Think Like a Pancreas

by Gary Scheiner

  Carbohydrate Gram Counting

  As mentioned in the previous chapter, carbohydrates are the primary blood sugar–raising elements in the diet. All carbohydrates (simple and complex), with the exception of fiber, convert into blood glucose fairly rapidly. Thus, quantifying the carbohydrates in our meals and snacks is of the utmost importance.

  For those who are attempting to match their mealtime rapid-acting insulin to food intake, carbohydrates should always be counted in grams. This is the most precise and practical way to count carbs; using carb “choices” or “exchanges” tends to make things more complex and less precise. If you are accustomed to using the exchange or choice system, the transition to grams can be made by using Table 4-4 below. Simply add the amount of carbohydrates you are getting from each exchange, and you have your carb total for your meal.

  Table 4-4. Converting exchanges into grams of carbohydrate

  1 bread exchange = 15 grams carb

  1 fruit exchange = 15 grams carb

  1 milk exchange = 12 grams carb

  1 vegetable exchange = 5 grams carb

  1 meat exchange = 0 grams carb

  1 fat exchange = 0 grams carb

  In other words, a meal consisting of two breads, two fruits, a milk, and three meats contains (2 × 15) + (2 × 15) + (1 × 12) + (3 × 0), or 72 grams of carbohydrate. Just make sure you have the right portion sizes for each exchange. For example, one ordinary banana may be one, one and a half, or two fruit exchanges, depending on the size of the banana.

  As a general rule, counting all carbs equally is best. True, there are some subtle differences in how quickly different carbohydrates raise the blood sugar, but all carbs (except for fiber) eventually turn into glucose, so count them all the same. For example, 12 grams of carbohydrate from milk will raise the blood sugar more slowly than 12 grams of carbohydrate from bread, but after several hours the total rise will be equal.

  If you consume a food high in fiber, such as whole grain bread, beans, or bran cereal, you may not see as much of a blood sugar rise as you might expect. Fiber is a carbohydrate that is resistant to digestion and hence does not tend to raise the blood sugar. When taking nutrition information from a food label, subtract the fiber grams from the total carbohydrate. For example, a high-fiber cereal that contains 8 grams of fiber and 31 grams of total carbohydrate should be counted as 23 grams of carb (31–8).

  Now this is really important: The more accurate you are at carb counting, the better you will be able to control your blood sugar. There are a number of techniques for counting carbs. One of the simplest and most effective is label reading. All food manufacturers in the United States (as well as most other industrialized countries) are required to list the serving size, total carbohydrate content, and carbohydrate breakdown on their food labels. Note that food labels include the fiber in the total carbohydrate even though fiber does not convert into blood sugar.

  Sugars (simple carbohydrate)

  + Starch/other (complex carbohydrate)

  + Fiber

  = Total carbohydrate

  Figure 4-5. Sample food label

  Figure 4-5 shows a sample food label: A serving of Gloopers (a half cup) contains 20 grams of total carbohydrate. If you consume a full cup, you would have 40 grams of carb.

  Sugar alcohols such as sorbitol, mannitol, and xylitol are also included in the total carbohydrates. Sugar alcohols are used as sweeteners in many sugar-free foods. Although slow to act, sugar alcohols will raise blood sugar, albeit less than most other carbohydrates will. As a rule, it is a good idea to deduct half (50 percent) of the sugar alcohol grams from the total carbohydrate.

  Another tool for carbohydrate gram counting is a nutrient guide. There are many pamphlets, books, and websites that list the carbohydrate content of various foods. Some cover specific categories such as restaurant food or ethnic food; others cover a wide range of commonly consumed foods. Several are listed in the resources section in Chapter 10. My book The Ultimate Guide to Accurate Carb Counting serves as both a nutrition reference and a detailed teaching guide for becoming a more proficient carb counter. Feel free to visit my website (www.integrateddiabetes.com) or call my office (877-735-3648) to order a copy.

