Practical Carbohydrate Counting. Hope S. Warshaw

owns her own health care consulting business. She is married and has one 10-year-old child. She was diagnosed with type 2 diabetes recently and was referred to a local diabetes education program. Benita had gestational diabetes in her only pregnancy and has struggled with her weight most of her adult life. She has gained 50 pounds over the years since her pregnancy. She has been on a host of diets over the years with little success. However, during her pregnancy, she did follow a meal plan to manage her gestational diabetes successfully.

      Physical and Lab Data: Ht: 5′0″; Wt: 175 lb; BMI: 34; A1C: 7.4%; Hypertension is not under control; Total Cholesterol (TC): 225 mg/dl, HDL-C: 27 mg/dl, LDL-C: 132 mg/dl; Triglycerides (TG): 153 mg/dl

      Blood Glucose—Lowering Medication(s): None

       Food Habits/Daily Schedule:

      Workdays:

      • Wakes: 6 AM

      • Breakfast: 7:30 AM: One whole banana and one bagel with cream cheese (eaten in her car on the way to work) or she skips breakfast. She drinks several cups of coffee with half and half and sugar throughout the morning.

      • Lunch: 12:00 PM: Usually a restaurant meal—grilled chicken sandwich with French fries; tuna fish or chicken salad sandwich with potato chips; or chef’s salad. Once or twice a week, larger lunches out with clients.

      • Evening meal: 7:30 PM: Home or in restaurants with clients or family. Her husband does the cooking. Meals at home generally contain salad, vegetable, starch, and meat. Benita notes that she probably eats too much because she is very hungry at this point. Meals in restaurants are often Italian, Continental, or Mexican food. She has trouble limiting portions in these settings.

      • Evening snacking: Nibbles on chips or candy through the evening.

      Weekends:

      • Wakes: Later on the weekends.

      • Breakfast: Time varies: Usually has a large breakfast.

      • Lunch: Time varies: Often eats a light lunch of a meat sandwich.

      • Evening meal: Time varies: Evening meal is often out at ethnic restaurants.

      Physical Activity: She has just started walking her dogs again. Prior to this, however, she had done limited exercise.

      Self-Monitoring Blood Glucose (SMBG): None to date.

      Meal Planning: Benita worked with a dietitian during her pregnancy complicated by gestational diabetes. She was able to follow a meal plan during this time, but after the pregnancy went back to her old ways of eating. She wants to know how much carbohydrate she should eat at her meals and snacks. She realizes she needs to lose weight to control her blood glucose and other parameters.

       Action Plan:

      1. Benita was taught the basic concepts of carbohydrate counting by the dietitian in a one-on-one session. The dietitian provided Benita with carbohydrate intake goals (grams) for meals and one snack in the evening.

      2. The dietitian reviewed Benita’s current eating habits with her and provided suggestions for change to help her lose weight and eat healthier. She suggested Benita focus on portion control at home and in restaurants and provided a variety of tips.

      3. The dietitian also encouraged Benita to use measuring equipment, particularly initially, to help her re-familiarize herself with proper portions.

      4. Benita will attend the diabetes education center’s class, Managing Type 2 Diabetes, to help her learn more about the elements of diabetes care and how to set goals to make behavior and lifestyle changes.

      5. Benita was taught how to use a blood glucose meter and was encouraged to check her blood glucose two times a day at varied times before and one to two hours after she begins to eat her meals. The dietitian provided Benita with her target blood glucose goals.

       Benita’s Goals:

      1. Eat about 45 grams of carbohydrate at breakfast and lunch and 60 grams at the evening meal each day.

      2. Find and use measuring equipment to use when eating at home in order to learn to eat proper portions at home and in restaurants.

      3. Use tips to control portions when in restaurants. Eat more salads for lunch. Do not order French fries or chips most days of the week.

      4. Check blood glucose two times a day and record. Bring records to visit in one month.

      Return Appointment with the Dietitian (One Month Later): Benita is pleased to report that her blood glucose levels are in her target ranges. Generally, her blood glucose is 90 to 100 mg/dl fasting and before meals. After meals her blood glucose ranges from 125 to 160 mg/dl. She has lost 4 pounds. Benita notes that she is focusing on weighing and measuring her carbohydrate foods and is really shocked at the small amounts she needs to eat to follow her carbohydrate counting plan. She is now drinking coffee with low-fat milk and a no-calorie sweetener and is choosing healthier options and smaller portions when she eats out. She notes that on the weekends she is less rigid with her food choices. This helps her not feel so restricted. Getting her walks in has been challenging. She is averaging a 15-minute walk about three days a week.

       Educator Action Plan:

      1. Applaud Benita for making many behavior changes, including learning SMBG, and learning more about how much she was previously eating. Encourage her to continue these positive behaviors.

      2. Discuss strategies and develop a goal for increasing physical activity. Discuss the importance of physical activity in weight and diabetes control.

      3. Reinforce the importance of continuing to weigh and measure foods. Encourage her to do this a couple times a week.

      4. Discuss strategies for healthier snacking and eating on the weekends.

      5. Let Benita know that her physician will be contacted and informed of her excellent progress. Inform her that her progress indicates that she does not currently need blood glucose—lowering medications, but this is likely to change over time, even with adherence to a healthy eating plan and sufficient physical activity. This is a common progression of type 2 diabetes.

      CASE STUDY #2: MARY

      Situation: Mary is a 52-year-old married woman who has been diagnosed with type 2 diabetes for four years. She works five days per week (Monday through Friday), from about 8:30 AM to 5:00 PM, as an office receptionist. Mary’s family physician referred her to the diabetes education program at her local hospital. Mary wants to get her blood glucose levels in range and lose about 20 pounds.

      Physical and Lab Data: Ht: 5′4″; Wt: 164 lb (weight has been stable within 3 pounds for eight years); BMI: 28; A1C: From 8.2% to 9.5% over the last two years; Hypertension controlled on medications; HDL-C: 34 mg/dl, LDL-C: 151 mg/dl; TG: 179 mg/dl

       Blood Glucose—Lowering Medication(s):

      • Before breakfast: 1000 milligrams metformin, 8 mg Amaryl (glimepiride)

      • Before evening meal: 1000 milligrams metformin

      • Mary’s physician recently started her on 5 micrograms of exenatide (BYETTA) twice a day

       Food Habits/Daily Schedule:

      Workdays:

      • Wakes: 7 AM; Meds: 7:30 AM

      • Breakfast: 7:30 AM: 8 ounces orange juice, 1 1/2 cups cornflakes, 1 cup 2% milk, one whole banana, coffee with 2% milk and sugar substitute

      • Lunch: 12:30 PM: 6-inch sub sandwich (ham and cheese or turkey and cheese) and 1 1/2-ounce bag potato chips or fast food hamburger and French fries (medium-size order), one