Chapter 2
Carbohydrate Control
Have you heard any of this advice from well-intentioned family members, friends, or acquaintances?
“You can’t eat sugar or sweets anymore.”
“Avoid bananas and oranges because they’ll make your blood glucose levels too high.”
“No more potatoes or carrots for you.”
“Skip the bread and pasta.”
The good news is that none of these recommendations are actually true when it comes to healthy eating with diabetes. Granted, the foods mentioned above are rich in carbohydrate, and, as you may know, carbohydrate raises blood glucose levels. But carbohydrate-containing foods do not have to be totally avoided when you have diabetes.
Why the Concern about Carbohydrate?
So, what is the story on carbohydrate? Most people with diabetes enjoy carbohydrate foods—a plate of pasta, warm crusty rolls, gooey chocolate brownies, a tall glass of cold milk, a colorful bowl of berries, or fresh-squeezed orange juice. But figuring out how much carbohydrate and which carbohydrate foods to eat are important decisions you’ll need to make every day. Before you can really know what or how much to eat, a basic understanding of what carbohydrate is and its impact on diabetes is just what the diabetes educator ordered.
Carbohydrate is one of three key energy-containing nutrients—or building blocks—that make up all of the foods you eat. The other two building blocks are protein and fat. (You’ll learn more about protein and fat in Chapter 8.) Your body needs all three nutrients to be healthy. Keep in mind that because each of these three provides fuel for your body, they can contribute to weight gain. And, as discussed in Chapter 1, weight gain can contribute to insulin resistance and the worsening of average overall glucose control.
While carbohydrate, protein, and fat all provide fuel for your body, carbohydrate is your body’s preferred fuel. Carbohydrate gets the most attention when it comes to diabetes because carbohydrate is the component of your meals and snacks that is most directly responsible for the rise in blood glucose after eating. Protein and fat do not affect your after-meal blood glucose rise to anywhere near the same extent as carbohydrate does.
As you read on, you’ll learn more about which foods and beverages contain carbohydrate, and how much carbohydrate they contain. You’ll also learn some general basics about how to control your carbohydrate intake each day.
Carbohydrate at Work In Your Body
Simply put, when you eat foods or drink beverages that contain carbohydrate, your body breaks that carbohydrate down into glucose (a type of sugar), which then raises the level of glucose in your blood in order to fuel your body. Eating too much carbohydrate may raise your blood glucose too high. But too little carbohydrate may cause your blood glucose to drop too low, especially if you take diabetes medicines that lower blood glucose.
Carbohydrate begins to raise blood glucose levels within 15–20 minutes of eating. Maybe you’ve already noticed that you feel “different” a few minutes after you eat—that may be due to your blood glucose level rising. Before you had diabetes, after eating a meal or snack, your body could sense the glucose coming from the carbohydrate you ate and would automatically regulate the amount of glucose in your bloodstream. Now that you have type 2 diabetes, your body is no longer able to automatically keep the right amount of glucose in your bloodstream, so the more carbohydrate you eat, the higher your blood glucose level may rise (unless you take action to change it). Blood glucose levels peak about 1 1/2–2 hours after you begin eating. Then they should begin to drop. Controlling your carbohydrate intake helps reduce that after-meal blood glucose peak, with the goal of keeping your blood glucose in your target range.
Blood Glucose Targets
In general, the American Diabetes Association recommendations for blood glucose targets are as follows:
• Before a meal: 80–130 mg/dL
• 1–2 hours after the start of the meal: <180 mg/dL
Make sure you consult with your diabetes health-care team to determine what blood glucose targets are safest for you.
Just because carbohydrate raises blood glucose doesn’t mean you should eliminate carbohydrate from your diet. Your body requires carbohydrate each day to stay strong and healthy. Studies examining the ideal amount of carbohydrate intake for people with diabetes are inconclusive. With that said, drastically limiting your carbohydrate intake may leave you feeling weak and lethargic. (Remember, carbohydrate is your body’s preferred fuel.) Many carbohydrate-containing foods are healthy foods. They not only taste good and fuel your body, but also provide important vitamins, minerals, and fiber that your body needs.
Carbohydrate Control, Consistency, and Counting!
Whether you eat at home or dine out, counting and controlling the carbohydrate you eat and drink is a key strategy to help you control your blood glucose (especially your after-meal blood glucose), feel well, and manage your diabetes.
