1. Dietary Education for
People with Diabetes
Bsc. Nutrition & Food ProcessingBsc. Nutrition & Food Processing
Colonel Hana Khasrouf MudabberColonel Hana Khasrouf Mudabber

2. Outline
Aims of Nutritional Advice
The goals of dietary advice
Role of the dietician
Dietary Education Tools:
Stage1
Healthy Eating
The food pyramid
The signal system
The hand jive
The plate model
 Stage 2
 Food Exchanges
 Carbohydrate Counting
1. Portion Estimation
2. Food Package Labels
3. Carb factors
 Advanced carb counting
carb: insulin ratio
Methods: #1 #2 & #3
 Glycemic Index

3. Aims of Nutritional Advice
 The aim is to provide those who need advice
with the information requirement to make
appropriate choices on the type and quantity of
food which they eat.
 It must take into account the individuals:
- Specific needs
- Personal and cultural preferences
- Beliefs and lifestyle
- Wishes and willingness to change

4. The Goals of Dietary Advice
Are:
To maintain or improve health through
the use of appropriate and healthy food
choices
To achieve and maintain optimal
metabolic and physiological outcome

5. Role of the dietician
The role of the dietitian is to translate
nutritional objectives into practice in a way
which is realistic and practical for the diabetic.
Focussing on modifying the patient’s existing
eating habits, food choice and timing of
meals.

6. Role of the dietician
The dietitian needs to assess diet for:
Food choices
Meal plan
Nutritional adequacy and overall dietary balance
Beliefs or misconceptions held about diet and diabetes
Physical activity, occupation, literacy, economic
circumstances , etc
Body weight
Other medical conditions – Coeliacs, visual handicap,
nephropathy, etc
Alcohol consumption

7. Avoid looking like a school teacher!Avoid looking like a school teacher!
• Simple words
• Open-ended questions
• Encouragement
• Positive feedback
• Active listening
• Repetition
Role of the Dietician
Implementing Good Communication
Skills

8. Role of the dietician
Example:
Open-ended question
 At what time do you take your
meals?
Closed question
 Do you take your meals on time?

9. Patients can be
overwhelmed, the dietician
must not cram all teaching
points into one session
Adult learners have an
attention span of about 20
minutes
Scheduling follow-up
Role of the dietician
How to educate DM patient?

10. Role of the dietician
Utilizing Interactive Tools and Educational
Materials for Teaching
Diabetes dietary education color books or
educational stories for kids.
Diabetes dietary education games for teens
and adults (softwares or CDs)

11. ‫لصحتي‬ ‫المفيد‬ ‫الجيد‬ ‫الطعام‬ ‫أتناول‬ ‫أنا‬
‫ا‬ً ‫وخصوص‬ ‫ال‬ً ‫قلي‬ ‫وأرتاح‬ ‫أجلس‬ ‫أن‬ ‫الى‬ ‫أحتاج‬ ‫ا‬ً ‫أحيان‬
.‫ا‬ً ‫كثير‬ ‫لعبت‬ ‫إذا‬
‫ا‬ً ‫منخفض‬ ‫الدم‬ ‫سكر‬ ‫كان‬ ‫إذا‬ ‫خفيفة‬ ‫وجبة‬ ‫وأتناول‬

12. ‫تساعدني‬ ‫الفطور‬ ‫أتناول‬ ‫أن‬ ‫قبل‬
.‫النسولين‬ ‫أخذ‬ ‫في‬ ‫والدتي‬
.‫ا‬ً ‫تمام‬ ‫مثلك‬ ‫سكري‬ ‫لدي‬ ‫أنا‬
‫أخذ‬ ‫قبل‬ ‫بالدم‬ ‫السكر‬ ‫فحص‬ ‫على‬ ‫نعمل‬
.‫الطعام‬ ‫تناول‬ ‫وبعد‬ ‫النسولين‬
.‫بذلك‬ ‫ا‬ً ‫أحيان‬ ‫أبي‬ ‫يساعدني‬
‫الدم؟‬ ‫سكر‬ ‫تفحص‬ ‫هل‬ ‫ا‬ً ‫أيض‬ ‫وأنت‬

