Hispanic Health Care International, Vol. 12, No. 3, 2014
© 2014 Springer Publishing Company http://dx.doi.org/10.1891/1540-4153.12.3.138
Understanding Basic Carbohydrate Counting, Glycemic Index, and Glycemic Load for Improved Glycemic Control in Hispanic Patients With Type 2 Diabetes Mellitus Lidia Guadalupe Compeán Ortiz, PhD Autonomous University of Tamaulipas, Tampico, Mexico Diane C. Berry, PhD, ANP-BC, FAANP The University of North Carolina at Chapel Hill Octelina Castillo Ruiz, PhD Eunice Reséndiz González, PhD Paulina Aguilera Pérez, MNS Elva Del Ángel Rivas, ME Autonomous University of Tamaulipas, Tampico, Mexico Hispanic patients with type 2 diabetes mellitus generally have poor glycemic control. Constant hyperglycemia in individuals with type 2 diabetes can cause microvascular and macrovascular complications that lead to early morbidity and mortality. Good glycemic control requires a balance between diet, exercise, and medication, but dietary balance is difficult to achieve for many patients. Of the macronutrients, carbohydrates mostly affect blood glucose levels. Basic carbohydrate counting, glycemic index, and glycemic load are important tools for patients to master to control their blood glucose levels. Los pacientes hispanos con diabetes tipo 2 suelen tener control deficiente de la glicemia. La hiperglicemia constante en los individuos con diabetes mellitus tipo 2 puede causar complicaciones microvasculares y macrovasculares que conducen a una morbilidad y mortalidad precoz. Un buen control de la glucemia requiere equilibrio entre dieta, ejercicio y medicamentos, pero el equilibrio en la dieta es difícil de alcanzar para muchos pacientes. De los macronutrientes, los carbohidratos son los que más afectan los niveles de glucosa en la sangre. Por lo tanto, el conteo básico de carbohidratos, el índice glicémico y la carga glicémica son herramientas importantes para que los pacientes controlen sus niveles de glucosa en la sangre. Keywords: carbohydrate counting; glycemic index; glycemic load; type 2 diabetes mellitus; carbohydrates; glycemic control
T
ype 2 diabetes mellitus is a major global public health concern. In 2000, approximately 366 million people older than the age of 20 years were diagnosed with type 2 diabetes. It is estimated that by 2030, that number will increase to 552 million worldwide
(International Diabetes Federation, 2011). In Mexico, approximately 10.6 million (9.2% prevalence in a population of 115,170,278) people older than the age of 20 years are currently diagnosed with type 2 diabetes. It is estimated that by the year 2030, the number of cases will 138
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DSM is achieved by seven elements of care outlined by the American Association of Diabetes Educators (AADE, 2011): (a) healthy eating, (b) being active, (c) monitoring, (d) taking medication, (e) problem solving, (f) healthy coping, and (g) reducing risk (AADE, 2011). Diabetes self-management education (DSME) and diabetes selfmanagement support (DSMS) are important elements in the care of individuals with diabetes (Haas et al., 2012). DSME and DSMS involve a long-term process of working with patients to develop the knowledge, skill, and ability to self-manage their diabetes in all aspects of their lives (Haas et al., 2012). In Mexico, several institutions have prepared health care professionals (doctors, nurses, and nutritionists) as diabetes educators to improve DSM. In the United States, a formal accrediting agency, the AADE provides certification for certified diabetes educators (CDEs) and board certified advanced diabetes management (BC-ADM). A CDE can be a clinical psychologist, registered nurse, occupational therapist, optometrist, pharmacist, physician, dietitian, nurse practitioner, physician assistant, exercise physiologist, or health professional with a master’s degree such as a social worker. A BC-ADM can be a registered nurse, registered dietitian, registered pharmacist, nurse practitioner, physician assistant, or a