Carbohydrate Control
The period right after you are diagnosed with type 2 diabetes can be an overwhelming time as you try to sift through and process tons of new information. When it comes to eating, the good news (as you learned in Chapter 1) is that there’s no one “diet” or ideal amount of carbohydrate (or protein and fat, for that matter) that everyone with diabetes should eat, just as there’s no one perfect diet for people without diabetes. With that said, carbohydrate control is a priority. The amount of carbohydrate best suited to you to keep your blood glucose in target should factor in your current eating patterns, preferences, and health goals. For instance, if you’re a runner or work in a physically active job, you may need more carbohydrate and at different times of day than if you’re trying to drop a few pounds and tend to be physically inactive.
Carbohydrate Consistency
Another key thing to remember: The more consistent your carbohydrate intake is from meal to meal and day to day, the more stable your blood glucose levels are likely to be, particularly your after-meal blood glucose. And in the end, that translates into better diabetes control.
Carbohydrate Counting
To control carbohydrate and maintain consistency, you can track the grams of carbohydrate consumed at each meal and snack (whether from food or beverages). This approach to tracking carbohydrate and maintaining carbohydrate consistency from meal to meal, day to day, is rightfully called “carbohydrate counting.” Greater explanation of carbohydrate counting will follow later in this chapter.
While this book focuses primarly on tracking or measuring carbohydrate in grams (abbreviated as g), you may also run across—and can use, if you wish—a unit of measure known as a carbohydrate choice (or serving). Here are some simple tips to help you understand these two different carbohydrate measurements:
• One carbohydrate choice (or serving) = 15 grams of carbohydrate
• To arrive at the number of carbohydrate choices (servings) in a food, take the grams of carbohydrate and divide by 15.
• Alternatively, to get the number of carbohydrate grams from the carbohydrate choices (servings), take the number of carbohydrate choices and multiply by 15.
Over the years, we’ve had many patients come to us and say they eat three or four “carbs” at a meal. We’ve learned that they actually mean three or four carbohydrate choices, not grams of carbohydrate. It’s easy to get confused.
3 Steps to Carbohydrate Control
Now let’s take a look at three important steps to carbohydrate control. You’ll also find specific guidelines and tips in this section to get you started with carbohydrate control no matter which eating pattern or meal plan you choose to follow (see “Eating Patterns for Diabetes and Weight Loss” in Chapter 1). Whether you choose to monitor your carbohydrate intake through carbohydrate counting or simply by estimation based on experience, these steps and tips can help. Your diabetes health-care team can provide further guidance about what’s best for you.
Step 1: Get Familiar with Which Foods and Beverages Contain Carbohydrate
First things first. You have to know which foods and beverages contain carbohydrate before you can work on consistency with your carbohydrate intake. Carbohydrate is found in many of the foods we eat. While some foods, like honey, are pure carbohydrate, many foods contain a combination of carbohydrate, protein, and/or fat. For instance, peanut butter is a mix of all three nutrients, and chicken is primarily protein with a little fat. However, as you can see in “Where Can You Find Carbohydrate?” on the next page, many foods contain at least some carbohydrate.
For good health, try to include a variety of carbohydrate-containing foods at meals and snacks each day. If you have a sweet tooth, the really good news is that you can even work sweets into your meal plan. Sugar is not the evil that it was once thought to be for people with diabetes. Now you truly can have your cake and eat it too—at least in small amounts (see “Are Sweet Treats Off Limits?” on the next page)!
Carbohydrate in Food Groups
Since the total amount of carbohydrate eaten is the primary predictor of after-meal blood glucose response, you should know which foods contain carbohydrate. Check out Table 2.1 for a general idea of how much carbohydrate is in each of the different food groups. (More specific examples follow later in the chapter.)
As you see, foods in the Protein group—such as meat, fish, poultry, shellfish (without breading, sauce, or gravy)—are carbohydrate free, as are many fats, including oils, butter, margarine.
When Choosing Carbohydrate-Containing Foods, Stick Close To Nature
It turns out Mother was indeed right when she said “Eat your fruits and vegetables!” But we can expand that to include whole grains, beans, and dairy products too! Choosing nutrient-dense, high-fiber foods whenever possible (See Chapter 8 for more information on fiber)—instead of processed foods with added sodium, fat, and sugars—provides vitamins, minerals, and other healthful substances for relatively few calories.
