The following two case studies illustrate the role carbohydrate counting plays as a meal planning tool for the pediatric population.

Kelsey's parents were initially taught a "no concentrated sweets" diet at another facility. They were told that this meal planning approach is best suited to the naturally erratic eating habits of very young children.

Kelsey's parents are aware that Kelsey's ever-changing eating habits contribute to her erratic blood glucose control, but they do not have the tools to better manage. Kelsey's logbook shows many elevated blood glucose levels from 200–375 mg/dl.

Anthropometrics:

Kelsey's parents provide a 24-hour food recall, which is estimated at 1,500–1,600 calories/day, significantly higher than her calorie needs based on Recommended Dietary Allowances for age and weight (102 kcal/kg, or 1,200–1,300 calories/day.) Kelsey's parents remark that she is currently eating much more than usual; her voracious appetite is assumed to be due to suboptimal glycemic control.

To avoid excessive weight gain as glycemic control improves, Kelsey's parents agree to work with more age-appropriate portions and carbohydrate counting goals. A meal plan of approximately 1,200–1,300 calories/ day with the following carbohydrate targets is established:

Kelsey's parents are taught how to use the exchange system meal plan and carbohydrate counting principles to establish an optimally healthy diet and make food and blood glucose levels more predictable. Portion control is introduced using the exchange system portions as well as food labels for other carbohydrate-containing foods.

At the next follow-up visit, how best to work with Kelsey's erratic eating habits is discussed. Emphasis is placed on using the carbohydrate targets flexibly with the goal of allowing Kelsey to "eat to her appetite."⁵ While establishing optimal glycemic control is important, allowing her to have some reasonable and appropriate control over food choices and portions is equally important. The goal is to avoid creating any food conflicts or control issues and to allow for enjoyable family meals and snacks.⁶

Kelsey's carbohydrate targets provide a range of ±15 g carbohydrate at a meal and ±5 g carbohydrate at snack time. Kelsey's parents are asked to give her more food if needed, starting with age-appropriate free foods, such as cooked vegetables, sugar-free gelatin or Popsicles, or more protein-containing foods, such as a slice of cheese or strips of luncheon meats, to facilitate better blood glucose management.

Finally, the option of using lispro insulin after eating to more safely manage unpredictable eating is introduced. For example, 1/2 U lispro, rather than her usual 1–2 U lispro, will be given after dinner if Kelsey only eats half of her dinner (15 g carbohydrate, rather than 30–45 g).

Kelsey's meal plan and carbohydrate targets are adjusted over time based on her appetite and calorie needs for growth. Her HbA_1c values improve to between 7.5 and 8.8% with no frequent or severe hypoglycemia. Her mother reports that Kelsey has a healthy appetite and continues to be a delight at the family table.

Joseph's logbook shows many blood glucose levels over 200 mg/dl at dinnertime during the week and at bedtime on the weekends. Joseph corroborates that the higher readings occur frequently after eating with his friends. Joseph has had excellent blood glucose control since diagnosis, with HbA_1c values 5.3–7.1%, but his most recent HbA_1c was 8.2%. Joseph feels that the current carbohydrate targets are appropriate, and his food recall substantiates this, but he admits that he needs to better manage his eating when with his friends.

Joseph states his current carbohydrate targets as follows:

His meal plan is estimated at approximately 2,500 calories/day.

The lispro pen is introduced to promote ease in giving extra insulin to cover snacks and restaurant meals that do not fit into his usual meal plan. The lispro pen offers portability, discretion in use, and the quick action time of lispro insulin.

A carbohydrate-to-insulin ratio is determined using Joseph's blood glucose levels, grams of carbohydrate consumed, and current insulin dose. A carbohydrate-to-insulin ratio of 1 U lispro for every 10 g carbohydrate is established. Joseph is given a fast food guide to calculate the carbohydrate grams of his favorite fast foods and is asked to monitor his blood glucose levels 2 hours after the additional bolus dose to evaluate the coverage.

When Joseph and his mother return to Diabetes Clinic, Joseph's logbook shows fewer elevated blood glucose readings at dinner and bedtime with the majority of the readings in target range after he eats. Joseph states that he is using the pen before eating with his friends when he knows he will overeat (such as pizza or fast food), as well as immediately after an unplanned higher-carbohydrate meal or snack. Both Joseph and his mother feel that the use of the lispro pen and the carbohydrate-to-insulin ratio are tools that allow Joseph to be "like any other teenager."

