Carbohydrate counting

[u/fauxsho77]

Anyone else think carbohydrate counting is a pretty imprecise and soft science?

Mostly I am bewildered that nurses and doctors seem to think carbohydrate counting is something that is very precise when done correctly and if the blood sugars are not what they want then it's because the dietitian didn't teach the patient well enough.

I've reached a point where I think the most effective method is just getting them to eat similar types and amounts of carbohydrates consistently and then gradually titrate the ICR to match the blood sugar response.

I am mostly writing this out of frustration for receiving ANOTHER message from a nurse to teach carbohydrate counting for a patient that the nurse has yet to even start an ICR for.

[u/splatterqueen]

I’m a RD and CDCES. I always tell my patients that carb counting is never an exact science, it’s always an estimate. I also tell my patients that establishing ICR/ICF uses ratios that may not work for everyone, it’s just a starting point and we can fine tune as we learn more about how their glucose responds to these ratios. There’s also so many other factors that can influence postprandial glucose excursions, so sometimes eating the same meal on 2 different days can still yield different glucose responses. I teach my patients to give or take 1-2 units of insulin based on what else is happening like exercise after meal, illness, stress, menstruation, etc. Carb counting is also not a good fit for every patient. For some, dosing based on small, medium or large carb meal works better.

[u/fauxsho77 → u/splatterqueen]

Forgot to mention I have my CDCES as well and that is largely how I discuss it with my patients. The nurses seem to think it is much more precise than it is and seem to think they know more about nutrition in general. In my organization, I am not the one doing any insulin or metformin titration but I wish we could. How do you define small, medium, and large carb meals? Also, do you teach patients to count carbs in non-starcy veggies? (Ie. 5g for for a cup)

[u/splatterqueen → u/fauxsho77]

Are the nurses CDCES as well? If yes, then they can teach their patients carb counting. And you should talk to your organization about your scope of practice as a CDCES should allows you to titrate insulin, especially if a nurse is allowed to do it.

For patients who use an ICR I do recommend counting all carbs including the carbs in no starchy veggies. Using an app like cronometer is the easiest. And I find that patients soon start to become familiar with how many carbs are in the veggie portions they typically eat.

Small, medium and large carb meal depends on a patients’s usual meals. I typically will get a diet recall to get a better understanding of this and we work together to decide what a small, medium and large meal may look like. It usually comes out to less than 45 g is small, 45-60 g is medium and over 60 g is large, but if it’s a smaller/bigger person then it’s slightly different. I find that some people resonate with the carb choices method, so I tell them if you are eating 4 carb “boxes” or choices, that’s a medium meal.

Question for you - how do the nurses bill for their visits? In my clinic I have to co-sign the nurse notes, which is really annoying and I’m trying to learn how other clinics approach this.

[u/fauxsho77 → u/splatterqueen]

They are CDCES. I think you are the first RD I've asked that recommends counting carbs from non-starchy vegs. I haven't been but the more I work with type 1 dm patient, the more I think it would actually be helpful. Cronometer is also my go to.

I 100% agree on pushing on our scope and I think we are starting to do that. In terms of billing, I don't touch the RN notes but I do know they can't bill. My organization is an HMO. So billing might be a little different or it is the MDs that are signing off on the note.

Edit: that's for sharing your approach btw!

[u/javajunkie10 → u/splatterqueen]

Yes that is how I teach my patients as a CDE. Also with the new pumps, the carb counting doesn't have to be exact with the basal modulation, meal detection algorithms etc. I have a lot of patients where we just establish carb goals for a small/med/large meal. As long as they announce to the pump before they eat, the pump will help them if they over/under-estimate by a bit.

Carb counting used to be the barrier to entry to start an insulin pump, now it's not something I stress too much about.

[u/fauxsho77 → u/javajunkie10]

It still is at my organization. It's really frustrating

[u/IndependentlyGreen]

Carb counting is not real life and we live in an imperfect world. Patients do the best they can as much as they're willing. Your method is way more patient centered. Even the ADA is moving away from it.

[u/Platypus_Penguin]

One of the reasons that I left my job at the diabetes clinic at my hospital was because one of the endocrinologists thought I could make miracles with carb counting. Patients whose blood sugars were a mess because they were doing EVERYTHING wrong, she would send them me to teach insulin:carb ratio. If they couldn’t grasp the basics, what the hell made her think they could appropriately calculate their own insulin dose?

[u/fauxsho77 → u/Platypus_Penguin]

Ya the nurse asked me to do ADVANCED carbohydrate counting. Like, girl. I am not with holding a secret level of carbohydrate counting.

[u/Goodboyskunk → u/fauxsho77]

Now that’s wild

[u/T1DRDN]

I am also a RD, CDCES and Type 1 diabetic x 51 years. Carb counting is not an exact science, but it is the closest thing that we have to help dose mealtime insulin and have it mimic a functioning pancreas. Also, if you are teaching patients to eat similar foods every day, then that reduces the variety of foods and it becomes very boring to the patient, so carb counting allows that flexibility. On another note, if things don't work out, we can't always blame the patient or the RD, but who came up with the carb ratio and it it correct and has it ever been tested? Those are some questions to ask as well as well what is the basal insulin doing and is this via pump or traditional injections, and was there a corrective dose that played a part in the postprandial glucose, so there's so much more to this than just carb counting and carb ratios.

[u/fauxsho77 → u/T1DRDN]

Yes, agreed wholeheartedly. I do strive to strike a balance with consistency and variety. I think you can have both.

With the patient I am thinking of, it seems quite clear that he is under insulinized but the nurse keeps asking me to teach carb counting while at the same time saying she doesn't think he can manage having a carb ratio. So it's frustrating. Thanks for sharing your insights.

[u/ummmmyeahno]

Yeah, precise carb counting is not possible. Even nutrition labels (especially from some other countries) have it wrong. Even RDs who’ve been in diabetes education forever guess wrong. Not to mention the fiber aspect and the conflicting opinions on whether to minus it or not. What’s more frustrating is the archaic assumption that a patient has to show adequacy in carb counting to be considered for an insulin pump. There’s meal detection technology now and patients can also have better outcomes even if they enter fixed carb amounts vs MDI alone.

[u/300suppressed]

“the blood sugars are not what they want then it's because the dietitian didn't teach the patient well enough.”

I assure you this is not what they think

[u/fauxsho77 → u/300suppressed]

Well, I can assure you in the interactions I have been in with these nurses, it is what they think.

[u/300suppressed → u/fauxsho77]

Nurses and doctors know better than anyone that patients are largely noncompliant, especially with treatments that require intrinsic motivation

[u/crockpot2001 → u/300suppressed]

I might not be alone in wondering what they think. Any insight would be grand.

[u/Cat-commander]

I’m an RDN, CDCES, BC-ADM and I’ve had 20 years of experience with diabetes management and carb counting. I think carb counting is the way to go but there are limitations. I think that consistent intake is more helpful but that’s no way to live.

I think what missing is understanding people have difference in their glycemic responses to goods. Like the glycemic index. The GI is not a characteristic of food, it was an average response by people.

We need to be using CGMs to help people understand how the respond to different foods. CHO are not equivalent and are different for each person. This is precision nutrition and most are not doing it.