze how our thoughts and actions contribute to unhealthy behaviors, so that you can change those thoughts and actions.

Specific strategies that are often used in combination to reinforce behavioral changes include1:
Nutritional counseling. Making a plan of action designed to achieve a behavioral change.

Motivational interviewing. A strategy designed to achieve behavioral changes by helping you explore and resolve ambivalence to a specific change.

Self-monitoring. A strategy that involves you keeping a record of thoughts, emotions,behaviors, physical activities, and health measurements (eg, blood glucose, calorie consumption), with the record later reviewed to identify patterns and triggers associated with the negative behavior. These patterns and triggers can be used in problems solving and goal setting to overcome a behavior.

Meal replacements and structured meal plans. Nutritional counseling using meal replacements and structured meal plans aims to change behaviors and control and change eating habits by portion control.

Rewards strategies. This strategy uses a system of incentives to reinforce behavioral changes. For instance, in nutrition, rewards may be used for completion of food records, weight loss, or achieving a pre-defined goal.

Problem-solving. This strategy involves identifying barriers that stand in the way of making a behavioral change and brainstorming to come up with solutions, implementing solutions, and evaluating the outcome for effectiveness. If a given solution proves unsuccessful, then the process can be used again to come up with alternate solutions.

Social support. Social support is an important strategy in any program of behavioral change. It attempts to build a network of family, friends, colleagues, and healthcare professionals that can be used for information, encouragement, and emotional support to reinforce efforts to change a behavior.

Goal setting. This is a collaborative strategy undertaken by you and your dietitian to identify and determine potential courses of action for changing a behavior.

Cognitive restructuring. This is an approach used to increase your awareness of your beliefs and perception of yourself related to your eating habits, weight, and expectations and to changes these beliefs and perceptions to facilitate behavioral changes.

Stress management. Since stress can often contribute to perpetuating a certain behavior, this approach uses counseling to and other tools (relaxation exercises, stress management strategies) to control stress.

Stimulus control. This strategy involves modifying social or environmental triggers that encourage a certain behavior.

Individual and group counseling. Counseling, either one-on-one or in a group setting can be a useful tool in exploring and changing behaviors.

ADA general nutritional recommendations

The American Diabetes Association (ADA) has issued general nutritional guidelines for people with diabetes that include decreased calorie intake and monitoring carbohydrate intake to achieve blood glucose (glycemic) control. These guidelines are based an adaptation of the US Department of Agriculture’s (USDA) Food Pyramid for people with diabetes and are similar to recommendations for the general population and will inform your diabetes dietary plan.2

American Diabetes Association General Dietary Recommendations1

Carbohydrate intake
  • Evidence is lacking in terms of a “ideal” amount of carbohydrate intake for people with type 2 diabetes. Therefore, carbohydrate intake should be tailored to individual needs.
  • In developing an eating plan and determining carbohydrate intake, available insulin and response to blood glucose after eating should be considered.
  • Carbohydrate intake monitoring through counting carbohydrates or estimating based on experience is an important tool for blood glucose control.
  • A healthy eating plan should include carbohydrates from fruits, vegetables, whole grains, legumes, and dairy products, instead of carbohydrate sources that include added fats, sugars, or sodium.>/li>
  • In addition to controlling total carbohydrate intake, consuming foods with a lower glycemic index can also be useful in glycemic control.
Types of eating plans
  • A variety of eating patterns are acceptable for people with diabetes, including low fat, low carbohydrate, vegetarian/vegan, and Mediterranean eating plans.
Fat
  • Evidence is lacking in terms of a “ideal” amount of total fat intake for people with type 2 diabetes. Therefore, fat intake should be tailored to individual needs.
  • Quality of fat is more important than the quantity. Saturated fats (red meats, butter, cheese, margarine, and shortening) and trans fats (processed and fried foods) contribute to heart disease and should make up no more than 10% of daily calorie intake.
  • Monounsaturated and polyunsaturated fats (found in fish, olive oil, nuts) are protective when it comes to heart disease
Total cholesterol
  • Total daily dietary cholesterol intake should be kept at less than 300 mg.
Protein intake
  • Evidence is lacking in terms of a “ideal” amount of protein intake for people with type 2 diabetes and no evidence of kidney disease. Therefore, protein intake should be tailored to individual needs.
Fiber intake
  • Daily fiber intake should be at least 14 grams per 1000 calories (25 grams/day for women and 38 grams/day for men).
  • High fiber intake significantly improves glycemic control.
Sodium intake
  • Daily sodium intake should be less than 2,300 mg, with further reduction in sodium intake for people with both diabetes and high blood pressure).
Sugar intake
  • Fructose naturally occurring in foods such as fruit may result in better glycemic control than sucrose or starch, as long as intake is not excessive (greater than 12% daily calorie intake)
  • Consumption of sugar-sweetened beverages (sweetened with high-fructose corn syrup or sucrose) should be limited.
Nonnutritive sweeteners
  • Products containing nonnutritive sweeteners (aspartame, saccharin, acesulfame-K, neotame, stevia, and sucralose) may be useful in reducing caloric and carbohydrate intake is used in place of caloric sweeteners such as sugar.

