other cases, there is no intermediary period between Basic and Advanced Carbohydrate Counting. The person with type 1 diabetes who seeks a more flexible insulin regimen and eating plan may want or need to progress beyond Basic Carbohydrate Counting immediately. Chapter 6 provides a more in-depth discussion of determining a person’s readiness to progress.
CHAPTER THREE
Concepts to Teach—
From Basic Nutrition to
Meal Planning
Regardless of the initial knowledge level or ultimate goals of the person learning carbohydrate counting as a meal planning approach, all will begin with Basic Carbohydrate Counting. In chapter 2 we discussed assessing carbohydrate counting skills and presented an Assessment Checklist (see page 14) that summarized the necessary skills involved with Basic Carbohydrate Counting. In this chapter, we’ll discuss many of those concepts and some strategies for teaching those concepts.
CONCEPTS TO TEACH
Rationale for counting carbohydrate
It is important that a person understands the rationale for counting carbohydrate. Give a brief explanation that calories are provided from three macronutrients—carbohydrate, protein, and fat. Next explain that foods are made up of combinations, or “packages” of varying amounts of carbohydrate, protein, and fat.
Concrete examples work best, so provide examples in terms of real foods. The following examples often work well:
• A slice of bread (white or whole wheat) contains mainly carbohydrate and a small amount of protein.
• A piece of grilled chicken contains mainly protein and a small amount of fat.
• A piece of fruit contains mainly carbohydrate.
• A glass of milk (8 ounces) contains mainly carbohydrate, but is also a source of protein and may contain some fat, depending on the type of milk.
After you’ve established carbohydrate as a constituent of food and given some general examples of carbohydrate-containing foods, move on to the role carbohydrate plays in diabetes self-management. Some concepts to explain:
• It is the carbohydrate in foods that is the main contributor to the rise of blood glucose after eating. Carbohydrate counting as a meal planning approach focuses on counting the amount of the nutrient (carbohydrate) that causes the greatest rise in blood glucose levels.
• Equivalent amounts of carbohydrate from a variety of carbohydrate-containing foods raise blood glucose to about the same degree in about the same amount of time (ADA 2008b).
• There are some foods and some factors about the qualities of food that may cause them to raise blood glucose faster or slower than others.
• To help keep blood glucose in control while following a healthy meal plan, it’s important to consume healthy sources of carbohydrate in consistent amounts through the day.
• When foods that provide mainly protein (meat, fish, etc.) and fat are eaten in amounts consistent with a healthy eating plan, they raise blood glucose levels minimally.
Identify foods (food groups) that contain carbohydrate
Ensure that the person knows the list of foods (food groups) that contain carbohydrate. Do not assume that people know this. It is quite common for people to equate starches with carbohydrate and have no knowledge that foods such as fruits, milk, and ice cream also contain carbohydrate.
Food groups that contain carbohydrate:
• Starches, including breads, grains, and cereals
• Starchy vegetables, including beans (legumes)
• Fruit and fruit juices
• Vegetables (nonstarchy)
• Milk, yogurt, ice cream, and some other dairy foods
• Sugary foods
• Sweets and desserts
• Fat-free foods (often in the form of carbohydrate-based fat replacers)
• Sugar-free foods (which contain polyols)
Identify foods (food groups) that do not contain carbohydrate
Assure that the person also knows the list of foods (food groups) that do not contain carbohydrate.
Food groups that do not contain carbohydrate:
• Meats, seafood, poultry
• Eggs
• Cheese (hard and soft cheeses contain minimal carbohydrate)
• Fats, such as margarine, butter, and mayonnaise (Note: Do point out that some fats, such as commercially prepared salad dressings, do contain some carbohydrate. Also point out that many fat-free foods contain some carbohydrate.)
• Oils
• Nuts (other than chestnuts, which contain minimal carbohydrate)
Understand that many foods that contain
carbohydrate are healthy and offer energy and
an array of vitamins and minerals
A common reaction, once a person realizes that carbohydrate raises blood glucose levels, is to eat less carbohydrate than is recommended for health and healthy eating. This belief is also cultivated by promises of low-carbohydrate, high-protein diets to improve metabolic control and produce weight loss. People often don’t know that sources of carbohydrate are not the same and carbohydrate-containing foods essentially fall into two groups—healthier and less healthy sources of carbohydrate. People also often think that the current American diet is high in total carbohydrate, which is untrue. Americans eat about 50 percent of their calories as carbohydrate. The concern is that a large percent of carbohydrate intake is from added sugars, as opposed to more desirable sources (U.S. Department of Health and Human Services et al. 2005).
Consider teaching the following points:
• Many carbohydrate-containing foods are among the healthiest foods to eat: whole grains, fruits, vegetables, and low- or fat-free milk and yogurt (Institute of Medicine 2002). Carbohydrate-containing foods are the body’s primary and preferred sources of energy and provide many essential vitamins and minerals. Also, whole grains and many fruits, vegetables, and starchy vegetables are the body’s main source of various types of dietary fiber.
• Delineate between healthier food sources of carbohydrate and less healthy sources. Today, Americans in general eat insufficient amounts of healthy carbohydrates and overconsume less healthy carbohydrates (U.S. Department of Health
