Less than healthy sources to mention:
• Reinforce that careful attention to the portion size of carbohydrate-containing foods is critical to achieving blood glucose control—even when eating healthier sources of carbohydrate.
• Many people ask when they need to start counting carbohydrate from nonstarchy vegetables. This question is often beside the point, since most people do not consume enough nonstarchy vegetables. For most, the amount of carbohydrate from nonstarchy vegetables at meals is likely <10 grams of carbohydrate. However, people who eat several servings (about 1 cup raw, 1/2 cup cooked) of vegetables at meals should count the carbohydrate once it equals 10 grams or more. Educators should certainly encourage people to eat more nonstarchy vegetables, but also note that large quantities of some vegetables, such as carrots and tomatoes, can affect blood glucose.
Understand that healthy foods that contain
carbohydrate should not be significantly limited
or avoided as a means to achieve glycemic control
Reinforce the message that blood glucose control should not be achieved by avoiding healthy foods. Limiting foods that contain healthy sources of carbohydrate can compromise nutritional status.
Some people with type 2 diabetes facing the need to start an oral or injectable blood glucose—lowering medication may attempt to limit carbohydrate intake as a means to lower blood glucose. They believe that this will further delay the need to add or transition to new medication regimens. For this reason, it is important to discuss with them the common progression of type 2 diabetes. People need to understand that, as time goes on, they will produce less insulin and continue to have insulin resistance. They will need to introduce and/or modify their blood glucose—lowering medication to continue to achieve target blood glucose goals.
Know how much carbohydrate to eat per day
A person’s need for carbohydrate relates to his or her calorie needs. Calorie and carbohydrate needs depend on numerous factors:
• Height
• Weight and weight history
• Usual food habits and daily schedule
• Level of physical activity
• Blood glucose control
• Blood lipid levels
The current American Diabetes Association (ADA) nutrition recommendations note that no optimal nutrient mix for carbohydrate, protein, and fat has been determined for people with diabetes (ADA 2008b) and that the Dietary Reference Intake (DRI) of 45–65% of total calories from carbohydrate is reasonable to follow (Institute of Medicine 2002). On average, Americans eat about 50% of their calories as carbohydrate, although a greater than desirable percent of these calories comes from less healthy carbohydrate sources (Institute of Medicine 2002; U.S. Department of Health and Human Services et al. 2005). It is optimal to individualize carbohydrate intake based on the above factors and healthy eating goals. Table 3-1 provides general guidelines for the amount of total daily carbohydrate intake and servings from food groups for various calorie ranges. As provided, these would supply approximately 50% of calories as carbohydrate, 20% as protein, and 30% as fat.
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