13. Diabetes Dietary Education
Books & Stories for Kids

14. Diabetes Software for Teens &
Adults

15. Approach to meal
planning
A uniform approach to meal planning
does not work for everyone
A flexible plan or a variety of
approaches is required to deal with
differing needs

16. Background
Historically advice given on carbohydrate
exchanges or portions
In 1980s carbohydrate restriction found to
be unnecessary – advice changed to
healthy eating : plate model
New DAFNE trial / Carbohydrate
Counting

17. Dietary
Education Tools

18. Dietary education
Stage 1 (simple education methods)
 Awareness of the basics of healthy
eating/ balance of good health
 The food pyramid
The signal system (healthy food
choices)
The hand jive
The plate model

19. Dietary education
Stage 2
(advanced & require teaching skills)
Food Exchange System
Carbohydrate Counting
Glycemic Index

20. Healthy Eating
Australian
Food Guide

21. Healthy
Eating
Grain
products
Vegetables
and fruits
Milk
products
Meat and
alternatives
Canadian
Food Guide

22. Balance of Good Health
Bread, cereals
& potatoes
Milk &
dairy
products
Foods
rich in
sugars
and fat
Meat, fish &
protein
alternatives
Fruits &
vegetables
UK Food
Guide

23. My Food Pyramid (USDA(

24. Utilizing Interactive
Activities for
Teaching My
Pyramid
for
Kids

25. Diabetes Dietary Education Games
for Teaching My Pyramid

26. Signal System
The signal system is based on a traffic lights concept:
 Red foods (to be taken in small amounts)
 those rich in fat
 sugars (refined carbohydrate)
 high glycemic index foods
 low fiber content
 Yellow foodsYellow foods (to be taken in moderation)
 Moderate glycemic index foods
 low fiber content
 Green foods (healthy choice)
 low glycemic index
 high fiber content
 low in fat

27. Healthy versus unhealthy food
choices?
Food groups Green zone Yellow zone Red zone
Rice Steamed or
boiled rice
Fried rice/biryani
Bread Whole wheat
bread
White bread Croissants and cakes
Noodles Steamed or
boiled noodles
Deep fried noodles
Potatoes Baked potato French fries
Vegetables Steamed
vegetable
Sauteed
vegetable
Deep fried vegetable
Salad Green salad Salad with
mayonnaise
Sauce Tomato based Cream based
Chicken, fish
& red meat
Grilled Pan fried Deep fried

28. Hand
Jive (starch): choose an amount equivalent to the size of 2
Carbohydrates fists.
 Fruit: choose an amount equivalent to the size of 1 fist .
 Protein: choose an amount equivalent to the size of the palm of
your hand and the thickness of your little finger.
 Vegetables: choose as much as you can hold in both hands.
These should be low carbohydrate vegetables – green or yellow
beans, cabbage or lettuce.
 Fat: limit fat to an amount the size of the tip of your thumb. Drink
no more than 250 ml of low-fat milk with a meal

29. Plate Model
Protein
Starch/cereal
Vegetable
Vegetable
Fruit
Fat Milk/yoghurt

30. Advanced Education Tools –
Stage 2
Food Exchanges
Carbohydrate Counting
Glycemic Index

31. The “Exchange” System
Foods with common nutrient values
are grouped together.
1 Fat
1 Meat
1 Vegetable
1 Milk
1 Fruit
1 Starch
0 5 10 15

32. Food exchanges
Within groups, a single food based on weight/
measure/ size has the same carbohydrate or
Calorie value as another and can be interchanged
Cereal exchanges: 1 slice of bread can be
exchanged for 1/3 cup rice
Foods from different groups cannot be
interchanged – 1 slice of bread cannot be
exchanged for 1½ tsp of butter