In general, the more natural a food is, the better it is for you. Consider, for example, the difference in nutrition between a sweet potato and sweet potato chips. Sticking close to nature, a baked sweet potato is lower in fat, lower in calories, higher in fiber, richer in vitamins and minerals, and more filling than a serving of highly processed potato chips. (And cheaper too!)
It’s More Than Just Sugar: Sizing Up Serving Sizes and Total Carbohydrate
If you’ve already been looking at the nutrition information label on the foods you eat, good for you! (Chapter 4 will give you a full rundown on how to use the information on the nutrition information label.) If not, then it’s time to start familiarizing yourself with the serving sizes listed on the labels of your favorite foods and beverages. Compare those serving sizes to the amount of these foods and beverages you normally consume. (Chapter 3 provides tips on portion control and estimated portion sizes.)
Also, when reading nutrition information labels, take a look at the amount of total carbohydrate for the serving size. Many people with diabetes focus just on the sugar content of foods, but sugar is only one type of carbohydrate. Looking only at the grams of sugar does not factor in all of the carbohydrate in the food that will affect your blood glucose. Today, begin refocusing your attention on “Total Carbohydrate” on the nutrition information label, which accounts for all of the carbohydrate in the food. That’s the number to use when tallying your carbohydrate count. Many people prefer to track exact grams of carbohydrate. Others prefer to track carbohydrate in terms of carbohydrate choices (servings). Every 15 grams of carbohydrate equals one carbohydrate choice, as noted earlier in this chapter (see “Carbohydrate Counting”).
Step 2: Build Awareness of How Much Carbohydrate You’re Eating and Drinking
Admittedly, familiarizing yourself with portion sizes and the associated carbohydrate content of foods and beverages takes some thought and effort, especially in the first few weeks. Chapter 3 provides a multitude of tips to size up your portions both by actually measuring them and by estimation.
To assist in building your carbohydrate awareness, you can keep a carbohydrate count list (whether written, on your computer, or on your smartphone), with the carbohydrate count of portions of your favorite foods for quick reference. Based on our years in practice, we find that most people have around 100 foods and beverages that they routinely consume. Since many people eat the same foods from week to week, our patients often share that they quickly become familiar with the carbohydrate amounts in their favorite foods and beverages. Carbohydrate counting and control become much easier—almost second nature—the more you practice.
There are several resources available to help you quantify the amount of carbohydrate in foods you eat:
• Nutrition information labels on food and beverage packaging: This is the most direct source for carbohydrate information. (You’ll learn lots about how to understand nutrition information labels in Chapter 4.) Of course, fresh foods, such as apples and broccoli, don’t often come with labels. But you can become familiar with the carbohydrate content of these foods through the variety of other resources available.
• Reliable websites:
+ Calorie King (www.calorieking.com) is a popular website that offers a free, huge, online database that you can search by food or even by specific brands.
+ USDA National Nutrient Database for Standard Reference (http://ndb.nal.usda.gov)
+ SuperTracker (www.supertracker.usda.gov)
• Internet search by restaurant for food/beverage names: Chains and larger establishments often have the nutrition information for their menu items posted online. Many food and beverage manufacturers also post nutrition information of their products on their website.
• Mobile apps: MyFitnessPal, for example, is a favorite among our patients.
• Carbohydrate-counting guidebooks: Books such as The Diabetes Carbohydrate & Fat Gram Guide, 4th Edition and The Complete Guide to Carb Counting, 3rd Edition are available from the American Diabetes Association (http://store.diabetes.org).
• Choose Your Foods: Food Lists for Diabetes booklet: This resource is available from the American Diabetes Association and the Academy of Nutrition and Dietetics (http://store.diabetes.org).
Ask your diabetes educator or registered dietitian/registered dietitian nutritionist for other reputable resources.
Step 3: Know How Much Carbohydrate You Need
Determining the right amount of carbohydrate for you (both per meal/snack and per day) depends on several things, including your:
• Weight
• Height
• Age
• Physical activity
• Food preferences
• Eating patterns
• Diabetes medications (if any)
• Health goals (such as managing blood lipids or weight)
Basic Carbohydrate Goals for Meals and Snacks for Women
As a general starting point, most women need about 45–60 grams of carbohydrate (3–4 carbohydrate choices) at each of their 3 meals and 15 grams for a snack (1 carbohydrate choice). A carbohydrate reduction to 30–45 grams of carbohydrate per meal (2–3 carbohydrate choices) may assist even more with weight loss.
