Teaching Patients to Carb-Count

I always find it fascinating to have a window into diabetes “from the other side” — i.e. what doctors and healthcare providers are doing and talking about. Something that caught my eye in the latest issue of the AADE’s journal, The Diabetes Educator: a new 10-step guide to teaching carbohydrate counting, called (oh so cleverly!) C-O-U-N-T C-A-R-B-S.Carb_counting

It’s apparently a program to help nurses teach diabetes patients diet tactics with more confidence, which is “shown to produce better behavioral outcomes that the didactic strategies commonly used in hospitals at present.” Well, that sounds good.

Staff nurses are first encouraged to explore each patient’s “individual medical and motivational factors.” Right, no one size fits all!

Then — after a number of other preliminaries — they are encouraged to implement the following steps, based on Gray’s evidence-based teaching strategy. Here are the 10 steps in shorthand:

1) Create a typical meal. The nurse is supposed to talk through the details of an ordinary meal the patient eats on a regular basis, including sauces, condiments, and beverages.

2) Offer information. Here the nurse defines carbohydrate, and explains which foods from the previous step contain them.

3) Use food lists and labels. A quick lesson in reading food packaging labels, including paying close attention to Serving Size, and the idea of 15-carb “units.”

4) Now it’s {the patient’s} turn. The patient is next asked to try to estimate the total carb value of their typical meal in Step 1.

5) Take time. I quote: “Answer questions and provide clarification and performance feedback. (This step could last several days for many of us :)

6) Compare patient choices to written dietitian recommendations. The nurse is encouraged to be constructive and focus on the positive. (As in, “I see you enjoy your tortilla chips…”)

7) Adjust meal. Talk about ways to alter meal choices based on dietitian recommendations. Here’s where the nurse can use “visualization” for portion sizes, etc. I’m guessing they mean those plastic chicken legs and such.

8) Recalculate, record, reinforce. (Sound like a contest entry?) The patient gets to recalculate their initial meal as a sample entry in a food diary. The nurse demonstrates how to record BG readings and insulin doses. Learning is reinforced using “case scenarios.”

9) Bolus. I guess they’re actually practicing eating the meal at this point, ’cause the nurse is supposed to assist with administering an appropriate bolus.

10) Support learning. The nurse is supposed to provide resources for the patient to consult later on, like web sites, support groups, and customized food lists based on the patient’s preferences. (Man, I need a list like that!)

So, my question is… how did you learn to carb-count? Did the person who taught you use anything like the method above? If you’re like me, do you sort of “have it down” now and yet still feel like you’re just eeking by most of the time?


24 Responses

  1. elizabeth joy
    elizabeth joy March 26, 2008 at 8:16 am | | Reply

    I don’t like pre-packaged foods, but they make it SO much easier to carb count. When I cook, especially using sauces, it’s really hard to come up with a true estimate. But I’ve been diabetic over 30 years, and for most of it I’ve just used the S.W.A.G.(Scientific-Wild-Ass-Guess) method for foods I’m not sure of. I guess after all this time I’ve been able to refine my guesses pretty well (except for the times when I wake up over 300, and realize I forgot to count the honey-mustard salad dressing…)

    A scale, by the way, is fantastic for figuring out the carbs in things like bread or fruit. I only started using one this past year, and it’s really worth the counter space it eats up.

  2. Kelly K
    Kelly K March 26, 2008 at 8:28 am | | Reply

    My Diabetes Educator was the person who taught me, and I’m so grateful she drilled it into my head.

    I read labels like crazy and am also a big fan of the S.W.A.G. method that Elizabeth mentioned (I love the name!) as well.

    I’m not perfect, I still make mistakes, but nothing feels as good as after eating a formally forbidden carb (in my case, pizza) and reaching “blood sugar Nirvana” two hrs later. ” I just wanna shout to the world!
    “I did it! I counted my carbs, bolused for the numbers, ate my pizza and made them them my biotch!” Pardon my language Amy, I’m just being honest.

  3. Jan
    Jan March 26, 2008 at 8:33 am | | Reply

    Find the above post amusing. The Nurses and docs seem to me to be over-complicating the issue. Although the substitution idea sounds good. We needed to learn how to carb count quickly, as she was dx’d at 8 and very carb sensitive. Initially, we used nutritional information on the back of the label, Calorie King book, which is still used religiously, and measuring cups. We had a Weight Watchers scale to weigh fruit, unlabeled bread and such by the ounce. We now have a Salter scale right on our counter, next to the Calorie King book. I have found, using the Salter, that packaged nutritional information can be off, although not WAY off, too much off for a child. So if we are at home I use the nutritional info on back of package and weigh it on the Salter. I even took the Salter to the Outback restaurant to weigh cheese fries. Outback’s child-sized cheese fries were 6.9 ounces. Didn’t work too well, as the excessive fat in the fries kept her from digesting the carbs. But I tried…. Weighing on the Salter is accurate and the only way to truly know the carb count.