33. The Exchange Lists1
Groups/ Lists Carb. Protein Fat Calories
Carbohydrate Group
Starch 15 3 1 or less 80
Fruit 15 ___ ___ 60
Milk
Skim
Low-fat
Whole
12
12
12
8
8
8
0-3
5
8
90
120
150
Other carbohydrates 15 varies varies varies
Vegetables 5 2 ___ 25
Meat and Substitute Group
Very lean
Lean
Medium-fat
High-fat
___
___
___
___
7
7
7
7
0-1
3
5
8
35
55
75
100
Fat Group ___ ___ 5 45
1. Exchange Lists for Meal Planning, The American Diabetes Association, The American Dietetic Association, 1995

34. Counting Carbs Using the
Exchange system
Breakfast Exchange/# Carb Grams
1 pita bread (4 oz) starch (4) x 15 60g
1 tsp. olive oil fat (1)x0 0g
1 hard boiled egg protein (1)x0 0g
1/2 cup orange juice fruit (1) 15g
6 oz skim milk (3/4) x 12 9g
Total Carbs 84g
One oz.
pita bread 15g carbExample
:

35. Carbohydrate Choices
One oz.
slice bread
Small piece
of fruit
One cup
unsweetened
cereal
1 small ear of
corn ½ cup of
juice
One
small potato
1 cup of milk
1/3cup rice
One oz.
pita bread

36. Carbohydrate
Counting

37. Carbohydrate Counting Defined
 A meal-planning approach based on the
following ideas
 Carbohydrate is the main nutrient affecting
postprandial glycemic response
 Total amount of carbohydrates consumed is
more important than the source of
carbohydrates

38. Meal 1 Hr 2 Hrs 3 Hrs 4 Hrs 5 Hrs 6 Hrs 7 Hrs 8 Hrs
Timed Effect on Blood Sugar
Levels
* In absence of dietary carbs ** may cause insulin resistance in large qty
CarbohydrateCarbohydrate: rapid digestion, total absorption/conversion to glucose (100%)
Sugar AlcoholsSugar Alcohols: moderate digestion, partial absorption as glucose (50%)
Protein…………..Protein…………..slow digestion, partial conversion to glucose* (~40%)
Fat………………..Fat………………..slow digestion, little conversion to glucose** (<20%)
Bloodglucoselevel

39. Why Count Carbohydrate?
Keeping carb intake consistent at meals from
day to day
Base for rapid-acting insulin dosing with
meals/snacks
Allow more flexibility with eating for people with
type 1 diabetes
Result in reduced post-prandial hyper- and
hypoglycemia

40. Prerequisites
The ability & willingness of the diabetics
to :
Perform basic carb counting
Do simple math
Use nutrient analysis information, measuring
cups, spoons and scales
Keep accurate, detailed records:
Blood glucose results
Carbohydrate eaten
Insulin or other meds
Physical activity/exercise

41. Methods for Basic Carb Counting
1. Portion Estimation
2. Food Package Labels
3. Carb factors

42. Portion Estimation
Using Food Models

43. 1. Portion Estimation
Method
Examples of 1-cup Carb Estimates:
Potato: 40g
Pasta: 40g
Rice: 50g
Rolls: 25g
Cereal: 25gCereal: 25g
Fruit: 20gFruit: 20g
Cooked Vegetables: 10g
Salad Vegetables: 5g
Milk: 12g
Corn: 30g
Peas: 30g
Beans: 40g
Pretzels: 25g
Chips: 15g
Popcorn: 5gPopcorn: 5g
Ice Cream: 35g
Cake: 45g

44. Portion Estimation Method
Example: 1
1cup fruit ⇒ 20g carb
X 1 ¼ cups
≅ 25g carb

45. 1cup popcorn ⇒ 5g carb
X 4 cups
≅ 20g carb
Portion Estimation Method
Example: 2