  A somewhat more sophisticated technique for counting carbs is portion estimation. This method is particularly useful when dining out or enjoying foods that vary in size, such as fresh fruit, starchy vegetables, or baked goods.

  Portion estimation involves using a common object such as your fist or a deck of cards to determine the approximate size of a particular food item. Then the carb count is determined based on the typical carb content for a standard size of that item.

  Common measuring devices:

  soda can = 1½ cups

  adult’s fist = approx. 1 cup

  large handful = approx. 1 cup

  tennis ball = approx. ½ cup

  cupped hand = approx. ½ cup

  child’s fist = approx. ½ cup

  tip of thumb = approx. 1 inch across

  adult’s spread hand = approx. 8 inches diameter

  adult’s palm = approx. 4 inches diameter

  Approximate carb counts for standard portion sizes:

  potato ≈ 30g/cup

  pasta (w/sauce) ≈ 35g/cup

  rice (boiled) ≈ 50g/cup

  sticky rice ≈ 75g/cup

  salad/raw vegetables ≈ 5g/cup

  cooked vegetables ≈ 10g/cup

  rolls ≈ 25g/cup

  dense bread (bagel/soft pretzel) ≈ 50g/cup

  fruit ≈ 20g/cup

  ice cream ≈ 35g/cup

  cake/muffin/pie ≈ 45g/cup

  pretzels ≈ 25g/cup

  chips ≈ 15g/cup

  popcorn ≈ 5g/cup

  cereal ≈ 25g/cup

  milk ≈ 12g/cup

  juice, soda ≈ 30g/cup

  sport drink ≈ 15g/cup

  sub sandwich rolls ≈ 8g/inch

  pizza ≈ 40g/8-inch diameter (round)

  pizza ≈ 30g/closed hand (slice)

  cookie ≈ 20g/4-inch diameter

  pancake ≈ 15g/4-inch diameter

  tortilla ≈ 15g/8-inch diameter

  For example, an adult’s fist is equal to about a one-cup portion. If a cup of boiled rice contains 50 grams of carbohydrate and you consume one and a half fist-size portions of rice, you will have eaten about 75 grams of carbohydrates. Three large handfuls of chips will contain 3 × 15, or 45 grams of carbohydrates. A six-inch-long sandwich will contain 6 × 8, or 48 grams of carbs.

  A more precise technique for counting carbs involves using carb factors. By weighing the portion of food that you plan to eat on a gram scale and multiplying by the food’s carb factor, you will obtain a precise carb count. A carb factor is actually the percentage of a food’s weight that is carbohydrate. For example, apples have a carb factor of 0.13, which means that 13 percent of an apple’s weight is carbohydrate. If an apple weighs 120 grams, the carb content is 120 × 0.13, or 15.6 grams. For an abbreviated list of carb factors, see Appendix B.

  When you’re ready to put your carb counting skills to the test, try taking the Carb Counting Quiz at my website, http://integrateddiabetes.com/carbquiz.shtml. Solutions and a scoring guide are provided—but no cheating!

  Dietary Discipline

  Mastering the fine art of carb counting does not give you free reign to consume everything and anything in sight. For one thing, providing the necessary spacing between meals and snacks is important. This gives your mealtime insulin a chance to get your blood sugar back down to normal before you eat and thus temporarily drive it up again.

  Think of it this way: If you were on a small boat that had sprung a leak, what would you do? If you let the water keep pouring in and just bail out, you’re never going to get the water completely out of the boat. But if you seal the leak and then bail, you should have a dry boat in no time. Eating too frequently, without allowing space between meals, is like letting the water continue to pour in—but in this case, it is glucose
flowing into your bloodstream. Your blood sugar is never going to come back down to normal because you’re constantly adding additional glucose. Waiting a while after eating is like plugging the hole: The mealtime insulin bails the glucose out of your bloodstream and your blood sugar comes back down to normal.

  Spacing meals and snacks at least three hours apart will help you keep your blood sugar levels close to normal.