Considerations in designing a meal plan

As you design your dietary or meal plan you will want to consider several issues, including3,4:

  • What foods you like to eat
  • Your daily activities including your exercise schedule
  • If you are overweight, how much weight you should lose to reach a healthy weight
  • Other concurrent health problems, such as high blood pressure, high cholesterol, or heart disease

Your dietitian will work with you to determine:

  • Which foods you should eat and which ones you should stay away from
  • How your preferred type of diet (non-vegetarian, vegetarian, vegan) can be tailored to be part of your diabetes care plan
  • How much you should eat (total daily calorie intake)
  • How many grams of carbohydrate you should eat at each meal and over the course of a day
  • How many grams of fat you should eat per meal and over the course of the day (generally, fat should comprise no more than 30% of your total daily calorie intake)
  • How you should adjust your eating to take into account daily exercise
  • How you should adjust your eating when you are sick
  • What foods you should have on hand in case you should develop hypoglycemia
  • Ways of reducing your consumption of sodium (salt)
  • How to read food labels (Nutrition Facts) to better determine intake of carbohydrates, fat, and protein

Learn more about which foods to eat and which foods to avoid.

Consistency in carbohydrate content and meal timing

Carbohydrates (sugars and starches) are a staple in most diets and are an important source (after digestion) of instant energy in the form of the sugar glucose. Most foods contain at least some carbohydrates, with the main sources including grains, fruits, legumes, vegetables, dairy, and sugar. Since carbohydrates intake results in an increase in blood glucose, any eating plan for diabetes must control carbohydrate intake.

Your dietary plan should establish consistency in terms of the amount of carbohydrates you consume and the timing of your meals. Establishing consistency in carbohydrate intake will allow you to prevent big sudden increases or decreases in your blood glucose. Consistency is particularly important if you are taking diabetes medication, such as sulfonylureas, or insulin to help you control your blood glucose. Since what you eat has a direct effect on your blood glucose, the dosing of these medications depend to a certain degree on being able to predict regular changes in blood glucose resulting from meals.3

Carbohydrate counting

Set your goal

Consistency
  • Eat a consistent amount of carbohydrates during meals and for snacks

Monitor your carbohydrate intake and blood glucose

Keeping track of carbohydrate intake
  • Keep a record of your daily carbohydrate intake and blood glucose (if you do home monitoring)
  • Learn what healthy portions are by weighing or measuring foods. This way you’ll develop an eye for how much you should eat during meals.
  • Carbohydrates can be counted by reading food labels and measuring or weighing foods

Methods of counting carbohydrates

Counting methods
  • Read food labels and calculate total grams of carbohydrates (based on single serving)
  • Weigh or measure foods and calculate grams of carbohydrates
  • Exchange system: carbohydrate content is broken down into food groups (by portion size)

Adapted from Delahanty LM, McCulloch DK. Nutritional considerations in type 2 diabetes mellitus. Nathan DM,

Lipman TO, Mulder JE, eds. UptoDate. Wolters Kluwer Health. Accessed at: www.uptodate.com. 2013.