  4. mollyjade
    mollyjade March 26, 2008 at 8:35 am | | Reply

    I was only three when I was diagnosed, so eating “diabetic” is the only thing I’ve known. We started out measuring food on a spring scale (electronic ones didn’t exist yet), but that only lasted a few months. One thing I find very helpful is to use the same dishes for every meal. I know what one cup of anything looks like on my bowl or plate that I use at home because I’ve eyeballed it so many times. And for lunches that I pack, my tupperware containers all list their volume on the bottom.

  5. CALpumper
    CALpumper March 26, 2008 at 9:06 am | | Reply

    I learned from my Diabetic Educator and Nutritionist (and yes she had the plastic portion sizes strewn throughout her office).

    There was no formal discussion of what I like to eat etc then related it to actual carb counting. I did my best with labels.

    I still struggle as mentioned above, prepackaged has the labels I need for serving size and total carbs. Plus the darn stuff is cheaper.

    Although any veggies or protein I have never needed to count.

  6. Mike Lawson
    Mike Lawson March 26, 2008 at 9:12 am | | Reply

    Counting carbs can be confusing stuff…

    I made this video: http://www.youtube.com/watch?v=8QUqJRJ0mZw

    Which is part of a series where I document my life as a PWD.

  7. Kim
    Kim March 26, 2008 at 9:14 am | | Reply

    I’ve learned from weighing things on the lovely electronic scale at home, and then remembering what so many grams of something looks like. I know that a green bell pepper is about 4g, that a big bowl of lettuce is around 7g, that a handful of cherry tomatoes is about 5g, etc. The problem is, when my substitute endo (favorite endo was on maternity leave) said I needed to review carb-counting , the CDE asked me to estimate carbs for things listed on a sheet of paper – it listed hamburgers, french fries, bread, baked potatoes, chinese food, among other things. I told her I had no clue b/c I don’t eat that crap. She didn’t really know what to tell me. I mean, how does one estimate the carbs in a scoop of tabouli or quinoa salad? And on the other hand, how does one estimate the amount of carbs in a restaurant salad dressing?

  8. Lili
    Lili March 26, 2008 at 9:36 am | | Reply

    I learned through a combination of reading labels since I was 16 (although I was diagnosed at 27), having a close Type 1 friend, and once I was diagnosed, Calorie King. I weigh anything I can’t eyeball, which is a lot. Everyone assured me I would get better at eyeballing and wouldn’t have to weigh, but I didn’t (and hadn’t really thought I would), so I just do it, and it doesn’t bother me.

    I have yet to see a helpful dietitian. I’ve seen three (not by choice) and they all 1. told me I should be eating more than 200 grams of carbs a day (the first two when they thought I had Type 2) 2. hadn’t heard of any of the foods that make up my normal diet. So they’d give me “typical meals” of things I would never eat. One insisted on meat at every meal because being a vegetarian is “so unhealthy.” I can’t say it was all that helpful. The last one at leas t admitted I should “keep doing” what I’m doing.

  9. Bearly
    Bearly March 26, 2008 at 10:07 am | | Reply

    I went from eating everything in sight whenever I wanted to stone cold follower of Dr. Bernstein’s Diabetes Solution recommendations.

    Yes, it is hard to follow, but it is something I can follow. I saw a dietician (sp) last fall who just chucked the ADA booklet about exchanging this or that. It was a carb festival!

    I am happy that I ignored her and found Dr. Bernstein and resources like this blog.

    I slip up sometimes like realizing too late that my beloved chicken sausages have balsamic vinegar…but I need the Dr. B tough love approach to carbs.

  10. Russell
    Russell March 26, 2008 at 12:38 pm | | Reply

    I am a fan of Dr. Bernstein also. My last A1C was 4.9 but I am backing off of that number a little after going thru kidney stones I am re-structuring a little. But I am a type 2 Byetta baby.(age 61)

  11. Michelle
    Michelle March 26, 2008 at 1:39 pm | | Reply

    We were taught where to find the resources for carb counts – packaging, calorie king, USDA online etc etc etc.

    What we weren’t taught was carb factoring with a scale. That is our preferred method now.

  12. June S.
    June S. March 26, 2008 at 7:10 pm | | Reply

    I was diagnosed in 1972, back in the days when we were allowed to spend an entire week in the hospital being “trained.” The dietician came by with the Food Exchange Lists, which I used for at least one year after my diagnosis. I know the carbohydrate content of most “bread” exchanges and “fruit” and “milk” exchanges is about 15 grams, and I have those serving sizes memorized. I also have a little food scale in my apartment which I use to weigh bread, bagels, etc. When I eat out, I always request pasta “on the side.” I do pretty well with carb. counting, though I was diagnosed in the days before anyone wore an insulin pump!

  13. Hannah
    Hannah March 26, 2008 at 8:05 pm | | Reply

    When I was diagnosed in 1990, it was all exchanges. From the time I was 8 until I was 18, I knew more than all of my friends about nutrition labels and serving sizes. Dinner was two starches, a protein, a fruit, a veggie, a fat, and whatever “free foods” figured in.

