A pharmacist's first thought in chronic diseases is usually on medication therapy. We initially jump to think of appropriate drug selection, correct dosing, adverse effects, and drug interactions to consider. But for our diabetes patients, pharmacists have a unique opportunity to provide them with education on the therapeutic lifestyle changes that are an integral part of their disease management. Therapeutic lifestyle changes include exercise, weight loss, and especially a healthy dietary plan. While the majority of diabetes patients do need to see a nutritionist for comprehensive dietary assessment and planning, community pharmacists can talk with patients about some of the basic choices that they have for meal planning. Although all components of a healthy diet are important, such as limiting saturated fats and increasing fiber, this article will focus on appropriate carbohydrate intake.
Often when I see newly diagnosed diabetic patients, they come to me with the assumption that they will have to completely eliminate all carbohydrates and sugar from their diets. I typically see a sigh of relief when I begin to explain that this is not the case at all. Patients need to understand that carbohydrates, although converted to sugar in the body, are a necessary component of their diet. Carbohydrates are the body's main source of energy for all cells, including brain cells. Many diabetic patients are still under the assumption that the only ingredient they need to focus on when looking at a food label is the grams of sugar present. While it is commonly believed that sucrose and other sugars lead to a more rapid and exaggerated response in blood glucose, research has now shown that sucrose does not have a greater impact on blood glucose levels than other carbohydrates. Many factors influence the glycemic response from different carbohydrates. Therefore, it is important to explain to patients to focus on the total carbohydrate content for any given meal rather than the amount of sugar present.
Carbohydrate counting is one approach to diabetic meal planning and works well for many patients. First, a patient needs to understand what types of foods are carbohydrates. Explain to patients that examples of carbohydrates include starches (rice, pasta, dried beans, bread, grains, etc), starchy vegetables (potatoes, corn, green peas), fruit, milk, yogurt, and sweets. Understanding actual serving sizes of these foods is a concept many patients do not have. I use the following examples to explain serving sizes for carbohydrates:
For beans, starchy vegetables, and cooked cereals (oatmeal): 1/2 cup
For bread: 1 slice or 1 medium dinner roll
For cooked rice and pasta: 1/3 cup
For most cereals: 3/4-to 1 cup
For most fruits: about the size of a tennis ball
Many pamphlets and educational pieces of literature are available that explain carbohydrate serving sizes, but these examples give patients a good starting point.
Second, explain that 1 carbohydrate serving is approximately 15 g of carbohydrates. Therefore, 2 carbohydrate servings would equal 30 g, 3 would equal 45 g, and so forth. So, for example, a lunch consisting of a ham sandwich (2 carbohydrate servings), an apple (1 carbohydrate serving), 1/3 cup of pasta salad (1 carbohydrate serving), and a diet soda would total 4 carbohydrate servings or 60 g.
For the average woman, a diet consisting of approximately 3 carbohydrate servings (45 g) per meal is reasonable. For the average man, a diet consisting of approximately 4 carbohydrate servings (60 g) per meal is adequate. In addition, most patients do well with 1 to 3 snacks per day, 15 g, or 1 carbohydrate serving each. This will, of course, vary from patient to patient and may include as few as 2 carbohydrate servings per meal for patients trying to lose weight or as many as 5 to 6 carbohydrate servings per meal for those patients who are very active or athletic individuals. For that reason, advice and individual meal planning from a dietitian are helpful. But since pharmacists are often the most approachable health care providers, we can provide patients some initial information to let them know that carbohydrates will still need to be a healthy part of their diet.
Dr. Brian is a clinical specialist with Cornerstone Health Care, High Point, NC.
Some helpful resources for patients to learn more about carbohydrate counting include:
Carbohydrate Counting and My Food Plan, both available from www.idcpublishing.com.
Flash Carbs and Carb Counting Made Easy, both available from the American Diabetes Association Web site, www.diabetes.org.
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