46. Portion Estimation Method
Long Sandwiches 8g carb per inch (2.5 cm)
Pizza
30g carb per adult hand-sized
piece (fingers together)
Cookies
20g carb per adult-sized palm
Breaded
meat/veg/cheese
4g carb per small (“thumb/nugget sized”)
10g carb large (“patty/palm-sized”)

47. 1hand pizza ⇒ 30g carb
X 1 1/3 hands
≅ 40g carb
Portion Estimation Method
Example: 4

48. 2. Nutrition Facts Label
Method
Labels are the best resource for carb
counting but considering
Serving Size
Total Carbohydrate
Fiber & Sugar Alcohol (if any)

49. Sugar Alcohols and Carb Counting
Artificial Sweeteners
Found in sugar free products e.g. chewing gum,
mints, jam, ice cream, cookies and candy
Digest slowly and partially (∼ 50%)
Requires little or no insulin to be metabolized.
Can have laxative effect (bloating, gas, diarrhea) if
consumed in large amounts.

50. Comparison of Sweeteners
Sweetener Cal per gram
Artificial (Aspartame, Saccharin, Splenda) 0
Sugar Alcohols: Erythritol
Mannitol
Isomalt
Lactitol
Maltitol
Xylitol
Sorbitol
Hydrogenated starch hydrolysates
0.2
1.6
2.0
2.0
2.1
2.4
2.6
3.0
Glycerine, sucrose, fructose, lactose 4.0

51. Example: 1
Nutrition FactsNutrition Facts
Serving size: 2 piecesServing size: 2 pieces
Amount Per ServingAmount Per Serving
CaloriesCalories 3.83.8
Calories from Fat 0
Total Fat 0g (0%)
Cholesterol 0g (0%)
Sodium 0g (0%)
Total
Carbohydrate
1.6g (1%)
Sugars 0g
Sugar Alcohol
(Xylitol)
1.6g
Protein 0g
If all carb is from sugar
alcohols
< 10 grams: FREE food

52. Example: 2
Nutrition FactsNutrition Facts
Serving size: 5 piecesServing size: 5 pieces
( about 16 grams)( about 16 grams)
Amount Per ServingAmount Per Serving
CaloriesCalories 4040
Calories from
Fat
10
Total Fat 1g (2%)
Saturated Fat 0.5 g (3%)
Trans Fat 0 (0)%
Cholesterol 0g (0%)
Sodium 70mg (3%)
Total
Carbohydrate
14g (5%)
Sugars 0g
Sugar Alcohol
(lactitol) 14g
Protein 0g (0%)
If all carb is from sugar
alcohols >10 grams: count ½
of the total carb
If serving size = 5 pieces
sugar alcohol: 14 g = 7g
2

53. Nutrition FactsNutrition Facts
Serving Size: 1 Tbsp (17g).Serving Size: 1 Tbsp (17g).
Servings per Container: 20.Servings per Container: 20.
Calories per serv.: 10.Calories per serv.: 10.
AMOUNT PER
SERVING
% DAILY
VALUE*
Total Fat:
0g
0%
Sodium: 20mg 1%
Total Carbohydrate:
3g
1%
Sugars: 0g
Sugar Alcohol:
3g
Sorbitol
Protein:
0g
 If all carb is from number of
sources, including sugar
alcohols
 Subtract ½ of the sugar alcohol
grams from the total carb
 If 2 servings used = 2Tbsp
6g Carb + 6g sorbitol = 9 g Carb
2
Example: 3

54. 3. Carbohydrate Factor Method
Getting total carb count by:
Weighing the portion of food
Multiplying the weight by its
carb factor*
A carb factor is the percentage of the food’s
weight that is carbohydrate.
The rest is water, protein, fat and minerals.

