In my full-time practice with an endocrinologist and diabetologist, I see a large population of patients with type 2 diabetes. Nutrition services are provided in one-to-one consultations, and 8–12 patients are seen per day. Our type 2 diabetes population spans the spectrum in terms of educational and socioeconomic level. Whether working or retired, many eat the majority of their meals out or on the run, because their spouse has died, their children are grown, or busy lifestyles don't allow for meals at home. Most have a misconception of the role nutrition plays in their diabetes control.

When patients enter our practice, they often express frustration with their lack of glycemic control, lack of success with weight loss, and continuing problems with weight gain. Patients report frustration that, although they are following a meal plan and their premeal blood glucose levels are close to target, their HbA_lc levels are still elevated. It is often at this frustration point that a patient first meets with the dietitian, and the concept of carbohydrate counting is introduced.

Carbohydrate counting with fat- gram counting is an effective way to work on weight loss and to improve the control of diabetes. Carbohydrate is converted to blood glucose almost 100% within approximately 90 minutes after the meal.² Fat consumption, especially consumption of saturated fat, increases insulin resistance^3,4 along with abdominal body fat distribution, which is often associated with type 2 diabetes.⁵

Patients who understand how different nutrients affect their blood glucose level may be more receptive to strategies designed to improve blood glucose control. Working with patients on an individual basis, I am able to tie diabetes management therapies into their daily experience. My first visit usually includes an overview of diabetes, the role of medications if they are on any, and the role of nutrition and meal planning. One of the most useful tools I have found when working with diabetes patients is the post-meal blood glucose level excursion.

After a discussion of the different nutrients, I have patients do what I call "carbohydrate homework." This involves recording nine meals and blood glucose levels pre- and 90 minutes post-meal. Patients record their blood glucose levels pre- and post-meal for three different breakfasts, three lunches, and three dinners. They also are asked to record the foods they eat, the amount, and if possible (depending on the educational capabilities of the patient), the carbohydrate grams and the fat grams (Table 1).

Often when patients return with their completed homework, they can determine their own diet prescription. When patients see the connection between what they eat and the glycemic response, they are usually impressed. Their pre- and post-meal blood glucose levels guide their carbohydrate and fat choices and portion sizes.

Postprandial blood glucose levels are vital to overall diabetes control. Postprandial blood glucose excursions often cause elevated HbA_1c levels.⁶ Patients may be surprised by the magnitude of these excursions. When evaluating the carbohydrate homework, I average the pre- and post-meal blood glucose levels for each of the three meal categories. I then average the total carbohydrate grams for each of the meals separately and look at the fat consumption. In doing the homework assignments, I suggest:

The tools I use to teach carbohydrate-gram counting include food labels and carbohydrate exchange lists. For fat-gram counting, I use the food labels and a handout on the fat content of foods developed by Nutrition Graphics. The food pyramid and the exchange lists facilitate discussion of which foods contain specific nutrients. Food models are also useful tools for demonstrating what size portions contain specific grams of carbohydrate, fat, and protein.

Most patients find that carbohydrate- and fat-gram counting gives them the flexibility they need for family gatherings and special occasions. Today's lifestyle often does not allow the three structured meals that were common not so long ago.

Carbohydrate-gram counting may be easier to use than the traditional exchange lists. However, some patients may be overwhelmed by counting carbohydrate and fat grams. With these patients, I may use carbohydrate exchanges or possibly the food pyramid to count carbohydrate servings. If a patient is still overwhelmed, a structured individualized meal plan outlining what and when to eat is developed. The patient is encouraged to use American Diabetes Association/ American Dietetic Association cookbooks and the Month of Meals books.

Regardless of the meal planning approach selected, the carbohydrate homework is the basis for the meal plans since it provides information about carbohydrate tolerance for both the patient and me to use. This homework also helps patients understand that sometimes food choices may not be the only reason for blood glucose excursions; medication may be required to control blood glucose levels.

If weight loss is a goal, the carbohydrate homework lets patients know precisely how much they are eating, especially if they are able to count the grams of carbohydrate. Serving sizes are often distorted, and many individuals are often surprised to find out just how many carbohydrate and fat grams they are consuming.

M.A. is taking an oral antidiabetic medication but not insulin, although she has taken insulin in the past. She is 5 ft., weighs 219 lb, and has a body mass index (BMI) of 43, despite working hard on weight loss.

Her HbA_1c is 9.3%, and her glucose logbook shows recorded premeal blood glucose levels averaging 140 mg/dl. M.A. has nonproliferative retinopathy and neuropathy affecting her feet and legs such that she can only walk with the assistance of a cane. She does not want to go back on insulin, yet she needs better control of her diabetes and expresses a desire to lose weight.

M.A.'s carbohydrate homework is shown in Table 2.

E.V. is retired and lives with his wife. He is following a low-fat diet secondary to a history of cardiac problems. He weighs 205 lb, and is 5'7" inches with a BMI of 32. He has not lost weight on the low-fat diet.

E.V.'s carbohydrate homework is shown in Table 3.