Katherine Isacks, MPS, RD, CDE
If you have been diagnosed with diabetes, then you know that controlling blood glucose is a critical part of your treatment plan. Good control requires a balance between:
Although not a medical device, the MyNetDiary Diabetes Tracker is a powerful tool that can help you understand your diabetes better. Please see our companion article, “Tracking Diabetes with MyNetDiary” for specific information about this incredibly useful program that is available on the web and as an iPhone app.
Carbs, Blood Glucose, and Diabetes
Carbohydrates (“carbs”) are found in abundance in grains, grain products (e.g. bread), dried beans and peas (legumes), starchy vegetables (e.g. potatoes), fruit, juice, milk, yogurt, sugars, syrups, and sweets. The carbs that you eat and drink directly affect your blood glucose level. All digestible carbs are eventually converted to glucose, a simple sugar. Glucose travels through the bloodstream to provide cells with energy. Insulin, a hormone produced in the pancreas, is necessary to allow glucose to enter most types of cells in your body. Diabetes is a condition where there is not enough insulin, no insulin, or the insulin is not handled properly in the body so that levels of glucose in the blood rise and stay high. When blood glucose is high enough, glucose leaks into the urine. “Diabetes mellitus” means sweet flow or siphon. Over time, high blood glucose can cause damage to our eyes, kidneys, nerves, gums, and vascular system (e.g. heart and brain vessels).
There are four major types of diabetes: Type 1, Type 2, Prediabetes, and Gestational (pregnancy) Diabetes. For detailed information about each type, please visit the American Diabetes Association’s website. What is common to all types is the fact that blood glucose is too high for health and increases the individual’s risk for poor health and lower quality of life.
For all types of diabetes, it is critical that diet, exercise, and medication work in concert so that blood glucose neither rises too high nor drops too low. Tracking all of these helps identify relationships between food and beverage intake, exercise, medication, weight, and blood glucose. Once these relationships are understood, you can analyze, plan, and implement behavioral changes to better control your blood glucose levels, and therefore, diabetes.
The information contained in this article is mostly appropriate for Type 2 Diabetes and Prediabetes, but has relevance to other types of diabetes as well. If you have been diagnosed with diabetes, then I urge you to get diabetes self-management education and training. Ask your doctor about getting a referral so that you get access to individualized care, goals, meal plans, self-management education, and appropriate follow-up.
Since I work as a diabetes educator, I hear patients describe all sorts of dietary strategies to control their blood glucose. Some just avoid sugary foods while others have completely eliminated all “white foods” from their diet. Your dietary strategy for effective blood glucose control will depend partly on your diagnosis, type of diabetes medication (if any), and whether or not you exercise.
Whatever strategy you choose, it is important that you know how to count carbs since that will have the greatest impact on your blood glucose level. The most common mistake I see is that folks only count sugar grams. This is a huge error since it severely underestimates the total carb count of meals and snacks.
The most common method of carb counting is to count total carb grams listed on the Nutrition Facts panel. Another common method is to use net carbs, which is total carbs minus fiber and sugar alcohols.
For those of you who use an insulin to carb ratio to dose your rapid-acting insulin, if you were recently diagnosed and educated, then you are likely using the updated carb count method, not net carbs, to count carbs. MyNetDiary Diabetes Tracker includes this method of carb counting as an option and we call it “Diabetes Carb Count”
Total Carbs − ½ (fiber if ≥ 5 grams/serving) − ½ (sugar alcohols if ≥ 5 grams/serving)
If you still use net carbs (=total carbs − all fiber − all sugar alcohols) to dose your insulin, then consider talking with your diabetes educator about using the modified carb counting method. I know that many people like to use net carbs since it is the lowest of all the carb counts, but it can underestimate the true digestible carb load. Some amount of soluble or viscous fibers, although not digested in the small intestine, can be broken down in the large intestine, absorbed, and then converted to glucose. Also, some amount of sugar alcohols (low caloric sweetener used in processed foods) can be broken down and converted to glucose. See Yale-New Haven Hospital’s Nutrition Advisor for more information on sugar alcohols.