55. Apple: 0.13
Apple Pie: 0.32
Carrot (raw): 0.06
Chocolate Cake: 0.51
mixed grain bread: 0.46
White bread: 0.50
Pancake: 0.28
Pizza (cheese): 0.32
Potato, baked: 0.22
Potato Salad: 0 .09
Rice: 0.27
Spaghetti: 0.26
Vanilla Ice Cream: 0.23
Watermelon: 0.06
Carb Factor Examples:

56. Carbohydrate Factor Method
How much carb?
is in a baked potato weighing exactly 300 grams?
300 x 0.22g = 66g carb
Example: Calculating grams of Carb content

57. Impact of Fiber
in Carbohydrate Counting
Included in total carbohydrate
Does not convert to glucose
Subtract fiber from the Total Carbohydrate

58. Impact of Fiber
Example:
1 Serving size:
13 g Total Carb
- 3 g dietary fiber
Count as 10 g carb

59. How Much Carbohydrate is
Needed1
Calorie level ~ 1200 ~1400 ~1600 ~1800 ~2400 ~2800
Calorie range 1200-1500 1300-
1600
1400-
1700
1600-
1900
1800-
2300
2200-
2800
Carb grams 180 180 195 210 240 300
Carb choices 12 12 12-13 13-14 15-16 18-20
Grains, beans, &
starchy
vegetables
6 6 6 7 9 11
Vegetables 3 3 3 4 4 5
Fruits 3 3 3 3 3 4
Milk 2 2 2-3 2-3 2-3 2-3
Meats 2 (4oz) 2 (4oz) 2 (5oz) 2 (5oz) 2 (6oz) 3 (70z)
Fats g/servings 40/4 47/5 54/6 60/7 74/9 93/12
1. Practical Carbohydrate Counting, American Diabetes Association, 2001.
Calculated as 60% CHO from total calories.

60. Determining Amount of Carbs per meal
Population
Carb choices
per meal
Smaller, older, inactive women 2-4
Older, inactive men 3-5
Smaller, older, inactive men
Large, active women trying to lose weight
4-6
Most older men
Active women
Larger men desiring to lose weight
5-7
Active, younger men 6-8

61. Advanced Carb Counting
For those on insulin (MDI/ Insulin Pump)
Adjusts rapid-acting insulin based on carb
consumed and physical activity
Carb: Insulin Ratio
Calculates insulin dose for a specific amount of
carbohydrate

62. The Actions of Insulins1
Insulin Onset Peak Duration
 Rapid acting
Lispro (Humalog)
Aspart (Novolog)
<15 min
<15 min
0.5-1.5 hrs
0.5-1.0 hr
2-4 hrs
1-3 hrs
 Short acting
Regular 0.5- 1 hr 2-3 hrs 3-6 hrs
 Intermediate
NPH
lente
2-4 hrs
3-4 hrs
4-10 hrs
4-12 hrs
10-16 hrs
12-18 hrs
 Long acting
Ultralente
Glargine (Lantus)
6-10 hrs
2-4 hrs
10-16 hrs
peakless
18-20 hrs
24 hrs
1. Practical Carbohydrate Counting, American Diabetes Association, 2001

63. Basal insulin
Lantus
Or Levemir
Peak: 0.5-1.0 hour
Onset: 15 minOnset: 15 min Duration: 1-3 hrsDuration: 1-3 hrs
Peakless 24 hrs
Glargine
(Novolog) (Novolog) (Novolog)

64. Example of Carb Counting
DAFNE
Dose adjustment for normal eating
5 day structured teaching programme
Improve diabetes control by matching insulin
to carbohydrate.
Evidence shows improved HbA1c, reduced
severe hypo’s and less hospital admissions
from DKA