    At 18, I learned to count carbs by sitting down with a dietitian, who then informed me how many carbs I should be eating in a meal (which I’ve since forgotten, I always thought the number was assigned to me arbitrarily anyway). Two weeks later, I started on my first pump. Sort of a sink-or-swim situation when it came to carbs–I’ve been doggie paddling ever since.

  14. jef
    jef March 27, 2008 at 2:07 am | | Reply

    Every time I think I have it down I either find new foods that break the system or something strange happens and I have to rethink everything.

    I think it just boils down to knowing certain foods and not knowing others.

  15. Angela
    Angela March 27, 2008 at 3:43 am | | Reply

    The first dietitian I saw didn’t even try to teach me about counting carbs. I was handed a Type 2 meal plan – I do mean PLAN, with only three options for any meal in the day – that involved less than 1500 calories and only 120 carbs per day. I am a Type 1 and at that point I was literally running around all day as a waitress! I managed to get into Joslin, where I learned basic carb counting out of a workbook in a big class of aspiring pump users. Since then, I just pay attention to my body. If I find that my blood sugars are starting to go berserk after a meal, I will weigh and measure for a few days to get myself back on track, using the internet for nutrition info since I don’t eat many packaged foods. Close is good enough for me, especially since I know the CGM will tell me when I’m totally out of whack.

  16. AmyT
    AmyT March 27, 2008 at 8:04 am | | Reply

    You people are great. I too use the SWAG and Doggie Paddling systems. Sink or swim, for sure!

  17. kkonmymind
    kkonmymind March 27, 2008 at 8:19 am | | Reply

    Yes, this is how I learned. My CDE was (is!) great. I was paranoid in the beginning and stuck mostly to things that came with labels. But as I got the hang of it I got a little braver. My CDE mentioned the importance of a good food scale in this process. I took her advice and bought one I am really happy with.

    I still ask her about things I am not good at figuring out.

  18. Olga
    Olga March 27, 2008 at 10:38 pm | | Reply

    Wow, I guess it’s been 24 years already with Type 1 (!) — I was diagnosed at age 11, when we were living in Austria, and I spent 3+ weeks in the hospital getting SO much education that it puts today’s system to shame. Plastic food played a part, we memorized the 15g rule for “breads,” “milks,” and “fruits,” and had a scale at home (which, reading previous posts, I’m tempted to drag out again. Since I eat little prcessed stuff, weighing should be the way to go).

    But seriously, the SWAG Eyeball most of the time, except for treating lows (to avoid overtreating in a panic).

    I’ve found dietitians to be of very little help (and this at the UW, home of the one & only Irl Hirsch) — is it just me?

  19. Lauren
    Lauren March 29, 2008 at 12:17 am | | Reply

    I refuse to carb count or ever weigh an ounce of food I eat. I grew up with a type 1 brother diagnosed in childhood, and could not face adopting that kind of restrictive lifestyle myself. I eyeball what I eat, guesstimate, and exercise after carb-laden meals. A1c is 5.2 so I don’t plan to change my management style.

    When I’m a doctor I will probably not advocate that a patient do what I do, which is “wing it.” But everyone is different, and you have to find what works for you.

  20. Julie
    Julie March 31, 2008 at 10:35 am | | Reply

    I was diagnosed while I was pregnant and the dietician I was sent to see couldn’t wrap her head around the fact that I wasn’t “just gestational.” My Endo (who knew I was T1) just said that I could keep rescheduling with the same dietician if I needed more help. They gave me a sample meal plan that included mostly hot dogs and canned fruit…who would tell a pregnant lady to subsist on that? I was also a vegetarian…but that didn’t alter their 2-page “plan” at all. I discovered everything on my own on the internet and now use CalorieKing, TheDailyPlate, and a scale at home to carb count.

  21. Adam Becker Sr
    Adam Becker Sr March 31, 2008 at 12:35 pm | | Reply


    The picture that accompanies this post shows bread and potatoes. Do you eat much of those?

    I’m type 2; following Bernstein. All the ‘carb counting’ articles I’ve seen suggest much higher carb intake than my body can handle. I try to keep carbs below 20 g / meal, but I don’t weigh portions. If I were taking insulin, I’d probably be following my carb intake a lot more closely. Right now, I can keep below 140 mg/dl at 1 hr postprandial pretty easily.

    Adam Becker Sr

  22. AmyT
    AmyT March 31, 2008 at 1:08 pm | | Reply

    Hi Adam,
    I don’t like potatoes and I’m allergic to wheat, so no, I don’t eat a lot of those things. But LOTS of other foods have carbs too, of course. I’m envious of your post-prands, btw :)

  23. Karen Davis
    Karen Davis April 23, 2008 at 11:15 am | | Reply

    I use the tips in this article http://tinyurl.com/6xyqhu to help my sister (type 1) stay healthy. She stays away from rice though..it’s just too much for her.

  24. Sam
    Sam September 8, 2008 at 1:46 pm | | Reply

    I learned from my diabetes educator at Joslin. We went through awareness step by step in her office and she sent me home with a CalorieKing Book and an EatSmart Nutrition Scale. Time and persistence were the two biggies….now I can eyeball foods pretty well. It did take months if not years to get it right though.

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