physician. As the diabetes epidemic increases in Mexico and the United States, it will be important to train more professionals in delivering DSME. It is particularly important for professionals to provide information on diet, with a focus on carbohydrate counting, glycemic index, and glycemic load to improve glycemic control in the general population and in the Hispanic population. This article focuses on providing health care providers working in family practice, primary care, and clinics with an understanding of carbohydrate counting, glycemic index, and glycemic load in patients with type 2 diabetes. Teaching carbohydrate counting and calculating glycemic index and glycemic load were skills reserved for CDEs and diabetes
increase to 31.8 million (Gutiérrez et al., 2012). In the United States, approximately 25.8 million people older than the age of 20 years are diagnosed with type 2 diabetes, and by 2030, this number is projected to increase to 50.1 million (American Diabetes Association [ADA], 2014; Boyle, Thompson, Gregg, Barker, & Williamson, 2010). Diabetes is currently the leading cause of death in Mexico (Secretaría de Salud, 2007) and the seventh leading cause of death in the United States (Hoyert & Xu, 2012) secondary to microvascular and macrovascular complications. There are currently 50.7 million Hispanics in the United States, and 33 million of these are of Mexican heritage; 19.8 million are newly immigrated with limited English proficiency (Motel & Patten, 2012; Pew Hispanic Center, 2009). By 2050, it is projected that the Hispanic population will exceed that of non-Hispanic Whites in the United States (Centers for Disease Control and Prevention, 2009; Motel & Patten, 2012). Thus, it is essential to improve glycemic control to reduce the complications associated with diabetes both in Mexico and among Mexican Americans. Diabetes self-management (DSM) is critical to decrease morbidity and mortality caused by microvascular and macrovascular complications (ADA, 2014). Approximately 95% of people with diabetes are diagnosed with type 2 diabetes (ADA, 2014). Type 2 diabetes involves a complex interplay between hyperglycemia, hyperinsulinemia, and alteration in the metabolism of carbohydrates, lipids, and proteins (ADA, 2014). A primary objective of diabetes control is optimal glycemic control to prevent microvascular and macrovascular complications (ADA, 2014). Optimal glycemic control is defined as a preprandial (fasting) blood glucose between 70 and 130 mg/dl; peak postprandial (1–2 hr after meals) blood glucose less than 180 mg/dl; and a glycosylated hemoglobin (HbA1c) level less than 7% (ADA). Figure 1 shows the conversion of blood glucose to HbA1c levels.
4% .. 50–80 5% ..... 80–115 6% ........ 115–150 7% ............ 150–180 Value of A1c (Goal less than 7%)
8% ................ 180–210 9% .................. 210–245
Blood glucose (Goal: Half or more testing in the optimal range).
10% ..................... 245–280 11% ....................... 280–310 12% .......................... 310–345 13% .............................. 345 and more
Figure 1. Relationship between blood glucose levels and glycosylated hemoglobin. American Diabetes Association. (2014). Clinical practice recommendations. Diabetes Care, 37, S14–S67. 139
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nurses predominately in patients with type 1 diabetes. However, with the global epidemic of type 2 diabetes, health care providers working with Hispanic patients need to understand these concepts to help their patients with type 2 diabetes learn to be aware of carbohydrates and what they eat and that the timing of what they eat affects overall glycemic control (Gonçlaves Reis & Dullius, 2011; Martins, Ambrosio, Nery, Aquino, & Queiroz, 2013; Varela, Vega, & Valenzuela, 2012; Zipp, Roehr, Weiss, & Filipetto, 2010). Many patients diagnosed with type 2 diabetes transition to basal and bolus insulin regimes within several years of diagnosis for improved glycemic control (Meneghini, 2013).