Once again, I recommend talking to your diabetes educator and following his or her recommendation on carb counting.
How Many Carbohydrates per Meal or Snack?
Your carb goal per meal and snack depends upon your blood glucose response to the foods you eat, your diagnosis, your diabetes medication, and your level of physical activity. If you have personalized carbohydrate goals for meals and snacks that is working well for you, then stick with it. But if you want general guidelines, you can try starting with 30-45 grams total carbs per meal if you are a woman, or 45-60 grams total carbs per meal if you are a man. Most folks do well with a snack limited to 15 grams total carbs, but some people might need 15-30 grams total carbs per snack.
If you take medication that increases insulin production, or if you inject insulin, then your risk of hypoglycemia (very low blood glucose) rises if you consume too few carbohydrates. Hypoglycemia can be life threatening — if your blood glucose goes too low you can pass out. Imagine if that happens while you are driving, working on a roof, or operating dangerous machinery! As well, skipping meals, having too large of a gap between meals (e.g. more than 4-5 hours between meals), and skipping snacks if you have been instructed to consume them can increase your risk for hypoglycemia.
How do you know if your total carb goal for meals is appropriate? You won’t unless you measure your blood glucose. And that is another good reason to seek care from your doctor and diabetes educator — to learn how and when to monitor blood glucose. Your blood glucose testing schedule should be guided by a diabetes care professional. If you are only testing your fasting blood glucose yet your HgA1C test continues to remain high (e.g. > 7%), then please ask your doctor for a referral for diabetes self-management education and training (DSME/T) so you can learn how to better manage your blood glucose with diet, exercise, and medication.
Type of Carbs — Does it Matter?
Although the total carbohydrate content of your meal or snack will most directly affect your blood glucose level, the type of carb you consume also plays an important role. In terms of type, you want to choose carbs that won’t cause a huge rise after eating, even after controlling for total carb content. Glycemic Index (GI) is the term used for how a single food affects blood glucose levels compared to a “control” condition (either glucose solution or white bread) with the same amount of digestible carbs. See The University of Sydney’s website for a detailed description of the GI and its use. The concept is simple — lower GI foods will cause a lower rise of blood glucose over a 2-hour period compared to foods with higher GI values. Therefore, choose more foods with a lower GI (less than 55) than foods with a higher GI (greater than 70). What is not so simple is how to actually use the GI in meal planning for diabetes. Here are some limitations with using GI for food selection:
- Food databases that contain GI values are not yet extensive and do not provide GI values for many foods.
- We rarely eat single foods in meals or even snacks. Other meal components will also affect blood glucose levels after a meal.
- Not all low GI foods are healthy and not all high GI foods are unhealthy. You have to look at the big picture —
what else is in the food? A processed food high in saturated and trans fat and salt might have a low GI but that
is not going to be a good choice for someone with diabetes who has a much higher risk for heart disease and
Here is an example (from Sydney University’s GI database):
- Sara Lee Premium Ultra Chocolate Ice Cream (15% fat), 50 g (about 1/3 cup), GI = 37 (low)
- Fresh watermelon, 120 g (about 1 cup balls)), GI = 72-80 (high)
- How much of a food you eat also affects your blood glucose response. Glycemic Load (GL) is probably a better
than the GI since it accounts for portion size eaten or digestible carb load.
GL = (grams of digestible carbs in the portion size eaten) x GI / 100.
Lower GL foods should be chosen over higher GL foods. In the example above, despite very different GI values, their GL values are nearly identical. Now the playing field is level — so choosing watermelon over ice cream is an easy choice if health and weight control are also important goals to you.
- Research has mixed results on use of GI to control blood glucose — some studies show improvement and some do not.