  In my experience it is best to wait at least three hours between meals and snacks. After three hours rapid-acting insulin has done the vast majority of its work so the blood sugar should be close to normal again.

  Another aspect of the daily diet that requires attention is the amount of fat intake. As mentioned in Chapter 3, consuming large amounts of dietary fat can cause unusual and unwanted changes to blood glucose levels. Large amounts of fat in a meal can slow digestion to the point that rapid-acting insulin peaks before the blood sugar has a chance to rise. This can produce hypoglycemia soon after eating, followed by a blood sugar rise a few hours later. The fat itself can then cause a secondary blood sugar rise by causing insulin resistance and the liver to oversecrete glucose. Also, don’t forget that fat is very high in calories and tends to contribute to unwanted weight gain. This in turn can also cause insulin resistance and increased insulin requirements, and it may further increase your risk for large blood vessel (macrovascular) diseases.

  So the bottom line is don’t graze, and keep the fat intake modest.

  Insulin Dosage Adjustment

  By its very nature diabetes management requires ongoing adjustment of insulin doses. Self-adjustment of insulin is necessary to balance the factors that raise and lower blood sugar. Matching insulin to your precise needs is what your pancreas would do if it could. To “think like a pancreas” means to do what your pancreas would have done on its own.

  For starters, rapid-acting insulin doses should be adjusted based on

  •premeal/presnack blood sugar levels;

  •anticipated carbohydrate intake; and

  •changes to your usual sensitivity to insulin, which can be caused by

  physical activity,

  stress,

  hormonal changes,

  illness, and

  medications.

  In addition, adjustments should be made to your overall insulin plan (including basal insulin doses) in the event of recurrent hypoglycemia or hyperglycemia. Insulin dosage adjustment and overall plan changes will be the focal point of the next three chapters of this book.

  The Right Attitude

  I feel like every week I come across someone who has everything they need to manage their diabetes—the latest high-tech toys, a great plan, and all the self-management education, training, and support in the world. Everything . . . except the attitude needed to make it work. This is a common situation among adolescents, but it can—and does—occur in people of all ages and with varying levels of diabetes experience.

  A healthy mental approach to living with diabetes is just as important as the tools and skills outlined above—perhaps even more important. See how you fare in the following areas.

  Determination

  Exactly where does managing diabetes rank in your set of personal priorities? Although nobody would expect you to place your diabetes selfcare above the immediate well-being of your family, it should hold a prominent place in your life—and with good reason. Managing your diabetes enables you to fulfill all your other obligations and enjoy what life has to offer. Think about it: If your diabetes is not in control, how will it affect you at work? At school? At home? At the gym? In bed?

  Problem Solving

  There will be obstacles to taking care of your diabetes: time constraints, access to care and equipment, other health concerns, and costs. But, as I like to say, when the going gets tough, the tough get solving.

  For example, if your health insurance is unwilling to pay for a product or service that you feel you need in order to manage your diabetes, fight the company on it. Contact your state’s attorney general’s office if you suspect that your insurance company is not complying with regulations. And if necessary, pay out of pocket. You simply cannot put a price on your health.

  Persistence

  Michael Jordan was perhaps the greatest basketball player of all time. A prolific scorer, tenacious defender, and fierce competitor, MJ managed to win six NBA championships despite being undersized—he was a mere six-foot-six—and lacking a dominant “big man” in his supporting cast. But did you know that Michael “Air” Jordan, icon of the basketball world, was cut from his high school basketball team as a freshman? Had Michael chosen to throw in the towel and concentrate on baseball or—heaven forbid—his studies, he would have deprived himself and the rest of the world of his amazing talents.

  Persistence is a valuable trait in many aspects of life. From business to dating to basketball, persistence has a way of paying off in big ways. This is certainly the case when managing diabetes. Given the relentless nature of this disease, managing over the long term takes tremendous persistence.

  Over the course of your life with diabetes, there will be countless setbacks. When they occur, do not give up. It really helps to live your diabetes life one day at a time. You can’t change the past, so don’t worry about what you did—or didn’t do—yesterday. And you certainly can’t live tomorrow until tomorrow. Every day represents an opportunity for a fresh start.