65. DAFNE Timetable
Monday Tuesday Wednesday Thursday Friday
09.15-09.45
INTRODUCTION
09.15-10.30
Group Discussion:
Individual blood glucose levels
`
09.15-10.30
Group Discussion:
Individual blood glucose levels
09.15-10.30
Group Discussion:
Individual blood glucose levels
09.15-10.30
Group Discussion:
Individual blood
glucose levels09.45-10.45
WHAT IS DIABETES?
10.45-11.00 Coffee 10.30-10.45 Coffee 10.30-10.45 Coffee 10.30-10.45 Coffee 10.30-10.45 Coffee
11.00-12.30
NUTRITION 1
•Identify carbohydrates
10.45-12.30
NUTRITION 2
Putting carbohydrate
estimation into practice
10.45-12.30
NUTRITION 3
•Food Packaging
•Recipes
10.45-12.30
NUTRITION 4
•Alcohol
•Eating out
•Healthy eating/ weight
control
THEORY OF GOAL
SETTING
10.45-12.00
ANNUAL REVIEW
AND SCREENING
12.00-13.00
QUESTIONS FOR
THE DOCTOR
GOAL SETTING
12.30-13.30 Lunch 12.30-13.30 Lunch 12.30-13.30 Lunch 12.30-13.30 Lunch 13.00 – 14.30 Lunch
13.30-15.00
SELF MONITORING
13.30-15.00
DAFNE INSULIN
ADJUSTMENT
13.30-15.00
HYPOGLYCAEMIA
(Relatives/partners welcome)
13.30-15.00
PHYSICAL ACTIVITY
Walk – weather depending.
14.30-15.00
QUIZ
15.00-15.15 Coffee 15.00-15.15 Coffee 15.00-15.15 Coffee 15.00 – 15.15 Coffee
15.15-16.15
ALL ABOUT INSULIN
15.15-16.15
INSULIN INJECTION
TECHNIQUE
15.15-16.15
SICK DAY RULES
15.15-16.15
SOCIAL ASPECTS
(Contraception and pregnancy –
optional)
15.00-15.30
EVALUATION AND
FOLLOW UP
16.15-17.00
Group Discussion:
Individual blood glucose levels
16.15-17.00
Group Discussion:
Individual blood glucose levels
16.15-17.00
Group Discussion:
Individual blood glucose levels
16.15-17.00
Group Discussion:
Individual blood glucose levels

66. Insulin: Carbohydrate Ratio
Method # 1:
Food dairy, insulin dose,
and SMBG information
Method # 2:
Insulin: Carbohydrate ratio
The rule of 500 or 450
Method # 3:
Using the insulin sensitivity factor (ISF)

67. Carb to Insulin Ratio’s
Starting point (if new to carb/insulin ratio’s)
1:15 ratio (1 unit rapid acting insulin for
every 15 g carb eaten)
May need different ratio’s for different meals
Example:
If 65 g carb for lunch
Would need 4 units fast acting insulin coverage at
lunch (65 ÷ 15 =4)

68. Method #1
Food dairy, insulin dose, and SMBG information1,2
 Insulin: Carb ratio = Grams of carb at a given meal ÷
number of units of insulin taken at that meal
Example
 patient needs 4 units of insulin to cover 45g of carbs
 Insulin: Carb ratio = 45 ÷ 4 = 11
⇒ Ratio = 1:11
1. Carbohydrate Counting: Using Carbohydrate/Insulin Ratios, The American Diabetes Association, The American Dietetic Association, 1995
2. Practical Carbohydrate Counting, American Diabetes Association, 2001

69. Method #2 (The 500/450 Rule(
The rule of 450 or 5001
keeps post meal readings normal
 The 500 rule estimates accurately grams of carb per unit of
rapid acting insulin (Humalog or Novolog)
 The 450 Rule is used with Regular insulin.
Insulin: Carb ratio = 450 or 500 ÷ total daily insulin dose (TDD)
Example
 TDD = 36 units (Bolus + Basal)
Glucose levels are within target range
 Insulin: Carb ratio = 500 ÷ 36 = 14
⇒ Ratio = 1:14
1. Practical Carbohydrate Counting, American Diabetes Association, 2001