If you like GI as a tool to help you make food choices, and then use it with common sense. Do not simply choose foods based on GI alone, remember to look at the big picture — what else does that food provide? Given that the majority of people with diabetes die from heart disease, it is critical that one follows a heart healthy eating plan that also supports blood glucose and weight control.
Sugars, Syrups, and Honey
Do you have to cut out all sugars, syrups, and honey from your diet if you have diabetes? Not necessarily, but you do have to account for the carbs. Some items are so high in carbs for commonly consumed portion sizes that I recommend that people either severely restrict their portion size, avoid, or try artificially sweetened versions. For example, maple syrup is typically consumed in a ¼ cup serving (4 tablespoons), which contains about 200 calories and 54 grams of total carbs. That is a huge carb load, and we haven’t even accounted for the pancakes! The same amount of diet syrup, on average, will have about 30 calories and 10 grams of total carbs.
Should you avoid all foods with high fructose corn syrup (HFCS)? Well, it depends. If the food contains small amounts of HFCS yet has nutritional benefit, then I would eat it. However, many sweetened sodas, teas, and energy drinks have a high HFCS content and just based on their total carb content alone makes them a poor choice for anyone, whether or not they have diabetes. Same goes for many packaged sweets. How many total carbs are you getting for a typical portion size? The danger is using your meal and snack carbs on junk foods that provide little or no nutritional value and that are likely to spike your post-meal blood glucose level sky high.
Are artificial sweeteners safe? I recommend that you read the National Cancer Institute’s “Artificial Sweeteners & Cancer” to decide for yourself. I think moderation is wise. For instance, are you drinking one can of diet soda a day, or a liter or more? I personally do not see risk in using small amounts of artificial sweeteners on a regular basis.
If you like sweet foods but do not want to consume artificial sweeteners, then exercise portion control and modify recipes to help control total carbs. I highly recommend “Betty Crocker’s Diabetes Cookbook” for tasty, lower carb treats as well as for other modified recipes. The book also contains excellent chapters on diabetes self-management since two out of the three authors work with the International Diabetes Center at Park Nicollet Clinic.
Important Diet and Lifestyle Factors
- Lose weight if you are overweight or obese
- Control blood pressure
- Control blood lipid (cholesterol) levels
- Eat a healthful diet that helps you achieve all of the above
- Move more & exercise
Let MyNetDiary Help You!
MyNetDiary can help you with tracking of foods and carbs, blood glucose, insulin, and more, making mundane tracking fast and easy. Diabetes Tracker available online for MyNetDiary Maximum members and separately as a standalone iPhone app.
- Easy and comprehensive food and carbs tracking, with built-in barcode scanner on the iPhone.
- Large, high-quality database of over 135,000(use component template, this food count will grow in the future) foods, updated daily. If a food is not there or not up-to-date, you submit its photos directly from the app for addition to the database.
- Track blood glucose, customize your target ranges, and quickly view highs and lows
- Track insulin, other medications, and a host of other important physical parameters
- Exercise and water tracking.
- View tracking results in helpful charts and reports
- Integration of your Withings body scale and blood pressure monitor, and Fitbit data
You can take the reins and control your diabetes — it is within your grasp! If you have questions or comments about your tracking experience, please feel free to comment in MyNetDiary’s Community Forum or Facebook page. I would love to hear from you!
— Katherine Isacks, MPS, RD, CDE
- American Diabetes Association
- For more recipe ideas, explore “My Food Advisor”
- HealthTeamWorks: Gestational Diabetes
- Joslin Diabetes Center
- Mayo Clinic. Diabetes Nutrition: Eating Out When You Have Diabetes.
- MyNetDiary: Nutrition & Exercise Articles.
- MyNetDiary: Managing Your Diabetes with MyNetDiary Diabetes Tracker.
- National Institutes of Diabetes and Digestive and Kidney Diseases.
This article can be found at http://www.mynetdiary.com/food-diary-for-diabetes.html