  Of course, taking temporary breaks from your usual management routine is reasonable—and perhaps necessary—as long as you maintain a level of care that keeps you out of harm’s way. For example, take a day or two each month to relax your diet, exercise, frequent monitoring, and record-keeping routine. Just be sure to take your insulin and check your blood sugar at key times of the day.

  Discipline

  Despite being a general pain in the neck, some good things come from having diabetes. We can get seated in restaurants faster. We may be able to get around the long lines at amusement parks. And we also can develop a healthy sense of discipline.

  Being disciplined does not mean living like an emotionless robot. Rather, it means sticking to a plan even in the face of distraction and adversity—maybe not all the time, but certainly most of the time. And there is tremendous value to structure and consistency; it eliminates many of the variables that can mess up our control.

  Take, for example, avoiding the tendency to snack too often—even after Halloween, when there are little chocolate snacks everywhere. The benefits of spacing meals and snacks several hours apart were described earlier. Also be sure to engage in your usual exercise, even when you just feel like staying in bed. As we discussed in Chapter 3, physical activity can amplify the effects of insulin for up to forty-eight hours, but those who maintain a consistent pattern of exercise usually have more predictable insulin action. Those who exercise off and on usually have a harder time predicting how well their insulin will work.

  If you’re the weekend warrior type—lots of activity on the weekends, very little during the week—you will probably find that your insulin sensitivity varies considerably. You may be more prone to unexpected lows on Saturday, Sunday, and Monday, when your sensitivity to insulin is very high, and you might see unusual highs on Tuesday, Wednesday, Thursday, and Friday when you lose insulin sensitivity and your insulin fails to work as hard as you expect. By comparison, someone who exercises consistently throughout the week will have a fairly stable level of insulin sensitivity and hence more predictable insulin action.

  People who are disciplined about keeping written records, checking blood sugar levels, counting carbohydrates, calculating insulin doses accurately, taking their insulin on time, and seeing health care providers regularly also tend to have more consistent blood sugar control over the long term.

  Acceptance

  Despite your best efforts, you will not be in perfect control of your diabetes all the time—and that’s okay. If a baseball player went to pieces every time he failed to get a hit, we would have a lot
of .300 hitters sitting in the dugout crying.

  Set your expectations at a realistic level. Using the “acceptable range” chart earlier in this chapter might serve as a good starting point. If you are in-range 20 percent of the time currently, see if you can get it up to 30 or 40 percent by next month. And remember that even those with outstanding control are still out of range on a semiregular basis.

  As Clint Eastwood’s Dirty Harry character liked to say, “A man’s gotta know his limitations.” Accept that there are limits to what you can reasonably accomplish; trying to change too many behaviors all at once usually leads to disappointment and burnout. Making a list of all the things you could be doing to improve your control and then prioritizing them may help. Try to implement one at a time.

  For example, if you are just getting started with trying to manage your diabetes intensively, try implementing one key change each week:

  Week 1: Start checking your blood sugar before each meal and snack, and then write down the results. Don’t worry about what the numbers are—just check and record.

  Week 2: Start using a formula to adjust your mealtime insulin doses based on your premeal/presnack blood sugar.

  Week 3: Begin looking up the carb counts in your foods and writing them down, along with your blood sugars and insulin doses.

  Week 4: Learn to adjust your insulin doses based on carbohydrate intake.

  Week 5: Start getting some daily exercise, and add that to your written records.

  Week 6: Learn to adjust your insulin doses based on physical activity.

  Week 7: Try downloading your meter and evaluating the reports to see if adjustments to your dosing formulas are needed.

  Week 8: Send a batch of thank-you brownies to the author of your favorite diabetes book. (My address, incidentally, is 333 E. Lancaster Ave., Ste. 204, Wynnewood, PA 19096. Please don’t forget the rest of my staff . . . our office manager is especially fond of brownies!)