glucose production by activating glycogenolysis and gluconeogenesis (Nelms et al., 2010). Blood glucose can come either from ingestion of carbohydrates or from glycogen stores (Nelms et al., 2010). Hormones such as insulin, glucagon, growth hormone, and cortisol are necessary for glucose levels to remain stable (Nelms et al., 2010). Foods that are rich in carbohydrates stimulate production of insulin, which transports glucose into the cells within 60–90 min after ingestion to avoid postprandial hyperglycemia (Nelms et al., 2010). The excess glucose is stored as glycogen (Nelms et al., 2010). In diabetes mellitus, there is a deficiency of insulin production or the insulin does not act efficiently (ADA, 2014). Excessive blood glucose that cannot be absorbed by fat cells and muscle accumulates in the bloodstream, causing hyperglycemia (ADA, 2014). Patients with diabetes who understand healthy eating, carbohydrate counting, glycemic index, and glycemic load are in a better position to self-manage their blood glucose levels. Unfortunately, many patients of Hispanic heritage in both Mexico and the United States have received inadequate DSME (Golden et al., 2012; Gonzalez, Berry, & Davison, 2013). In Mexico, patients often have difficulty gaining access to health care providers trained to deliver DSME (Compeán-Ortiz et al., 2010; Golden et al., 2012). In the United States, many Mexican American patients have difficulty with access because of lack of health insurance and because of a lack of trained bilingual diabetes educators (Gonzalez et al., 2013).
PHYSIOLOGY OF CARBOHYDRATE METABOLISM Nutrition is a process that maintains the biochemical characteristics, composition, and function of tissues, organs, and body systems (Esherick, Clark, & Slater, 2013). Intermediary metabolism is the conversion of food at the cellular level (Whitney & Rolfes, 2011). This begins with the absorption of nutrients and ends when nutrients are used at their maximum capacity (Sizer & Whitney, 2013). Appropriate nutrition is an essential aspect of diabetes care and includes a balance of carbohydrates, proteins, fats, vitamins, and minerals (Sizer & Whitney, 2013). Carbohydrates are the nutrients that mostly affect blood glucose levels and are therefore strong predictors of glycemic response (ADA, 2014; Sizer & Whitney, 2013). Carbohydrates are chemical compounds composed of carbon, hydrogen, and oxygen and they are the main source of energy in the human diet (Sizer & Whitney, 2013). They are classified as monosaccharides (glucose, galactose, and fructose), disaccharides (sucrose, lactose, and maltose), oligosaccharides, and polysaccharides (starch; Sizer & Whitney, 2013). Digestion of carbohydrates begins in the mouth and continues in the stomach by the action of enzymes that produce simple compounds such as glucose, galactose, and fructose (Sizer & Whitney, 2013). Simple forms of nutrients (glucose, fatty acids, and amino acids) are available in the first hours (0–3) after food intake (the immediate postprandial or absorptive period; Nelms, Sucher, Lacey, & Roth, 2010). These nutrients then cross the intestinal wall and pass into the bloodstream, which takes them to the liver, muscle, fat, and other organs where they are either used to produce energy or are stored as energy compounds (glycogen and triglycerides; Nelms et al., 2010). In normal conditions, the production of insulin by the pancreas increases during this period so that the glucose transported by the bloodstream can pass into muscle and fat cells. During periods of fasting (postabsorptive period), pancreatic insulin secretion drops and an increase in glucagon secretion occurs (Nelms et al., 2010). Both conditions generate an increase in hepatic
HEALTHY EATING Healthy eating is extremely important for those with diabetes. Glycemic control cannot be achieved by patients who do not adhere to a healthy eating plan, even if they take medications and exercise regularly (Mechanick et al., 2012). Healthy eating is influenced by complex processes that include conditions, culture, and customs (Mechanick et al., 2012). The typical diet eaten by Hispanic patients in Mexico and the United States contains highcarbohydrate foods such as corn, flour, rice, and beans, and often, beverages high in sugar (Nelms et al., 2010; Sizer & Whitney, 2013). Nutrition education can provide a strong foundation on which to build a healthy balanced diet resulting in improved glycemic control. Patients should be taught basic carbohydrate counting, glycemic index, and glycemic load at a literacy level and in the language they feel most comfortable learning in.