70. Method #3 (The 1800 OR 1600
Rule(
Method # 3: Using the insulin sensitivity factor (ISF)1
can be used to bring down high blood sugars
 ISF = 1800 or 1600 ÷ TDD
 Insulin: Carb ratio = ISF× 0.33
Example
 TDD = 25 units (Bolus + Basal)
 ISF = 1800 ÷ 25 = 72 (meaning that 1 unit of rapid-acting insulin
Hum. or Novolog would drop BG approx. 72 mg/dL)
 Insulin: Carb ratio = 72 × 0.33= 24
⇒ Ratio = 1:24
1. Practical Carbohydrate Counting, American Diabetes Association, 2001

71. Example
 TDD= 34 units
 Target BG = 100 mg/dl
 Pre-meal BG = 226 mg/dl
 60g of carb are to be consumed
Answer
 ISF = 1800 ÷34 = 53
 Difference between target and actual BG = 226 – 100 =126 mg/dl
 Units of insulin to decrease high pre-prandial BGUnits of insulin to decrease high pre-prandial BG =126 ÷ 53 = 2.3 units
 Insulin: carb ratio
• 500 ÷ 34 TDD = 15
• Ratio= 1:15
 Units of insulin to cover carb consumed = 60 ÷ 15 = 4 units
⇒ Premeal insulin = 2.3 units + 4 units = 6.3 units (rounded to 6)
1. Practical Carbohydrate Counting, American Diabetes Association, 2001
Correcting Pre-meal Hyperglycemia1

72. Correcting Pre-meal Hypoglycemia1
Example
 Insulin: carb ratio = 1:13 ISF = 35
 Carbs to be consumed: 40g Actual BG level = 57 mg/dl
 Target BG level = 110 mg/dl
Answer # 1: Increase amount of carbohydrate
 13g of carbs will raise BG by 35 mg/dl
Answer # 2: Decrease pre-meal insulin dose
 Amount of insulin to cover carbs= 40 ÷ 13 = 3 units of insulin
 Amount of insulin to be subtracted= Difference between target
and actual BG levels(110-57) ÷ ISF = 53 mg/dl ÷ 35 = 1.5 units
insulin
 Pre-meal insulin = 3 units – 1.5 units = 1.5 units
Answer # 3: Delay pre-meal insulin
1. Practical Carbohydrate Counting, American Diabetes Association, 2001

73. Treating Hypoglycemia1
Amount of
Carbs
BGBG
Apple or
Orange Juice
Grape
juice
Milk
Cola/
Sprite
15 g
51-70 mg/dl51-70 mg/dl
120 ml 90 ml 300 ml 125 ml
20 g
41-50 mg/dl41-50 mg/dl
180 ml 120 ml 420 ml 190 ml
30 g
<40 mg/dl<40 mg/dl
240 ml 180 ml 600 ml 250 ml
1. Exchanges For All Occasions, Marion Franz, RD, MS, 1987

74. Exercise
Guidelines
Type of
Exercise
If BG Is:
↑ Carb. Intake
by:
Suggested Food
Short Duration
80-100 mg/dl 10-15 g. 1 fruit Or 1 bread
≥ 100 mg/dl Not necessary -------
Moderate
intensity
80-100 mg/dl
25-50 g before
exercise
then 10-15 g/hr,
if necessary
½ meat sandwich + milk
Or fruit
80-170 mg/dl 10-15 grams 1 fruit Or 1 bread
180-300 mg/dl Not necessary ---------
≥ 300 mg/dl Don’t exercise --------
Strenuous
activity or
exercise
80-100 mg/dl 50 g
1 meat sandwich + milk
Or fruit
180-300 mg/dl 10-15 g/hr 1 fruit Or 1 bread
≥ 300 mg/dl Don’t exercise -----------

75. Carbohydrate Counting 
Disadvantages
 Takes time and practice
 Increase in BG testing and need to keep
detailed records of blood sugars/foods
consumed
 Possible weight gain if high calorie foods are
eaten
 Diet may become unbalanced

76. Glycemic Index and
Load

77. Gylcemic Index – GI
GI value is a ranking (on a 100 point scale)
of how quickly 50g of CHO from foods
elevates blood sugar levels
The higher the number the quicker the CHO
enters the bloodstream.

