Diabetes Spectrum
Volume 13 Number 3, 2000, Page 149
From Research to Practice/ Medical Nutrition Therapy

Carbohydrate Counting: A Return to Basics

Carbohydrate Counting in Institutions

Standardized calorie-level meal patterns based on exchange lists have traditionally been used in hospital settings to plan meals for patients. However, it has been recommended that the term "ADA diet" no longer be used, as the American Diabetes Association no longer endorses any single meal plan or specified percentages of macronutrients.1 Diet orders such as "no concentrated sweets," "no sugar added," and "low sugar" are also inappropriate because they do not reflect the diabetes nutrition recommendations and unnecessarily restrict sucrose.

In the position statement "Translation of the Diabetes Nutrition Recommendations for Health Care Institutions,"1 a "consistent-carbohydrate" diabetes meal plan is a suggested alternative. However, despite these recommendations based on research evidence, the actual implementation of carbohydrate-based menu planning approaches has been a slow transition that has met much resistance.

This article summarizes the use of carbohydrate counting in adult inpatient, pediatric inpatient, and nursing home settings. Because published research is not available on the implementation of carbohydrate counting in institutions, an inquiry was posted on the e-mail of the Diabetes Care and Education (DCE) practice group of the American Dietetic Association to identify registered dietitians who have been implementing carbohydrate counting menu systems in their institutions. More than 20 dietitians responded. From this group, several individuals were interviewed in more detail. Their experiences reflect various similarities and differences depending on the type of institution and the client base.

Morton Plant Mease Health Care, Clearwater, Florida
The author's own institution is the 600-bed Morton Plant Mease Health Care hospital in Clearwater, Fla. The population at this hospital is mostly elderly, with a small pediatric unit. Diabetes is not the primary diagnosis for most patients. After the release of the diabetes nutrition guidelines, it was decided that the hospital menus, particularly those used for pediatric patients with diabetes, needed to be evaluated. The diabetes education and nutrition staff hoped they could make the food aspect of diabetes management easier and perhaps provide a more positive experience.

First, the diabetes nutrition educator (author) met with the Food and Nutrition dietitians to promote the idea of converting to a consistent-carbohydrate menu and to work on menu development. We started with the regular menu, but found it was not adequate due to the lack of information on the menu regarding food groups. Instead, an exchange list menu was used, all designations of exchanges were removed, and all the carbohydrate foods were identified. Foods containing ~15 g carbohydrate were labeled as one "carb."

A dessert choice was also added to either lunch or supper each day, along with the carb notation. If the dessert contained 30 g carbohydrate, it was marked as "2 carbs." Desserts containing three or more carbs were not included. At the top of the menu were directions to include 3–5 carbs at each meal, which provided 1,500–2,000 calories per day. If a patient needed more calories, the number of carbs per meal could be increased on an individualized basis.

Next, we met with the hospital's pediatricians to inform them of the new nutrition recommendations and the rationale for the new menu. The staff answered their questions and encouraged them to try the new menu. They were assured that the traditional exchange list menu would still be available. Reactions were mixed from the physicians, but the nurses on the pediatric floor were very receptive and anxious to try the new menu. They were able to understand the concept and felt comfortable using foods from the pantry to replace foods on the tray that patients might have refused. Soon, the menu was expanded to all patients with diabetes (adult and pediatric) in the hospital.

Inservice training sessions were provided to floor nurses, and handouts were developed for them to use. The teaching materials that the hospital's clinical dietitians used were modified to include carbohydrate counting, with encouragement for outpatient education after discharge.

Advantages to the consistent-carbohydrate menu system included more freedom with and greater variety of choices for patients. The food service clerks reported that checking the menu was much faster than checking the standard exchange menu. One disadvantage was the time it took the clerks to explain the menu to people who had not been taught carbohydrate counting. The clerks were encouraged to refer such patients to the dietitian for education.

Baptist Health, Little Rock, Arkansas
A similar experience in transitioning from traditional to carbohydrate counting menus was reported by Lorie Hale, MEd, RD, LD, the clinical nutrition manager at Baptist Health in Little Rock, Ark. A consistent-carbohydrate diet was implemented in all five of that system's hospitals, a project that took about 1 1/2 years to complete.

It was found that the menu was easier for patients to understand because it had only one category for carbohydrate—not four, as in the traditional menu. The consistent-carbohydrate menu was used with calorie ranges from low to very high. Modifications for additional nutrients, such as sodium, fat, protein, and potassium, or textures, such as soft, were added if needed.

Staff education was the most difficult part of this project. The nutrition department developed inservice training videos and provided one for each patient floor. The nutrition department also had to update its computer system with new data for the menu. Now, the new menu is the only option for patients with diabetes.

Outcomes were collected at Baptist Health based on how physicians placed diet orders. Hale reported about a 45% compliance rate for physicians ordering the consistent-carbohydrate menu instead of the traditional exchange menu.

Sunrise Hospital, Las Vegas, Nevada
Consistent-carbohydrate menus appear to be popular in pediatric settings. Holly Brewer, MS, RD, a pediatric dietitian at Sunrise Hospital in Las Vegas, Nev., reported that her hospital uses this menu only for their pediatric patients. The hospital also adapted the exchange lists menu to include portion size and carbohydrate choices for each item. The diet order is written as "pediatric diabetic diet," and the carbohydrate gram count and snack information is included in the comment section.

Brewer reported that advantages of the system include less plate waste because unwanted vegetables are not forced on patients. The menu does not include fat restrictions. Brewer said the menu is easier for patients to understand and can be easily translated into their own eating habits before they are discharged.