Basic Carbohydrate Counting Basic carbohydrate counting is essential for patients with type 2 diabetes who are controlled with diet and physical activity, with or without oral diabetic medications. This method can also be used by patients with type 2 diabetes treated with oral medications that are starting insulin. 140
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TABLE 2. Conversion From Grams of Carbohydrates to Portions of Carbohydrates
To learn basic carbohydrate counting, three steps are suggested: (a) identify which foods contain carbohydrates, (b) determine how many servings of carbohydrates there are in each food serving, and (c) identify the total amount of carbohydrate consumed in each dish (portion). Other factors that affect blood glucose, such as the medications used (oral hyperglycemic agents or insulin), physical activity, illness, and stress, must also be considered (ADA, 2014; Nelms et al., 2010; Sizer & Whitney, 2013). Step 1: Identify Which Foods Contain Carbohydrates. Foods may contain carbohydrates, protein, and fat; however, carbohydrates have the greatest effect on blood glucose levels (Nelms et al., 2010). The amount of carbohydrates consumed and the type of carbohydrates (simple or complex) affects blood glucose levels (Sizer & Whitney, 2013). Simple carbohydrates are easily and quickly absorbed into the bloodstream and include dextrose, fructose, maltose, white sugar, corn syrup, honey, and turbinado sugar (Sizer & Whitney, 2013). Complex carbohydrates are slowly absorbed into the bloodstream and include starches, glycogen, and cellulose and nutritional compounds composed of multiple monosaccharide (simple sugar) building blocks (Sizer & Whitney, 2013). Carbohydrates are found in bread, tortillas, corn, flour, rice, pasta, cereals, potatoes, legumes, fruits, juices, milk, yogurt, candy, and desserts (Table 1). It is important to recognize that some foods do not contain carbohydrates or contain minimal amounts; their main nutrients are proteins or fats (Sizer & Whitney, 2013). Protein foods include meats, such as beef, chicken, turkey, and fish;
Total Carbohydrates (g)
Quantity
Corn tortilla 6 in.
1 piece
Flour tortilla 10 in. Cooked beans
¹⁄³ piece ¹⁄³ cup ½ cup
Whole or skim milk
1 cup
Evaporated whole milk
½ cup
Cooked pasta
½ cup
Cooked lentils
½ cup
Small apple
1 piece
Papaya
1 cup
Banana
½ piece
Cereal w/o sugar
1 cup
Cereal w/sugar
¾ cup
Cooked rice
0–5
0
6–10
½
11–20
1
21–25
1½
26–35
2
36–40
2½
41–50
3
51–55
3½
56–65
4
66–70
4½
71–80
5
Sizer, F., & Whitney, E. (2013). Nutrition: Concepts and controversies. Belmont, CA: Cengage Learning.
eggs; tofu; cheese; and nuts (Sizer & Whitney, 2013). Fat foods include cooking oil, butter, margarine, salad dressings, cream cheese, and cream (Sizer & Whitney, 2013). Proteins and fats do not have much effect on blood glucose; however, it is important not to consume excess amounts because they promote weight gain and obesity (Sizer & Whitney, 2013). Sugar-free foods or foods with a small amount of carbohydrates (⬍5 g of carbohydrate per serving) such as coffee, sugar-free gelatin, spices, sugar substitutes, unsweetened teas, and water also have almost no effect on blood glucose levels (Sizer & Whitney, 2013). Dietary calories should be approximately 50%–60% carbohydrates, 10%–20% protein, and 25%–30% fat in patients with diabetes without complications (Sizer & Whitney, 2013). Step 2: Determining How Many Servings of Carbohydrates Are in Each Food Serving. A portion of carbohydrates is defined as the amount of food that contains 15 g of carbohydrates (Sizer & Whitney, 2013). Tables 1 and 2 show selected foods that are equivalent to one portion. The total carbohydrate number includes starches, natural sugars, added sugars, and fiber (Sizer & Whitney, 2013). Total grams of carbohydrates are included on the nutrition food label on packaged food. Total grams of carbohydrates can be found for nonpackaged foods on websites in both English and Spanish. Total carbohydrates for chain restaurants can be found on the restaurant website many times in English and Spanish. The ADA publishes The CalorieKing Calorie, Fat, & Carbohydrate Counter and The Diabetes Carbohydrate & Fat Gram Guide, which are very helpful to patients learning carbohydrate counting. There are also free applications that can be downloaded for iPads, iPod touches, tablets, and smart phones.
