COMMENTARY

Implementing Carb Counting in Primary Care: Helping Patients Master the Basics

Jay H. Shubrook, DO; Karen R. Bailey, MS, RD, LD, CDE

Disclosures

May 08, 2017

Jay H. Shubrook, DO: Hello. I am Jay Shubrook, DO, diabetologist at Touro University, California. I am happy to continue our series on Practical Insulin Use for Primary Care. Today I am speaking with Karen Bailey, a registered dietician and certified diabetes educator (CDE) who works at the Diabetes Institute at Ohio University in Athens, Ohio. Welcome, Karen.

Karen R. Bailey, RD, CDE: Thank you.

Dr Shubrook: Today we are going to talk about a really challenging topic: carbohydrate counting in diabetes. We have many patients who take insulin as part of their treatment, many of whom also take mealtime insulin. Mealtime insulin is really best when it matches not only the blood glucose level but also the food being consumed. How do we make sense of carbohydrate counting in primary care?

Ms Bailey: Carbohydrate counting can be a pretty useful tool for good glucose management after meals. It does require that your patient understand how to count carbs. I recommend that you send your patient to a CDE or dietician for instruction on carbohydrate counting. What they are going to learn is which foods have carbohydrates in them and ways they can count carbs, including label reading, lists of foods that include carbohydrates (such as starches, fruits, milk, and yogurt), and portion sizes. Once a patient has learned that, they may be able to make use of an insulin-to-carb ratio that is decided upon by the doctor and the patient.

Dr Shubrook: That sounds complicated. Walk me through some of these steps that I can use to advise my patients while I try to get them to a diabetes educator. I agree—that is a very important step to help my patients really obtain the best control they can.

Ms Bailey: I would recommend that clinicians provide a brief education on label reading. A lot of the foods that we eat these days do have labels. Having an example of a label to show the patient, and to show them where to find information about total carbohydrates and the serving sizes of foods the patient typically eats, is very helpful. Of course, not everything has a label on it, but that is a good start. Before an insulin-to-carb ratio is prescribed for a patient, suggest a food log and carbohydrate counting, looking up the carbohydrates in foods to help your patient start learning and feel a little more comfortable about this whole concept.

Dr Shubrook: I find that some providers struggle with carb counting themselves. If I do not feel like I have the confidence to teach carb counting, would it be appropriate to ask a CDE to help me with that?

Ms Bailey: It would be an excellent idea. Hopefully, the provider can find a CDE in their area. I would check with a hospital first, which often has a dietician that does outpatient counseling. Even if that person is not a CDE, a dietician should be able to teach carb counting. That educator might also be really happy to share some basic information with the clinician that will assist them with explaining the concept to their patient.

Dr Shubrook: I think that is really important because we have a limited amount of time when we see our patients, and this is a concept that has to be done carefully and thoughtfully. What I am hearing you say is that if I refer to a CDE to get a patient set up for carb counting, asking the patient to keep a food diary in advance would be really helpful.

Build in Before-and-After-Meal Glucose Checks

Ms Bailey: Yes. I think it is going to be really helpful for both the provider and the patient. It gets the patient started on thinking about what he or she is eating and how much. Having said that, it is not always easy to get a person to keep a food diary, is it? We often recommend that and then it does not happen. If a patient is not willing or able to look up foods and calculate carb intake, then there are other options. Maybe then, the doctor and the patient can instead calculate a fixed insulin dose for mealtime, starting conservatively. This approach does require that the patient check their blood sugars to determine whether that insulin fixed dose is appropriate. We still need some buy-in from the patient and some participation in their own care.

A lot of patients will be concerned that their insurance coverage does not allow the six strips a day needed to check before and after every meal. If the patient is only able to use one or two strips a day, then that is what you work with. Check one meal one day, the next meal another day, and the third meal another day. After a while, you have some data. You have at least some idea of how that fixed dose is working with each meal to help determine whether adjustment in the insulin dose is needed.

Dr Shubrook: So, checking before and after the meal will help your patient understand what that amount of carbohydrates did to the glucose level.

Ms Bailey: Checking before and 2 hours after the meal is such a powerful tool for the patient if they are willing to do it. It gives them immediate feedback. A rise of more than 50 or 60 mg/dL is an awfully big glucose jump. That patient probably should eat a little less carbohydrate or take a little more insulin for that meal.

Dr Shubrook: Of course, this is an estimate. Every day we eat slightly different amounts, and the change in glucose level is a little bit different each day.

Ms Bailey: That is exactly right. Ongoing learning about response to different meals is great information for your patient. A salad with chicken or burritos with rice—these are very different meals with very different blood glucose responses. So a blood glucose check before and 2 hours after these two meals will be very helpful.

Dr Shubrook: I want to send someone to a CDE to help with carb counting. I want to ask my patients to keep a food diary in advance of this appointment. I want at least some of those meals to have a pre-and post-glucose check. Combined, these tools help my patient with carbohydrate counting, correct?

Ms Bailey: Yes. The CDE normally will spend an hour with a patient, or an hour and a half—a luxury that providers just do not have. We may see that person on multiple occasions if they are willing to come back and reinforce what they have learned. We may recommend a diabetes support group which allows people to share their experiences with others. We may also recommend classes to learn not only about carb counting but also about good insulin injection sites, proper monitoring techniques, and the effect of activity on blood sugars, which can really make a difference in postprandial glucose.

Dr Shubrook: Patients who have not yet implemented carbohydrate counting and are taking a fixed mealtime insulin dose should have a carb-consistent meal then, correct?

Ms Bailey: Yes, they should, but there is the trick. A patient who is not willing to learn about carb contents of foods will have trouble knowing whether he is eating a fixed meal. If someone usually has a small meal at breakfast, a smaller dose is appropriate, versus a larger dose with a big meal at dinner or at a restaurant. For those patients, it may be better to talk about portions and the amount of food eaten with a meal. That is pretty logical for patients, and they get that. Sometimes I even have patients tell me that even though their provider told them how much insulin to take with meals, they give themselves a little more when they eat out. Intuitively, it makes sense for patients.

Dr Shubrook: Are there any resources you recommend to help patients or providers learn about carb counting?

Ms Bailey: Yes. The American Association of Diabetes Educators provides Diabetes Tip Sheets on healthy eating, glucose monitoring, and other information, many of which are available in both English and Spanish. The American Diabetes Association also has patient resources. Another organization is the Academy of Nutrition and Dietetics, which has a range of basic information about diabetes.

Dr Shubrook: I think this is an important topic that is a real challenge in primary care. You have given us some really good tips to help us and our patients to get a better start. Thank you so much.

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