(Polonsky and Jackson 2004). If hypoglycemia is occurring regularly, work with the person to determine the common reasons for their hypoglycemia and develop solutions that involve changes or timing adjustments with blood glucose—lowering medications and/or food intake. Include or eliminate snacks with the goal of achieving a balance between food habits and hypoglycemia prevention (if they take a medication that can cause hypoglycemia). If someone doesn’t want to include snacks and is not on blood glucose—lowering medication that can cause hypoglycemia, then snacks are unnecessary. If a person doesn’t want to include snacks and is on a multiple daily injection (MDI) insulin regimen or a continuous subcutaneous insulin infusion (CSII) pump, then snacks are unnecessary. An exception comes with young children. If a child has a small appetite at meals or difficult-to-control nighttime hypoglycemia, then snacks (generally three a day) are probably necessary to meet nutrition needs.
Table 3-2 provides a sample handout to help people learn how much carbohydrate to eat, how to divide the carbohydrate into meals and snacks, and space to work out or provide two sample meals.
Define a serving of a variety of common foods
People need to have a sense of how much food represents one, two, or three or more servings of a food that contains carbohydrate. They need to be able to translate the amount of carbohydrate (in either grams or servings) they should eat into real amounts of food. In the language of diabetes exchanges/choices, one serving of a starch, fruit, or milk serving equals about 15 grams of carbohydrate and one serving of nonstarchy vegetables equals about 5 grams of carbohydrate (Pastors, Arnold, et al. 2003). Table 3-3 provides a chart with the average macronutrients per serving in major food groups (Pastors, Arnold, et al. 2003).
The average amounts of carbohydrate in Table 3-3 can be used to teach generalities about the grams of carbohydrate per food group without mentioning the word “exchanges” or “choices.” Recognize that as the exchange/choice system is used less frequently to educate people with diabetes (particularly as more educators use carbohydrate counting), fewer people will be familiar with the exchange/choice system. Also recognize that there are different definitions of “servings.” Consider the definitions used herein as well as the definitions on the Nutrition Facts panels of foods set by the U.S. FDA. Table 3-4 provides examples of how these can be similar or different.
Even as counting grams of carbohydrate grows in popularity, many educators prefer to teach servings of carbohydrate. There is rationale for teaching one or the other or both. Some educators believe that if someone is familiar with the exchange/choice system and/or the fact that 15 grams of carbohydrate is a serving or one carbohydrate choice, then this knowledge should be used. The downside of only teaching servings (or choices) is that people have no base for translating the Nutrition Facts of food labels or other resources that only provide grams of carbohydrate.
Another downside of teaching exchanges/choices is that it introduces yet another term to a person’s carbohydrate counting lexicon. Some educators believe that teaching people to count grams of carbohydrate is more precise and makes it easier to use the variety of carbohydrate counting resources available. For people learning and using Basic Carbohydrate Counting, providing both a count of carbohydrate grams as well as servings (total and per meal) may be most helpful, as shown in Table 3-2. People who progress to using Advanced Carbohydrate Counting should be trained use the more precise practice of counting grams of carbohydrate. Averaging based on servings will not match medication as precisely.
Know how to plan meals
Converting the recommended servings and grams of carbohydrate into palatable meals is often the most challenging aspect of meal planning for many people with diabetes. People need to have a sense of what and how much they should eat at their meals to gain confidence that this is a plan they can follow. Use a form, such as the one in Table 3-2, to work out two sample meals. In a group setting, this is a form that people can complete and review with an educator. In a one-on-one setting, this is a form that can be completed together. Various teaching tools, such as those in the list on page 13 in chapter 2, can be used to help people gain confidence in this skill. In addition, people may be interested in online meal and menu planning.
Know how to integrate limited amounts of sucrose-
containing foods into a healthy eating plan
The current ADA (2008b) nutrition recommendation about the inclusion of sucrose and sucrose-containing foods reads as follows:
Sucrose-containing foods can be substituted for other carbohydrates in the meal plan or, if added to the meal plan, covered with insulin or other glucose-lowering medications. Care should be taken to avoid excess energy intake.
This recommendation is based on the scientific evidence that dietary sucrose does not increase glycemia more than the same amounts of starch. Sucrose-containing foods do not need to be limited because of a concern about exacerbating hyperglycemia (ADA 2008b). However, it is common for sucrose-containing foods to contain fat, saturated fat, and cholesterol as well as excess calories.
With these recommendations in hand, it is reasonable to teach people with diabetes that sugary foods and sweets have not been forbidden since the publication of the 1994 ADA nutrition recommendations. However, to maintain a healthy eating plan and achieve their diabetes and nutrition goals, sugary foods and sweets usually need to be limited. This recommendation is in sync with the Dietary Guidelines for Americans (U.S. Department of Health and Human Services et al. 2005).
In providing individual guidance about sweets, the educator should consider the person’s food habits and preferences along with their weight, glycemic, and lipid status. It is reasonable to assume that most people will want to include some sucrose-containing foods in their eating plan and it is important to help them learn how to do this within the context of achieving their nutrition and diabetes goals.
These tips can help people eat fewer and smaller portions of sweets:
• Choose a few favorite desserts and decide how often to eat them based on personal diabetes and nutrition goals.
• Take note of the calories, total fat, saturated fat, and cholesterol of preferred desserts. Make healthier choices.
• Recognize that smaller portions can satisfy the sweet tooth just as much as large portions. For this reason, split desserts when eating out. Take advantage of smaller portions when they are available, such as in ice cream shops, when you can choose the kiddie, junior, single, or regular scoop.
• Use the Nutrition Facts on the food label to learn the grams of carbohydrate per serving. Then use this information to appropriately swap a sucrose-containing food for another carbohydrate-containing food.
• Learn the impact of sucrose-containing foods on blood glucose. Check blood glucose 1 to 2 hours after eating to see the effect. People may find that sucrose-containing foods with more fat raise blood glucose more slowly.
• Explore palatable sugar-free options that are sweetened with no-calorie sweeteners.
Have general guidelines for what and
how much protein and fat to