TABLE 1. Examples of Foods Equivalent to One Portion of Carbohydrates Food
Portion
Note. The size of the cup is approximately 240 ml. Sizer, F., & Whitney, E. (2013). Nutrition: Concepts and controversies. Belmont, CA: Cengage Learning. 141
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Nutrition Facts Portion size Refers to the size of the portion (serving) per package. For each bar eaten, the amount of nutrients on the label is consumed.
Serving size 1 bar (25g) Servings per container 2 Amount per serving Calories: 93 Protein 1.9g Total fat 1.7g Saturated fat 0.6g Monounsaturated fat 0.5g Polyunsaturated fat 0.5g Cholesterol 0g Transfat 0g Sodium 115 mg Total carbohydrate 17.4g
Servings per container Refers to the amount of portions (servings) the package contains.
Total carbohydrate Amount of total carbohydrate in grams per serving.
Dietary fiber 1.8g Sugars 6.7g Folic Acid 8% RDV*
Other nutrients Should be low-fat and high-fiber.
*Recommended Daily Value for Mexican Population
Figure 2.
Example of a food label.
Patients must understand that the nutritional information provided on food labels is per serving (Figure 2). Therefore, the carbohydrate gram information will need to be adjusted to their portion size. Fiber is not broken down or absorbed by the body; therefore, the grams of fiber can be subtracted from the total carbohydrate grams because fiber does not affect blood glucose levels. Registered dietitians or certified diabetes educators should be consulted to establish each patient’s individual carbohydrate needs. Step 3: Identifying the Amount of Carbohydrates in Each Dish. It is important to recognize that the amount of carbohydrates each person needs is based on factors such as height and weight; amount of physical activity; and the person’s state of health, diabetes medications, and glucose levels. In general, women require 3–4 servings of carbohydrate at each meal (45–60 g) and men require 4–5 servings (60–75 g) at each meal (Sizer & Whitney, 2013). It is also necessary to have snacks two to three times a day, with 1–2 servings of carbohydrates (15–30 g), which will help to control blood glucose (Sizer & Whitney, 2013). Helping patients understand how to read a food label is instrumental to their success in basic carbohydrate counting. The food label provides information on portion size, the number of calories per serving, and other nutrients, such as fat and protein per serving (see Figure 2). It is important to review with patients the way to read a food label. First, examine the portion size. Second, examine how many portions in the package. Third, examine the total amount of carbohydrate per portion. Fourth, examine the other nutrients to make sure this is a low-fat and highfiber food. If the food portion has 5 g or more of fiber, subtract half the grams of fiber from the total number of carbohydrates (Sizer & Whitney, 2013).
To correctly calculate the amount of carbohydrates that a food contains using the food label is an important skill for health care providers to learn and teach their patients. For example, if a food label reports that a portion has 17 g of carbohydrates per portion (see Figure 2), and two portions are eaten, then the patient should multiply by 2 and will be consuming a total 34 g of carbohydrates.