Basic Carbohydrate Goals for Meals and Snacks for Men
As a general starting point, most men need about 60–75 grams of carbohydrate at each meal (4–5 carbohydrate choices) and 15–30 grams for a snack (1–2 carbohydrate choices). To lose weight, a reduction to 45–60 grams of carbohydrate (3–4 carbohydrate choices) per meal can help.
Carbohydrate Control Is Like Using a Checking Account
Think about carbohydrate control like this—your meal and snack carbohydrate goals are like a checking account. At each meal, you have roughly 45–60 grams of carbohydrate (or 60–75 grams of carbohydrate) in your account to “spend.” You can spend it on whichever carbohydrate-containing foods you wish. There are generally no “forbidden” foods, but you may find that you end up eating smaller portions of certain foods and eating some foods less often. While not the healthiest choice, you can even have an occasional splurge, like a chocolate donut, if you plan ahead and allocate grams of carbohydrate to spend on it. Of course, the goal is to spend the majority of your carbohydrate grams on a variety of healthy foods. If you “overdraw” your carbohydrate account, the “penalty” is that your blood glucose will run higher after the meal. The same rules apply for snacks.
Keep in mind that this approach does not allow you to reserve or save carbohydrate from one meal or snack to “spend” on a later meal or snack (unless you are instructed by your health-care team to follow advanced insulin matching rules). There is no savings account. Use it or lose it. So, spend your carbohydrate wisely to work in those foods that you enjoy!
Once you meet with a registered dietitian nutritionist and/or your health-care team, they can refine your carbohydrate goals for meals and snacks if necessary.
A Few Other Carbohydrate Considerations
“Free” Doesn’t Always Mean Free
Although some sugar-free foods, such as diet soda, are truly sugar free, carbohydrate free, and calorie free, most sugar-free foods still have calories, fat, and carbohydrate. “Sugar free” means simply that no sugar or sugar-based sweetener has been added to the food or beverage. “Sugar free” does not necessarily mean that the food is carbohydrate free or calorie free.
Often, “sugar-free” foods, such as sugar-free chocolates, contain a special type of sweetener called “sugar alcohols.” You may find the amount of sugar alcohols listed on the nutrition information label. You can check the ingredient list for sugar alcohols as well (see “Common Sugar Alcohols”). Be aware that these sweeteners do contain carbohydrate and will affect your blood glucose, although to a lesser extent than sugar. They may have a laxative effect, too, causing intestinal bloating, gas, and diarrhea.
Remember to check out the grams of total carbohydrate on the nutrition information label to see just how much carbohydrate is in a food or beverage. You might be surprised by what you find.
The Scoop on Chocolate Ice Cream
A 1/2-cup serving of regular chocolate ice cream contains 18 grams of total carbohydrate, whereas the same size serving of fat-free, no-sugar-added chocolate ice cream has even more grams of total carbohydrate—26 grams! You might have thought that the no-sugar-added ice cream would be a low-carbohydrate choice. Not so. The unexpected carbohydrate comes from sugar alcohols.
As this example illustrates, “sugar free” definitely does not mean “carbohydrate free.” Sugar-free foods can be part of a diabetes meal plan as long as you count the carbohydrate accordingly. Talk further with your registered dietitian nutritionist or certified diabetes educator about how sugar alcohols can fit into your meal plan.
Low-Calorie Sweeteners: A Personal Choice
Blue, pink, yellow, green, orange—such is the rainbow of packaging colors for the variety of low-calorie sweeteners available today. These sweeteners are also called “high-intensity sweeteners,” “non-nutritive sweeteners,” “sugar substitutes,” or “artificial sweeteners” (although the stevia and monk fruit sweeteners you’ll see in “Low-Calorie Sweeteners Available in the U.S.” are not artificial; they come from plant extracts). See Chapter 9 for more information on low-calorie (non-nutritive) sweeteners. Only a relatively small amount of a low-calorie sweetener is needed because they are several hundred to several thousand times sweeter than sugar. These sweeteners are different from sugar alcohols.
