The Diabetologist #24+25

a consistent carbohydrate meal plan when using a
fixed insulin regimen.10
The most widely used method of meal planning for
youth with T1D is carbohydrate counting. Rigid meal
plans have been replaced with more flexible ones,
matching insulin to the child’s nutrition (carbohydrate)
intake. For people who have difficulty with carbohydrate
counting, simplified, healthy eating meal-planning
guidelines are recommended. Which method a
child uses will depend on the insulin regimen and the
family’s skill level. Often, the youth will start a basalbolus
insulin regimen (multiple daily injections [MDIs])
and then transition to an insulin pump, if desired. Nutritional
recommendations will be made based on a
child’s age and eating patterns.10
To accurately count carbohydrate amounts, children
and their families are taught how to read the
nutrition facts on food labels for total carbohydrate
grams. Families should measure or weigh foods periodically
to reinforce accurate portion sizes, and thus
accurate carbohydrate content, so the correct insulin
dose can be taken. There are books, websites, and
smartphone applications that provide carbohydrate
content for unlabeled foods. Families should have
easy access to one of these resources to accurately
estimate carbohydrates. Some school districts are
displaying carbohydrate information for school breakfasts
and lunches, facilitating carbohydrate counting;
if not displayed, the information is available from the
school lunch program.10
Because accurate carbohydrate counting is essential
for accurate insulin dosing, researchers have evaluated
carbohydrate-counting accuracy in the pediatric
population. Research in children, adolescents, and
their parents indicates that individuals may not be accurately
estimating the carbohydrates. In one study,
parents of 4- to 12-year-old children overestimated
carbohydrate intake of their children by an average of
120% of the nutrition database calculated intake.62
Another study found that adolescents either significantly
over- or underestimated carbohydrate content
of 23 of 32 individual foods presented as real foods
or food models.63 Lastly, a study conducted in the
United Kingdom and Australia found that adolescents
estimated carbohydrates within 10–15 g of the
actual amount for 73% of meals presented.64 These
authors concluded that adolescents carbohydrate
count reasonably well, but if accuracy was defined
more stringently (within 10 g of the actual amount),
then many estimates would have been inaccurate.
Additional research is needed to help determine the
best strategies for helping children, adolescents, and
their families enhance their carbohydrate-counting
skills and potentially improve glycemic control.10
Fixed Carbohydrate Meal Plan
Both children and adults using fixed daily insulin
doses must use a carbohydrate-counting meal-planning
approach or some other method of quantifying
carbohydrate intake.10 Alternatives to carbohydrate
counting include 1) the plate method, and 2) preplanned
menus. Accuracy in portion sizes remains
important, and creative education is encouraged to
promote accuracy, such as using beverage glasses,
plates, and bowls that have lines or patterns that
guide serving (portion) sizes.
Food Factors Affecting Glycemic Control
Postprandial hyperglycemia involves more than
knowing how to count carbohydrates. Many T1D
patients struggle to understand why their blood glucose
levels dramatically fluctuate on a daily basis
despite eating consistent carbohydrate grams. One
explanation may be due to inadequate education on
how to accurately dose prandial insulin and quantify
carbohydrate intake.65 The CDC reports that
only 55.7% of people with diabetes participate in a
diabetes self-management education (DSME) class,
suggesting that many patients never receive formal
instructions on meal planning, such as carbohydrate
counting, to enable accurate quantification of carbohydrate
intake.66Consequently, they may either
under- or overdose prandial insulin requirements. An
accurate prandial insulin dose to actual food (carbohydrate
grams) intake is a critical component of
basal-bolus insulin therapy.12 Aside from correct
carbohydrate counting, several extrinsic and intrinsic
variables affect glycemic control. Extrinsic factors,
such as macronutrient distribution of the meal,
fasting or preprandial blood glucose level, available
insulin, antecedent exercise, and degree of insulin
resistance may influence the impact of carbohydrates
on the postprandial response.13 Additionally,
intrinsic variables include type and source of
carbohydrate, the physical form of the food (e.g.,
whole food vs. juice), starch type (e.g., amylopectin
vs. amylose), method of food preparation (e.g., baking
vs. frying), cooking time and amount of heat and
moisture used, degree of processing, and ripeness
of food.13 Individuals can use information from selfmonitoring
of blood glucose (SMBG) and continuous
glucose sensors to better learn how both the
extrinsic and intrinsic variables affect their glycemic
control.12
Meal-Planning Approaches and Tools
Other than carbohydrate counting, meal-planning
approaches such as the glycemic index also have
been studied. Australian researchers developed
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