Glycemic Index The glycemic index is also important for individuals with diabetes to be aware of as they make dietary choices (Table 3). The glycemic index is a ranking of how much a carbohydrate raises blood glucose level as compared to pure glucose (Craig, 2012; Sizer & Whitney, 2013). A glycemic index ⱕ55 is considered low; between 56 and 69 is considered medium; and ⱖ70 is high (Craig, 2012; Sizer & Whitney, 2013). Glycemic index values are determined by researchers who give 10 individuals a portion of food that contains 50 g of carbohydrate; the researchers test blood glucose levels before the food is consumed and at set times for up to 2 hr after consumption (Craig, 2012; Sizer & Whitney, 2013). Then on another day, researchers give the same individuals 50 g of glucose that is equal to 50 g of carbohydrates and measure blood glucose levels at the same time; the two sets of measurements are then compared (Craig, 2012; Sizer & Whitney, 2013). The glycemic index of foods varies slightly from person to person and depends on whether a food is eaten alone or with other foods (Craig, 2012; Sizer & Whitney, 2013). Consuming a carbohydrate along with protein and fat may have a lower glycemic index than eating a carbohydrate alone (Craig, 2012; Sizer & Whitney, 2013). In addition, how a food is prepared, how ripe a food is, and how quickly an 142
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TABLE 3. Glycemic Index, Serving Size, and Glycemic Load in Spanish and English Glycemic Index (1–100)
Tipo de Alimento (type of food)
Serving Size (grams)
Glycemic Load (per serving)
Pan y productos horneados (breads and baked products) Pastel de plátano con azúcar (banana cake with sugar)
47
60
14
Pastel de plátano sin azúcar (banana cake with no sugar)
55
60
12
Pastel con merengue (cake with frosting)
42
111
24
Bagel (bagel)
72
70
25
Pan de trigo entero (whole wheat bread)
71
30
9
Pan de pita (pita bread)
68
30
10
Tortilla de maíz (corn tortilla)
52
50
12
Tortilla de harina integral (wheat tortilla)
30
50
8
Bebidas (drinks) Coca Cola
63
250 ml
16
95 ⫾ 10
250 ml
40
Jugo de manzana sin azúcar (apple juice with no sugar)
44
250 ml
30
Gatorade
78
250 ml
12
Jugo de naranja sin azúcar añadida (orange juice with no added sugar)
50
250 ml
12
Jugo de Naranja Tampico (orange tampico)
Cereales (cereals) All-Bran
55
30
12
Corn Pops
77
30
20
Cornflakes
93
30
23
Maíz dulce (sweet corn)
60
150
20
Arroz blanco (white rice)
89
150
43
Galletas graham (graham crackers)
74
25
14
Vanilla wafers (vanilla wafers)
77
25
14
Galletas (shortbread)
64
25
10
Helados (ice cream)
57
50
6
Leche entera (whole milk)
41
250 ml
5
Leche descremada (skim milk)
32
250 ml
4
Yogur bajo en grasa (low fat yogurt)
33
200
11
Manzana (apple)
39
120
6
Plátano (banana)
62
120
16
Uvas (grapes)
59
120
11
Naranja (orange)
40
120
4
Durazno (peach)
42
120
5
Pera (pear)
38
120
4
Sandía (watermelon)
72
120
4
Granos (grains)
Galletas (cookies)
Frutas (fruits)
(Continued) 143
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TABLE 3. Glycemic Index, Serving Size, and Glycemic Load in Spanish and English (Continued) Glycemic Index (1–100)
Tipo de Alimento (type of food)
Serving Size (grams)
Glycemic Load (per serving)
Granos y frutos secos (beans and nuts) Frijoles negros (black beans)
30
150
7
Garbanzos (chickpeas)
10
150
3
Cacahuates (peanuts)
7
50
0
Macarrones (macaroni)
47
180
23
Macarrones con queso (macaroni and cheese)
64
180
32
Espagueti (spaghetti)
46
180
22
Hojuelas de maíz (corn chips)
42
50
11
Papas fritas (potato chips)
51
50
12
Galletas saladas (pretzels)
83
30
16
51
80
4
Pastas (pasta and noodles)
Bocadillos
Hortalizas (vegetables) Chícharos (green peas) Zanahorias (carrots)
35
80
2
Patata hervida blanco (boiled white potato)
82
150
21
Camote (sweet potato)
70
150
22
Yam (yam)
54
150
20
Atkinson, F. S., Foster-Powell, K., & Brand-Miller, J. C. (2008). International tables of glycemic index and glycemic load values. Diabetes Care, 31(12), 2281–2283. For example, one ripe 7-in. banana provides about 10 g of carbohydrates and has a glycemic index of 62. Therefore, the glycemic load is about 6 because 62 ⫻ 10/100 ⫽ 6.2. A glycemic load between 1 and 10 is considered low, a glycemic load between 11 and 19 is considered medium, and a glycemic load 20 or above is considered high (Craig, 2012; Sizer & Whitney, 2013).
