University College Hospital Practical counting Children and Young People s Diabetes If you need a large print, audio, braille, easy read or translated copy of this document, please contact us on 020 344 79364. We will try our best to meet your needs. What is Diabetes? Type 1 diabetes is a condition where the body no longer makes insulin. Carbohydrate foods are digested and broken down into glucose (another word for glucose is sugar). Glucose is absorbed from the gut into the blood stream. Glucose provides the body with energy. Glucose needs to be transported into the cells of the body to be used as energy. Insulin allows the glucose to be transported into the cells. Insulin is sometimes described as the key to the door of the cells. Without insulin, the door to the cells remains shut, the body cannot use the energy and the blood glucose levels rise. Young people with diabetes need to give insulin via injections or an insulin pump. Background or basal insulin is given as one or two injections each day of long acting insulin or a continuous basal rate via a pump. Background insulin keeps blood glucose levels stable, without food or drink, throughout the day and night. Fast acting insulin is given as an injection or bolus via the pump before food is eaten or if the blood glucose levels are high (above target).
What can children with Type 1 Diabetes eat? Children and young people with T1D can eat the same foods as everyone else. Eating a healthy balanced diet is important this means avoiding foods high in added sugars, saturated fats and salt most of the time. Glucose in the blood comes from the digestion (breakdown) of foods. To match the foods with insulin you need to learn about counting. What is Carbohydrate Counting? Carbohydrate counting is a way of adjusting fast acting (bolus) insulin based on the food you eat It aims to copy normal insulin production, where the amount of insulin released by the body matches the amount of eaten. It allows you to choose exactly what you want to eat and drink and choose when you want to eat and drink The right amount of insulin needed can be calculated for the amount of eaten Carbohydrate counting will help to manage blood glucose levels, keeping blood glucose levels more stable and reducing hypoglycaemia (low blood glucose levels) and hyperglycaemia (high blood glucose levels). Carbohydrate counting gives flexibility with food choices and timing, however it is still important to have a regular, healthy meal pattern. Nutrients in food Food provides three main nutrients: Carbohydrate Protein Fat
Which foods contain? Carbohydrate comes from starches, added sugars (for example sucrose, maltose and glucose) and natural sugars (fructose or fruit sugar and lactose or milk sugar). When these foods are eaten they will be digested and broken down into glucose. Foods containing starchy Foods containing added sugars All types of bread (includes wraps, pitta bread, teacakes, crumpets, croissants) Potatoes Pasta Rice Chapattis Breakfast cereals Noodles Bread Couscous Bulgur wheat Quinoa Yam Cassava Plantains Injera Sweet potato and squashes Crackers & bread sticks Pulses (baked beans, mushy peas, lentils, peas, chickpeas, Dahl, lentils) All foods containing flour e.g. pancakes, pizza base, pastry products, chicken nuggets, fish fingers, fish or meat in batter/breadcrumbs Check the labels of processed meats such as sausages and burgers, as some may include flour or breadcrumbs Biscuits Cakes Muffins, Cookies, Brownies, Doughnuts Sweets Chocolates Ice cream Puddings and Desserts e.g. mousse, trifle, cheesecake Jams and marmalades Food containing natural sugars All fruits Fruit juice Fruit smoothies Dried fruit Milk (including formula) Yoghurt Fromage Frais Drinking yoghurt Milkshake Custard Milk puddings e.g. rice pudding
Foods which do not contain and do not need to be counted include: Fresh, unprocessed meat including pork, lamb, beef, chicken and turkey Fresh, unprocessed fish Eggs All other vegetables Salad Cheese Butter, spreads, ghee and oils (These foods do not need to be counted, but may still impact blood glucose levels, speak to your Dietitian for more information) Carbohydrate counting There are various methods for counting accurately, you will soon work out which methods work for you and the types of foods you eat, such as: Carbs & Cals app (Android/Apple) or book Food labels and packaging Weighed portions Standard portion measures Café, restaurant and other food outlet websites Other apps, such as Cook and Count or UK Fast Food How to Carbohydrate Count using Food Labels To use the food label, remember to look at the total content, not the of which sugars or of which starch. Most packaged foods are labelled with the content per 100g and the content per a portion. Remember, your portion size might be different to the one on the packet. For foods where you know you are eating the recommended portion size you can use the labelled count, such as the slice of bread or biscuit below:
There is 20.4g of in one slice of bread There is 7.9g in one biscuit
For foods where your portion is different from the recommended portion size, such as breakfast cereals, pasta or rice, there are various options to count accurately: 1. In 30g of cereal there is 26g 2. In 100g cereal there is 87g, this means the cereal is 87% 3. Weigh multiples of 30g portions, for example 60g of cereal contains 52g, or 15g cereal contains 13g 4. Use the Carbs & Cals book and weigh their recommended portion sizes 5. Weigh your portion size and calculate the grams of in this portion using the per 100g and a simple equation, shown below
Carbohydrate counting weighed portions Example: There is 87g in 100g cereal. The weight of the weighed portion is 54g. 1. 87 100 = 0.87g (there is 0.87g in 1g cereal) 2. 0.87 x 54 = 47g (there is 47g in 54g cereal) Nutritional weighing scales are also available that do this calculation for you. The Carbs & Cals app can also do this calculation for you.