Few disadvantages were noted in this hospital, although Brewer did report a few limitations after discharge. Some patients do not completely understand the carbohydrate concept and eat unlimited amounts of all foods. Others may increase carbohydrate choices and insulin doses accordingly, but experience unwanted weight gain. This is especially common for new insulin pump patients. Another problem occurs when patients choose only the sweet carbohydrate foods and do not include the more nutritious choices.

Brewer said she now uses a variety of teaching tools, including measuring cups, food models, and food labels to explain the concept. She finds that food lists, especially for snack foods, are helpful. It appears that those taught carbohydrate counting in the hospital when newly diagnosed require less teaching time in the outpatient office. Patients report greater adherence to the meal plan, and there is an easier transition to the insulin pump when carbohydrate counting is already in place.

According to Brewer, the key to implementing the menu into other hospitals is educating the staff, including food service personnel who check menus, floor nurses who need to understand food substitutions, and physicians who write the diet orders.

Order of St. Francis Medical Center, Peoria, Illinois
Counting grams of carbohydrate is the focus of the meal plan for pediatric patients at Order of St. Francis Medical Center in Peoria, Ill. Jerri Haindfield, RD, who works at the hospital's Pediatric Diabetes Resource Center, reported their experience in implementing a consistent-carbohydrate menu in their pediatric setting. She plans to extend it to the adult population. The nursing staff initiated the change after patients with diabetes indicated low levels of satisfaction regarding meals on patient surveys. The center developed its new menu through a multidisciplinary team approach, including Food and Nutrition staff, nursing staff, the diabetes resource nurse and dietitian, and a physician.

Interestingly, the menu developed there has grams of carbohydrate for each menu item instead of rounding off to carbohydrate servings. Haindfield explained that when pediatric patients learn gram counting from the beginning, they get the clear message that foods containing carbohydrate are important.

She also believes that rounding off for this group does not provide the accuracy needed for best blood glucose management. Many of these children go on to intensive management using carbohydrate-to-insulin ratios, and the transition is smoother if they are already familiar with carbohydrate gram counting. Also, by including grams of carbohydrate on the menu, the hospital encourages parents to take the initiative to read food labels at home, giving them a head start on carbohydrate counting even before the outpatient meeting with the dietitian.

An explanation of the value of carbohydrates in blood glucose management is printed on the back of the pediatric diabetes menu. Everyone with diabetes receives the same menu, but the newly diagnosed children are allowed to eat according to appetite. After the dietitian assesses a patient's usual food intake, the number of grams recommended is listed on the menu within a 10-g range, i.e., 60–70 g per meal. The food pyramid is also printed on the back of the menu to reinforce the importance of eating a variety of foods from all food groups.

Another interesting aspect of this institution's menu is the inclusion of both sugar-free and regular choices of some items, for example, regular and sugar-free jelly and syrup. Patients can choose based on their carbohydrate gram goal as well as their food preferences.

Once again, staff education was the greatest challenge at St. Francis. Physicians needed to feel comfortable with the rationale of carbohydrate counting, and food service personnel needed to understand the import- ance of accurate portion control. Haindfield said the hospital's best strategy was seeking input from the multidisciplinary team. This increased participation in and acceptance of the new plan across disciplines. Inservice training was provided at multiple times of day for nurses, and grand rounds were planned for physicians. Printing the food pyramid and the explanation of carbohydrate counting on the back of the menu was also an effective strategy.

The Experience at Two Ohio Nursing Homes
The ADA position statement states that residents of long-term care facilities eat better when they are given less-restrictive diets with regular foods. It has been shown that short-term substitution of regular food for patients with diabetes did not significantly decrease blood glucose control. After 16 weeks, alternating between diabetic and regular meal plan periods, patients' fasting plasma glucose increased an average of 0.6 mmol/L on the regular meal plan, which was insiginificant.2

Veronica L. Gallo, MS, RD, LD, from Mayfield, Ohio, reported on the use of a consistent-carbohydrate menu in two different nursing homes in her state. With this menu system, all residents received the same food, which increased patient satisfaction. Also, the new menu resulted in a reduction in food budget and preparation time.

According to Gallo, the new menu has remained successful at one of the facilities, which has a full-time diet technician. The diet technician provides education and addresses the concerns of family members when they see menu items they think ought to be restricted. Unfortunately, at the other site, which does not have a dedicated nutrition staff member, the facility received so many concerned comments from family members who see regular food items on the menu that it has re-instituted the traditional exchange list menu.

The availability of someone to answer questions and help educate family members is critical to the successful implementation of a consistent-carbohydrate menu system.

The variety of experiences reported here demonstrates that every institution is different and that it is important to assess patient population, food service capabilities, and education opportunities in each situation. An interdisciplinary team approach to review and determine different meal planning options will help provide the quality of care patients deserve at a reasonable and sometimes reduced cost.

The advantages of consistent-carbohydrate meals in institutions include improved food intake by patients, less food waste, and better patient understanding of how to best manage diabetes through carbohydrate counting after discharge. Staff education is often the most difficult part of implementing this system, but the rewards in patient health and satisfaction are well worth the effort.

1American Diabetes Association: Position statement: Translation of the diabetes nutrition recommendations for health care institutions. Diabetes Care 23 (Suppl 1):S47-49, 2000.

2Coulston AM: Dietary management of nursing home residents with non-insulin-dependent diabetes mellitus. Am J Clin Nutr 51:67-71, 1990.

Beverly W. Paddock, RD, LD, CDE, is a diabetes nutrition educator at the Joslin Diabetes Center at Morton Plant Mease Health Care in Clearwater, Fla.

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Copyright 2000 American Diabetes Association

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