Boston's Children's Hospital cares for approximately 1,000 children and adolescents with diabetes. In 1999, approximately 200 newly diagnosed children were admitted to Children's Hospital, a third of whom were under 6 years of age. Initial meal planning and carbohydrate counting education begins during the 1–3 days that a child is in the hospital, with an age-appropriate meal plan that is based on the child's typical eating habits. The Children's Hospital meal plan is a large, one-page form that incorporates the meal plan, exchange list, and carbohydrate counting targets. By teaching both the exchange system and carbohydrate counting techniques, families are taught the value of good nutrition, as well as the goals for optimal glycemic control.

The dietitian in the outpatient Diabetes Clinic sees the family shortly after discharge. Newly diagnosed children are seen for at least 3–4 visits the first year. Children under 6 years of age are seen for nutrition visits at least twice per year; older patients are seen at least annually. New patients are scheduled for 60 minutes; follow-up visits last 30 minutes.

The emotional turmoil of having a child diagnosed with diabetes results in a challenging learning environment for the family as well as the educators. Some families come to their first appointment confident and comfortable with the meal plan; others struggle with fitting the plan into the family structure. Working parents, lack of supervision of the child after school, developmental stages, and previously unstructured family eating habits can contribute to a more difficult transition to the meal plan.

Two additional challenges that affect a consistent use of the meal plan after diagnosis are changes in the child's appetite and the honeymoon period. The polyphagia resulting from elevated blood glucose levels and weight loss before diagnosis usually resolves within 2 weeks of diagnosis. The child's decreased appetite necessitates gradual reductions in the caloric level of the plan. The honeymoon period diminishes the effect food has on the blood glucose level and can lessen the family's motivation to develop and maintain meal planning skills.

Carbohydrate counting principles are taught using carbohydrate grams and/or carbohydrate servings based on the exchange groups and food labels. Using the exchange food lists, each starch, fruit, or milk exchange is counted as 15 g carbohydrate, or one serving.⁷ The grams of carbohydrate, or carbohydrate servings, can be calculated based on the number of starch, fruit, and milk exchanges allowed for each meal and snack. Once families master these basic principles, the use of a carbohydrate-to-insulin ratio to proactively cover higher-carbohydrate meals and snacks, such as spaghetti or fast food, can be introduced.

In addition to the meal plan, other teaching tools used include the American Diabetes Association/ American Dietetic Association exchange lists, "kid friendly" snack lists, and fast food guides. Food models, measuring cups, and a variety of food labels aid in accurately estimating portion size. Visual tools are essential when English is not the family's primary language.

Once a child reaches school age, it is important that the child attends and participates in the nutrition visit. Children are encouraged to provide the food recall and are asked if they have any particular food questions or concerns. A school-age child can report what is actually eaten for school lunch⁸ or what is eaten at after-school programs or at friends' homes. Adolescents are given practical information on fitting in fast food and ways to adjust the meal plan for school sports, activities, jobs, and other times away from home as they become more independent in their diabetes care.

Carbohydrate counting offers a sense of normalcy for children and adolescents with diabetes that was not possible before. "Cheating" is less of a problem than in years past, as no foods are considered forbidden. Carbohydrate counting reduces parental worries regarding food on a daily basis and especially around the many food-oriented holidays, such as Halloween, Thanksgiving, and birthdays, and allows children to more normally experience these special times at school and at home.

The expanded food choices available with carbohydrate counting create new challenges regarding portion control and healthy eating. For example, 1 cup of Frosted Flakes will have a greater effect on blood glucose level than 1 cup of Cheerios. Families are taught to weigh or measure foods at diagnosis, but portion control often slips over time as families rely on "eye-balling" portions rather than measuring. Families are asked at each visit to reeducate "their eyes" by weighing and measuring the carbohydrate-containing food for at least 3–4 days after each visit.

On an everyday basis, the responsibility to teach healthy eating habits lies with parents, rather than with diabetes educators. Packing fruit as snacks, alternating between bringing lunch from home and buying school lunch, sitting down to dinner as a family, and acting as good role models are some ways parents can encourage healthy eating habits while a child is young.

Carbohydrate counting skills can be evaluated at each visit by reviewing the child's logbook and growth chart. A consistent and appropriate carbohydrate and calorie intake results in predictable blood glucose patterns and steady growth. The long-term goal of nutrition education is to provide appropriate management of food with exercise and insulin doses to maintain normal growth and development, improve quality of life, and prevent short-term and long-term complications.⁹

Carbohydrate counting has been an invaluable tool for families with diabetes. We can now enjoy being able to tell parents that there is no food that their child cannot have and that the meal plan will be designed around how and what the child likes to eat. We empower parents with the responsibility to balance the freedom carbohydrate counting allows with the importance of instilling healthy eating habits for life.