Use of low-calorie sweeteners is a personal choice for people with diabetes. Low-calorie sweeteners provide sweetness with nearly no carbohydrate or calories, meaning they don’t impact blood glucose; however, other ingredients in a food or beverage containing low-calorie sweeteners may in fact affect blood glucose. For instance, sugar-free, fruit-flavored yogurt contains a low-calorie sweetener but still has 12 grams of carbohydrate per 6-ounce cup, on average. An additional consideration is that while low-calorie sweetener use has the potential to reduce overall calorie and carbohydrate intake, that’s true only if they’re substituted for caloric sweetener without compensating by eating additional calories elsewhere.
There are currently eight low-calorie sweeteners available in the U.S. The U.S. Food and Drug Administration (FDA) has approved six low-calorie sweeteners for use in the U.S. The monk fruit and stevia low-calorie sweeteners have Generally Recognized as Safe (GRAS) status.
If you choose to use a low-calorie sweetener and don’t like the taste of the first one you try, switch to another. You may prefer the taste of one over another. Or, if you choose to refrain from using low-calorie sweeteners altogether and stick with a sugar-sweetened versions of your favorite foods/beverages, just know that the carbohydrate content of the “regular” versions will be higher. You’ll have to “spend” more carbohydrate to fit it in.
As for safety, low-calorie sweeteners and sugar alcohols are considered safe when consumed within the daily intake levels established by the FDA. If you’re concerned about sugar alcohols and low-calorie sweeteners, talk with your registered dietitian nutritionist or diabetes educator.
What about Glycemic Index and Glycemic Load?
Glycemic Index
You may have read about glycemic index (GI) and glycemic load (GL), or seen an advertisement touting the benefits of low GI/GL foods. While some organizations may suggest the use of a low-GI diet, research shows that GI and GL in relation to diabetes are complex because blood glucose response to a particular food varies among individuals and can be impacted by a number of factors.
The GI is a method that ranks carbohydrates on a scale from 0–100 according to how they raise blood glucose after eating. (See “Glycemic Index Rankings.”)
• Low-GI foods produce gradual rises in blood glucose levels because they are slowly digested and absorbed.
• High-GI foods are rapidly digested and absorbed and lead to marked elevations in blood glucose.
Two foods having the same carbohydrate content in grams, may have differing glycemic index rankings or glycemic loads.
Jelly Beans vs. Kidney Beans
For example, if you have one serving of jelly beans and one of kidney beans, and both portions have the same carbohydrate content, the jelly beans will be digested more rapidly and raise your blood glucose more than kidney beans. In other words, jelly beans have a higher GI than kidney beans. Of course, to deliver the same carbohydrate amount, the portion sizes of these two foods would be different.
To complicate matters further, the GI of a specific food can change based on a number of factors including what else is eaten during the meal or with the food, how the food is processed and prepared, the acidity, fat content, and fiber content of the food, and many other factors. Even factors unrelated to the food can affect the GI, such as time of day, mealtime blood glucose level, stress, and the physical fitness of the individual.
Glycemic Load
“But what about portion size?” you may ask. “What if I’m eating a bite of cheesecake, not a whole slice? Does that matter?” The GI of a food does not change whether you eat a bite of cheesecake or an entire slice. Eating a larger amount of a carbohydrate-containing food (such as a slice of cheesecake) will certainly raise your blood glucose more than eating a smaller amount (a bite of cheesecake, for example). That’s where glycemic load (GL) comes into the picture. GL takes into account the portion size and potential impact on blood glucose. Substituting low-GL foods for higher-GL foods may modestly improve blood glucose control. A searchable GL database is available at www.glycemicindex.com.
The Bottom Line on GI and GL
The GI and GL are tools that may help you fine-tune your blood glucose levels. The simplest approach to incorporating GI and GL is to choose foods with a lower GI and substitute low-GL foods for high-GL foods, when possible, while still being mindful of the portions you eat. It’s up to you whether you’d like to use these tools. Just keep in mind that a food’s effect on blood glucose may vary from person to person.
Meeting Your Registered Dietitian/Registered Dietitian Nutritionist and/or Certified Diabetes Educator
For more assistance and guidance on incorporating the carbohydrate foods you enjoy into your eating pattern in amounts that fit your personal health needs, consult with a registered dietitian/registered dietitian nutritionist (RD/RDN) who specializes in diabetes nutrition.
