Carbohydrates: to count or not to count, that is the question.

By Guest Contributor Sherri Shafer RD, CDCES

It is generally accepted that carbohydrate counting is the gold standard for managing insulin dosing for people with type 1 diabetes. It offers flexibility to meal planning and allows self-titrating of insulin to match carb choices. In the case of type 1 diabetes, the more accurate the carb counting the better; successful blood glucose management requires the careful matching of insulin doses to carbohydrate intake.

What about people with type 2 diabetes? Is carb counting useful, or is it unnecessary?

My answer would be—it depends on the individual.

Simpler methods of portion control may work well enough for some people with type 2 diabetes.

The Plate Method is one such example: visually divide the dinner plate into quarters, and then assign starches, lean proteins, vegetables, and fruits into their respective quadrants.

Alternatively you can fill 1/2 of the plate with nonstarchy vegetables and salad and still have a small serving of fruit on the side.

For some, that may be all the effort that is needed to control portions and eat a more balanced diet. The Plate Method is the teaching tool put forth by the USDA and it has replaced the Food Pyramid (which is ancient history now). Their website, ChooseMyPlate.gov, has a lot of useful information.

Visual cues work well for many people with type 2 who are trying to self-manage their diabetes.

If a person achieves blood glucose control with simpler methods, then why not keep things as easy as possible?

Keeping Portion Sizes in Check: Another visual reference that works well is to compare portion sizes to their own hands. At mealtime, serve a grain or starch portion the size of a tightly clenched fist.

Encourage patients to opt for a lean source of protein and keep the portion the size of the palm of their hand. Next, they are ready to load up on salad and nonstarchy vegetables. Fruit may be served for dessert, or later as a snack. Fruit portions can also be kept the size of a fist. A cup of milk may accompany any meal if desired. Patients can’t go wrong when their measuring devices are attached to their body!

Unfortunately, type 2 diabetes is usually progressive and years into the disease blood glucose control maybe become harder and harder to achieve. If diet, exercise, and weight management and medications are not enough to reach treatment targets, then carbohydrate counting may become quite beneficial.

Type 2 diabetes is marked by insulin resistance. There are limits to how much carbohydrate can be consumed at one time and still maintain reasonable blood glucose control.

Carb counting can be used to guide meal and snack choices and assure that carbohydrates are distributed in reasonable amounts throughout the day. If appropriate carbohydrate intake targets are established, then carb counting is a way to manage portion sizes of many foods including; grains, breads, starchy vegetables, legumes, fruits, treats, milk and yogurt. When carbs are counted (and portion sizes are controlled) then calories are simultaneously being managed.

Carb counting can be especially useful for the person with type 2 diabetes who is taking insulin.
Insulin to carbohydrate ratios are not solely reserved for those with type 1 diabetes. Calculating insulin doses for measured carb amounts works well for many people with type 2 diabetes. Or, if a sliding scale insulin regimen has been prescribed, then that is another reason to have carb consistency and implement carb counting. Doing so would allow those individuals to vary their food choices but stay within an established carb budget to balance with their set insulin dosing plan.

It’s not just about controlling carbs though. People with type 2 diabetes often have comorbidities such as dyslipidemia, obesity, and hypertension.

In addition to managing and quantifying carbohydrate intake, portion guidelines should be established for protein foods and for the reasonable use of heart healthy fats.

When considering carb counting for your patient with type 2 diabetes, consider:

• Will simpler portion guidelines such as the plate model or hand model suffice?
• Does the patient have the literacy and numeracy needed for successful carb counting?
• Consider the person’s age and circumstances. Is vision up to the task of reading the fine print?
• Are measuring cups available in the home and have carb counting food lists been provided and explained?
• Does the client have access to the internet or apps to look up carb counts?
• Is the patient motivated to learn how to count carbs?
• Does the person see value in learning this tool and agree to this method?
• For many, carb counting is certainly worth considering. It’s one more tool in the tool chest and may help to reach treatment targets and improve health outcomes.

Sherri Shafer, RD, CDCES works in the outpatient diabetes specialty clinics at UCSF Medical Center, where she has provided nutritional counseling and diabetes self-management education to thousands of people since 1992.
She has lectured extensively to medical professionals and public audiences; contributed to healthcare websites and professional publications; and developed dozens of diabetes educational materials. You can email Sherri Shafer for more info.

She has recently authored Diabetes & Carb Counting for Dummies which provides essential information on how to strike a balance between carb intake, exercise, and diabetes medications while making healthy food choices.