Cooked foods The weight of raw foods change when they are cooked, for example pasta and rice absorb water when they are boiled and become heavier, the longer they are cooked the more water they absorb and the heavier they become. Baked or roasted potatoes lose water when they are cooked as they dry out, therefore their weight deceases. When cooking for a family it is easier to weigh portions when they are cooked. We recommend always weighing the cooked food and using the values for the cooked weight of the food (from the Carbs & Cals book or food labels). Be careful, as some packages only label the in the uncooked (dry) weight. Carbohydrate counting using the Carbs & Cals Book or App: A Visual Guide to Carbohydrate Counting Carbs & Cals is available as a book or app, it is a visual guide to counting, containing pictures of many different foods, in multiple portion sizes, alongside their counts. It is recommended to continue to weigh portions of foods such as cereals, rice and pasta, as it is not easy to estimate the portion size of this food by eye.
Carbohydrate count = 50g Portion size = 330g This is an example from the Carbs & Cals book, a 330g portion contains 50g (www.carbsandcals.com) Carbohydrate Counting using standard portion measures Using standard portion measures, such as a cup measure can be useful for speeding up counting on a day to day basis, see our factsheet on Carbohydrate Counting using Cup Measures (www.uclh.nhs.uk/t1) for more information or use the table: Food Carbohydrate in one cup* Carbohydrate in half a cup* Milk 12.5g 6g Flour 116g 58g Sugar 225g 112g Cooked pasta 50g 25g Cooked rice 47g 23g Porridge oats 62g 31g Cornflakes 25g 12.5g Rice krispies 26g 13g Mashed potatoes 36g 18g Baked beans 40g 20g Spaghetti in tomato sauce (canned) 32g *Portions sizes and recipes may vary slightly, 1 cup = 250ml volume, ½ cup = 125ml volume 16g
How to Carbohydrate Count for Recipes Carbohydrate counting mixed recipes, containing multiple ingredients, such as lasagne, macaroni cheese, fish pie, pancakes or homemade bread or cakes requires a few more steps than counting individual foods. Calculate the amount of in each containing ingredient, add these together to calculate the count for the whole recipe, and then divide this by the number of portions the recipe produces. See a worked example below, there is 33g of per portion of the lasagne: Ingredients: Lasagne (serves 6): Meat Sauce: 2 tbsp olive oil 750g lean beef mince 1x can chopped tomatoes 200ml hot beef stock a little grated nutmeg 300g fresh pack lasagne sheets 125g ball mozzarella White Sauce: 85g Butter 85g Flour 750ml Milk Carbohydrate in whole recipe: Ingredient Weight Carbohydrate/100g Carbohydrate in Recipe 300g 31.8g 31.8/100 x 300 = 95g Lasagne Flour 85g 77.7g 77.7/100 x 85 = 66g Milk 750ml 5g 5/100 x 750 = 37g Total 95 + 66 + 37 = 198 Number of Portions: 6 Carbohydrate Per Portion: 198 divided by 6 = 33g
The Cook and Count app, Carbs & Cals app or British Nutrition Foundation Explore Food Website (http://explorefood.foodafactoflife.org.uk/) can also analyse and calculate the in recipes. There are many recipes online that have already been analysed and counted for you. How to Carbohydrate Count when Eating Out Many of the large chain restaurants, cafes and fast food outlets publish their nutritional information online; some also have printed information available in the restaurant. The Carbs & Cals book also includes information for some meals, takeaways and popular food outlets. If no information is available use the Carbs & Cals book/app or your experience from meals at home to estimate the content. Check blood glucose levels 2-3hours after eating and make any necessary corrections. Use your experience and adjust your estimation next time you eat the same food. Quick Tips You will become more familiar with the content of foods you eat regularly as time goes on. You will probably find you weigh portions less and less. For accurate counting weigh portions or use standard portion sizes as much as possible. We understand, there will be times when this is not possible, such as when eating out. If you don t weigh every day, it s good practice to check your weighed portion sizes every few weeks just to make sure your portion sizes haven t changed, it s easy for your portion sizes to increase as you grow, without you realising, which may mean you re underestimating your counts.