individual eats it play a part in the glycemic index of a food. For example, a banana that is green and underripe has a lower glycemic index than an overripe banana. In addition, how foods are cooked determines glycemic index. A white potato that is slightly undercooked and firm will have a lower glycemic index than a white potato that is cooked until soft and granular. Hence, it is important for persons with diabetes to learn how they respond to different carbohydrates and how they respond when they eat carbohydrates in combination with other foods. An individual’s blood glucose level immediately before a meal may also affect the glycemic index of a food. If an individuals’ blood glucose level is low prior to a meal, then the glycemic index of the food usually goes up; but when an individual’s blood glucose level is high prior to a meal, then the glycemic index of a food may be lower (Craig, 2012; Sizer & Whitney, 2013).
CONCLUSION Basic carbohydrate counting, glycemic index, and glycemic load are important for individuals with diabetes to learn to better manage type 2 diabetes. Many Hispanic individuals in both Mexico and in the United States have poor DSM, resulting in increased morbidity and mortality. Health care providers can help this population understand that the amount and type of carbohydrate eaten affect blood glucose levels. Monitoring carbohydrate intake is a key strategy in achieving glycemic control, and the use of the glycemic index and glycemic load may provide additional benefit. That is, individuals who choose carbohydrates that have a low to medium glycemic index may lower the overall glycemic load of their meals, thereby improving blood glucose levels.
Glycemic Load Glycemic load takes into consideration the amount of carbohydrate in the food that is consumed and the glycemic index of the food (see Table 3). An individual can calculate the glycemic load of a food by multiplying the glycemic index value by the number of grams of carbohydrate and then dividing by 100 (Craig, 2012; Sizer & Whitney, 2013). 144
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Understanding Basic Carbohydrate Counting, Glycemic Index, and Glycemic Load International Diabetes Federation. (2011). Global diabetes plan 2011–2021 (pp. 1–28). Brussels, Belgium: Author. Martins, M. R., Ambrosio, A. C., Nery, M., Aquino, R. C., & Queiroz, M. S. (2013). Assessment guidance of carbohydrate counting method in patients with type 2 diabetes mellitus. Primary Care Diabetes, 8(1), 39–42. http://dx.doi. org.10.01016/j.pcd.02013.00004.00009 Mechanick, J. I., Marchetti, A. E., Apovian, C., Benchimol, A. K., Bisschop, P. H., Bolio-Galvis, A., . . . Hamdy, O. (2012). Diabetes-specific nutrition algorithm: A transcultural program to optimize diabetes and prediabetes care. Current Diabetes Reports, 12(2), 180–194. Meneghini, L. F. (2013). Insulin therapy for type 2 diabetes. Endocrine, 43(3), 529–534. Motel, S., & Patten, C. (2012). The 10 largest Hispanic origin groups: Characteristics, rankings, top counties. Retrieved http:// www.pewhispanic.org/2012/06/27/the-10-largest-hispanicorigin-groups-characteristics-rankings-top-counties/ Nelms, M., Sucher, K. P., Lacey, K., & Roth, S. L. (2010). Nutrition therapy and pathophysiology. Belmont, CA: Cengage Learning. Pew Hispanic Center. (2009). Statistical portrait of the foreignborn population in the United States, 2007. Washington, DC: Author. Secretaría de Salud. (2007). Programa nacional de salud, 2007– 2012. Ciudad de México, México: Author. Sizer, F., & Whitney, E. (2013). Nutrition: Concepts and controversies. Belmont, CA: Cengage Learning. Varela, N., Vega, C., & Valenzuela, K. (2012). Relationship of consumption of high glycemic index food in the diet and levels of HbA1c in type 2 diabetic patients treated with diet and/or metformin. Archivos Latinoamericanos de Nutrición, 62(1), 23–29. Whitney, E. N., & Rolfes, S. R. (Eds.). (2011). Understanding nutrition update (with 2010 dietary guidelines). Belmont, CA: Cengage Learning. Zipp, C., Roehr, J. T., Weiss, L. B., & Filipetto, F. (2010). Impact of intensive nutritional education with carbohydrate counting on diabetes control in type 2 diabetic patients. Patient Preference and Adherence, 30(5), 7–12.