An RD/RDN may provide additional counsel on how to incorporate physical activity into your life as well. For a referral to an RD/RDN, ask your physician or locate one near you through the Academy of Nutrition and Dietetics website (www.eatright.org). Many RD/RDNs are also certified diabetes educators (CDE), and they can help you understand how any diabetes medicines you’re taking affect you, teach you how to monitor your blood glucose, and teach you how to solve problems and adjust emotionally to diabetes. For a referral to a certified diabetes educator, ask your physician or locate one through the American Association of Diabetes Educators website (www.diabeteseducator.org) or the National Certification Board for Diabetes Educators website (www.ncbde.org). To make the most of your time and the visit, review the checklist that follows in “Preparing for Your Visit” and take this information to your appointment.
Next Steps
• Contact a registered dietitian/registered dietitian nutritionist and/or diabetes educator to schedule an appointment.
• Review the “Preparing for Your Visit” checklist, and gather the information before your appointment.
• Begin compiling a list of favorite foods and carbohydrate counts of portions you frequently eat.
What Do I Eat for Breakfast?
For 45–60 Grams of Carbohydrate*
Recipe: Quick Cranberry-Cherry Walnut Oatmeal (1 serving)
1 (1-ounce) link turkey sausage
1 slice whole-wheat toast
1 teaspoon trans fat–free margarine
Coffee or hot tea (with low-calorie sweetener if desired)
1 cup low-fat milk
For 60–75 Grams of Carbohydrate*
Recipe: Quick Cranberry-Cherry Walnut Oatmeal (1 serving)
1 (1-ounce) link turkey sausage
2 slices whole-wheat toast
2 teaspoons trans fat–free margarine
Coffee or hot tea (with low-calorie sweetener if desired)
1 cup low-fat milk
*For most women, 45–60 grams of carbohydrate at a meal is a good starting point; for most men, 60–75 grams of carbohydrate per meal is appropriate. Check with your diabetes health-care team to find the amount of carbohydrate that’s right for you.
Swift, Simple Tip
• Buy ready-to-serve, precooked turkey sausage to heat in the microwave.
Quick Cranberry-Cherry Walnut Oatmeal
Serves: 1 / Serving size: About 1 cup
Preparation time: 3 minutes / Cooking time: 1 1/2–2 minutes
Ingredients
1 (1-ounce) packet plain instant oatmeal
2/3 cup diet cranberry-cherry juice
2 dashes cinnamon
2 teaspoons ground flax seed
1 tablespoon chopped walnuts
1. Empty oatmeal into a microwave-safe bowl. Stir in juice and cinnamon. Microwave uncovered on high power for 1 1/2–2 minutes, or until oatmeal starts to thicken (water or additional juice can be used to thin oatmeal if desired).
2. Stir and sprinkle with flax seed then walnuts. Serve right away.
Choices/Exchanges
1 1/2 Starch, 1 1/2 Fat
Calories 190
Calories from Fat 80
Total Fat 9.0g
Saturated Fat 1.0g
Trans Fat 0.0g
Cholesterol 0mg
Sodium 130mg
Potassium 185mg
Total Carbohydrate 23g
Dietary Fiber 5g
Sugars 3g
Protein 6g
Phosphorus 185mg
Food for Thought
• Carbohydrate counts most. Carbohydrate in foods and beverages impacts your blood glucose levels, so familiarize yourself with the total carbohydrate content of your favorite foods and beverages.
• Keep carbohydrate consistent. Try to eat and drink about the same amount of carbohydrate at meals and snacks each day to stabilize your blood glucose.
• Most foods can fit. You can work in and enjoy nearly any food if you count the carbohydrate and fit it into your meal or snack carbohydrate goals.
• Balance your plate. When serving your plate, try to keep it colorful and fill half of the plate with nonstarchy vegetables, one-fourth with lean meat/poultry/fish, and one-fourth with starchy vegetables, grains, or starchy beans. Round it out with a piece of fruit and a cup of milk/milk substitute if your plan allows it.
• Enjoy your food. Choose carbohydrate foods you enjoy in amounts that fit your carbohydrate goals, so you can feel satisfied.