Below are quick ways to work out the content of foods you eat often Bread One half of the weight of bread or bread rolls or pizza base = Weigh the bread and divide the weight by two to give the amount For example a 50g bread roll has 25g (A slice of bread without the crusts weighs about half of the weight of a full slice) A slice of pizza the size of an adult hand contains about 30g Mashed Potato One ice cream scoop of mashed potato contains about 10g
Cooked Rice and Pasta One third of the weight of cooked rice and pasta = Weigh the cooked rice or pasta and divide the weight by three to give the amount For example 30g cooked pasta or rice has 10g Cakes One half of the weight of sponge cakes is Weigh the cake and divide the weight by two to give the amount For example a 60g piece of cake has 30g Ice Cream One ice cream scoop of ice cream contains about 10g
How accurate do I need to be? It s important to be as accurate as possible. Weigh all of your portions when at home to ensure your counts are accurate. The more accurate you are at home, the easier it will be to estimate when out What time should I give my insulin? Always give fast acting insulin 15minutes before you eat. What happens if I don t eat everything I have planned to or I eat more than I think? For 5-10g more or less, this should be ok; you do not need to do anything. Check blood glucose levels 2-3hours after eating. If you have given insulin for 10g or more than you have eaten, there is a risk you may have a hypo 2-3hours after eating. Find another source of to make up the difference. Milk, juice or bread may be useful. If you eat more than 10g more than you have given insulin for, give another insulin injection or bolus for the extra. Insulin adjustment Calculate the insulin dose for the using insulin: ratio. The ratio may vary across the day. Carbohydrate ratios change as your grow. The only insulin that you can adjust for is the fast acting insulin e.g. Novorapid or Humalog or Apidra This type of insulin starts to work about 15 minutes after the injection and stays in the body for 2-5 hours The diabetes team will work out your insulin to ratio and write it below: Calculate the insulin dose by dividing the total amount of by the ratio, for example if the ratio is 1unit:10g, this means 1unit insulin for every 10g. If you ate 50g, 50 divided by 10 is 5, therefore you need 5units insulin (you will have a meter or a pump with a calculator to do this calculation for you).
My ratios: Time of day Meal Ratio This means: Breakfast Lunch Dinner Overnight 1 unit of insulin for every...g of 1 unit of insulin for every...g of 1 unit of insulin for every...g of 1 unit of insulin for every...g of Correction Doses If the blood glucose level is high before a meal, extra insulin will be needed to bring the blood glucose back into the target range. This is called a correction dose and is calculated using a correction factor (or sensitivity factor) The diabetes team will work this out and write it below: To calculate the correction dose, minus the blood glucose target from the current blood glucose level, then divide the result by the correction factor. For example if the blood glucose level was 14mmol/, the target blood glucose was 7mmol/l and the correction factor is 1u:3mmol/l, 14 minus 7 equals 7, 7 divided 3 = 2.3, therefore you need a correction dose of 2.3units (for injections, this would be rounded to the nearest half unit, 2.5units) Time of Meal Correction Blood glucose This means: day Factor target Breakfast 1 unit of insulin brings your blood glucose down by.mmol/l Lunch 1 unit of insulin brings your blood glucose down by.mmol/l Dinner 1 unit of insulin brings your blood glucose down by.mmol/l Overnight 1 unit of insulin brings your blood glucose down by.mmol/l
Snacks Snacks containing, also require insulin When using insulin injections, it may not be possible to have a small enough dose of insulin for a small snacks. Discuss this with your diabetes team. This will change over time, you may be able to have small snacks without insulin at the beginning, but as your grow you will need insulin with all snacks Contact Details You can contact the Childrens Diabetes Dietitians on childrensdiabetesdietitians@uclh.nhs.uk Expert advice and information about children and young people's type 1 diabetes can be found at www.uclh.nhs.uk/t1 First published: May 2017 Date last reviewed: May 2017 Date next review due: May 2019 Leaflet code: UCLH/S&C/PAED/CYPDS/PCC/1 University College London Hospitals NHS Foundation Trust