Carbohydrate counting

Carbohydrate counting is an important strategy that your dietitian or nutritionist may have you use to establish consistency in terms of carbohydrate intake. If you use carbohydrate counting, you will consume a certain pre-determined amounts of carbohydrates throughout the day.3,4

You will work with your dietitian to determine the amount of carbohydrates you should eat at each meal and over the course of the day. In determining your dietary carbohydrate level, your dietitian will take into account personal factors such as how much exercise you get. In general, women require 45-60 grams of carbohydrates per meal and about 15 grams per snack and men require 60-75 grams per meal and 15-30 grams total per snacks.6

The best way to keep track of the number of carbohydrates your getting is to become an expert at reading food labels. The “Nutrition Facts” label on many foods list grams of carbohydrates, fat, and protein per serving.

Learn more about reading food labels.

For the foods that don’t have labels, like fresh vegetables, fruit, and seafood, you’ll need to learn to calculate carbohydrates, fat, and protein. Your dietitian will provide you with resources to help you determine the nutrient counts for common foods.

Not all carbohydrates are created equal in terms of how easily they are converted to glucose. You should become familiar with the glycemic index of common foods. Learning the glycemic index of foods will allow you to more strictly control your blood glucose. In general, you should consume small amounts of carbohydrate foods that have a high glycemic index. When you eat carbohydrates, make sure that most have a moderate or low glycemic index.

Glycemic index of various foods

Food

Glycemic index

Baked russet potato 135
Cornflakes 119
White bread 100
Whole meal bread 99
Brown rice 96
Raisins 93
White rice 83
Banana (raw) 79
All-Bran 73
Sweet potato 70
Spaghetti (white) 66
Spaghetti (whole wheat) 61
Baked beans (tinned) 60
Ice cream, yogurt, whole milk, apple (raw) 49-53
Red lentils 43
Soy beans (tinned) 20

Exchange planning

One approach to counting carbohydrates developed by the American Dietetic Association and the ADA is called the “Exchange System”. Once you’ve determined targets for carbohydrate and other nutrient intake, you can use the exchange planning system to put together meals that add up to your targets. All foods are placed in the following categories: (1) carbohydrate, (2) meat or meat substitute, or (3) fat. Different carbohydrates can be exchanged to make up individual portions of meals according to the carbohydrate content. For instance, a single small apple is equal to one-third cup of cooked pasta. The exchange system also identifies sources of dietary fiber and sodium.3

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Calories and nutrient content for exchange planning

Group

Carbohydrate (grams)

Protein (grams)

Fat (grams)

Calories (grams)

Carbohydrate group

Starch 15 3 0-1 80
Fruit 15 0 0 60
Milk 12 8 varies 90-150
Other carbs 15 varies varies varies
Non-starchy vegetables 5 2 0 25

Meat and meat substitutes group

Very lean 0 7 0-1 35
Lean 0 7 3 55
Medium-fat 0 7 5 75
High-Fat 0 7 8 100

Fat Group

0 0 5 45

Source: Delahanty LM, McCulloch DK. Nutritional considerations in type 2 diabetes mellitus. Nathan DM, Lipman

TO, Mulder JE, eds. UptoDate. Wolters Kluwer Health. Accessed at: www.uptodate.com. 2013.

Timing of meals

Establishing consistent timing of meals is particularly important for people who are taking medications to control blood glucose, including sulfonylureas or meglitinides and different insulin regimens. If you are taking insulin, you will need to pay attention to the timing of meals (in addition to the amount of carbohydrates you eat) so that your insulin dosing schedule, which typically involves injections at the same time every day, works well to control your blood glucose. The same is also true if you are taking oral diabetes medications, which are typically taken on a regular daily schedule.3

Written by: Jonathan Simmons | Last reviewed: May 2014.
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