78. High GI eg: White bread
Low GI eg: legumes
Time
Bloodglucoselevel

79. Glycemic Index Classification
Classification GI Range Examples
Low GI 55 or less
Most fruits and vegetables (except
potatoes, melons & pineapple), grainy
bread, brown rice, freekeh, fish, egg,
fructose.
Medium GI 56-69
Pita bread, Whole wheat products,
maftool, quick oats, basmati rice,
sweet potato, honey & table sugar
High GI 70 or more
Flakes, rice krispies, instant oats,
popcorn, baked potatoes, short grain
white rice, rice noodles, white bread,
straight glucose (100)
(healthy choice)
(to be taken in moderation)
(to be taken in small amounts)

80. GI ExampleExample::
SpaghettiSpaghetti
GI = 37GI = 37
Only 37% of spaghetti’s carbs turn into BG
in the first 2 hrs.
The rest will convert to BG over the next
several hrs.

81. Glycemic Response
A measure of the increase in blood sugar
after a combination of foods is eaten

82. Glycemic Load
Represent the glycemic impact of more
typical portions of foods

83. High GI foods can be appropriate to treat
hypos and for exercise
It allows for knowing the proper timing for
injecting rapid insulin for quick or slow meals
It allows for occasional sweet food after a
low GI meal
How to use the GI in
Practical advice

84. Quick & Slow
Acting Carbs
Game for Kids

85. Which Way
to Go
Treating
Hypoglycemi
a
educational
game for kids

86. Timing of Rapid Insulin for
Quick or Slow Meals
1. Quick acting carb e.g. White roll bread,
mashed potato ⇒ inject insulin
before meal
2. Slow acting carb High fat &/or high protein slows
up rise in BG so for meals such as pizza, pasta,
(Freekeh), curry, fish & chips, Large Steak ⇒
inject after eating
3. Combined foods (Slow+ Quick) carb ⇒ inject
during meal

87. How to increase consumption of low GI
foods
Eat high-fiber breakfast cereals (oats, bran, barley)
Add berries, nuts, flaxseed and cinnamon
to high GI cereals.
OR
GI = 60 GI = 42

88. How to increase consumption of low GI
foods
GI = 85 GI = 39
Replace white bread with whole grain breads,
Watermelons & pineapples with pears & cherries
OR
Include 5-9 servings of
fruits and vegetables every day.

89. Replace white potatoes with yams or sweet potatoes.
OR
Just eat smaller portion of high GI potatoes.
How to increase consumption of low GI
foods
GI = 80 GI = 61

90. How to increase consumption of low GI snacks
GI = 83 GI = 14
Replace crackers, Pretzels, Chips, Doughnuts with Fruit,
Nuts, Ice Cream & Chocolates
Add nuts to high GI breads and crackers.
OR

91. Eat less refined sugars and convenience foods (soda,
sweets, desserts, etc.)
Combine nuts, fruit, yogurt, dark chocolates, ice cream
with commercial sweets – just watch portion sizes.
OR
GI = 57 GI = 32
How to increase consumption of low GI snacks

92. Promotes healthy eating
Increases fiber intake
Helps control appetite
Helps control BG levels
Helps lower blood lipid levels
Assists weight loss
Offers a more comprehensive approach for type 2 DM
Reduces risk of type 2 DM and heart disease
Low glycemic Index Diet –
Advantages

93. Standards of Medical Care in Diabetes 
2010
Monitoring carbohydrate intake, whether by
carbohydrate counting, exchanges, or experienced-
based estimation, remains a key strategy in
achieving glycemic control.
For individuals with diabetes, use of the glycemic
index and glycemic load may provide a modest
additional benefit for glycemic control over that
observed when total carbohydrate is considered
alone.
Summery

94. “Helping others is good,
teaching them to help
themselves is better.”
Thank You
George Orwell