REFERENCES American Association of Diabetes Educators. (2011). AADE 7 selfcare behaviors: American Association of Diabetes Educators (AADE) position statement. The Diabetes Educator, 1–11. American Diabetes Association. (2014). Clinical practice recommendations. Diabetes Care, 37, S14–S67. Boyle, J. P., Thompson, T. J., Gregg, E. W., Barker, L. E., & Williamson, D. F. (2010). Projection of the year 2050 burden of diabetes in the US adult population: Dynamic Dynamic modeling of incidence, mortality, and prediabetes prevalence. Population Health Metrics, 8–29. Centers for Disease Control and Prevention. (2009). Estimated country-level prevalence of diabetes and obesity—United States, 2007. Morbidity and Mortality Weekly Report, 58(45), 1259–1263. Compeán-Ortiz, L. G., Gallegos, E. C., Gonzalez-Gonzalez, J. G., Gomez-Meza, M. V., Therrien, B., & Salazar, B. C. (2010). Cognitive performance associated with self-care activities in Mexican adults with type 2 diabetes. Diabetes Educator, 36(2), 268–275. Craig, J. (2012). Carbohydrate counting, glycemic index, and glycemic load. Putting them all together. Diabetes SelfManagement, 29(2), 41–50. Esherick, J. S., Clark, D. S., & Slater, E. D. (2013). Current practice guidelines in primary care 2013. New York, NY: McGraw-Hill. Golden, S. H., Brown, A., Cauley, J. A., Chin, M. H., Gary-Webb, T. L., Kim, C., . . . Anton, B. (2012). Health disparities in endocrine disorders: Biological, clinical, and nonclinical factors—An Endocrine Society scientific statement. Journal of Clinical Endocrinology and Metabolism, 97(9), E1579– E1639. http://dx.doi.org/10.1210/jc.2012-2043 Gonçlaves Reis, C. E., & Dullius, J. (2011). Glycemic acute changes in type 2 diabetes caused by low and high glycemic index. Nutrición Hospitalaria, 26(3), 546–552. Gonzalez, L., Berry, D., & Davison, J. (2013). Diabetes selfmanagement education interventions and glycemic control among Hispanics: A literature review. Hispanic Health Care International, 11(4), 157–166. Gutiérrez, J. P., Rivera-Dommarco, J., Shamah-Levy, T., VillalpandoHernández, S., Franco, A., Cuevas-Nasu, L., . . . HernándezÁvila, M. (2012). Encuesta nacional de salud y nutrición 2012. Resultados nacionales. Cuernavaca, México: Instituto Nacional de Salud Pública (MX). Haas, L., Maryniuk, M., Beck, J., Cox, C., Duker, P., Edwards, L., . . . Youssef, G. (2012). National standards for diabetes self-management education and support. The Diabetes Educator, 38, 619–626. Hoyert, D. L., & Xu, J. Q. (2012). Deaths: Preliminary data for 2011. National Vital Statistics Report, 61(6). Hyattsville, MD: National Center for Health Statistics.
ACKNOWLEDGMENTS. This article is the result of research supported by the Ministry of Public Education through the Programa de Mejoramiento al Profesorado (PROMEP UAT-EXB 199) in the Nursing School at the Autonomous University of Tamaulipas in Tampico. Correspondence regarding this article should be directed to Lidia Guadalupe Compeán Ortiz, PhD, Autonomous University of Tamaulipas, Campus Tampico, Avenida Universidad, Boulevard López Mateos S/N, Tampico, Mexico. E-mail: lcompean@uat. edu.mx
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Understanding Basic Carbohydrate Counting, Glycemic Index, and Glycemic Load for Improved Glycemic Control in Hispanic Patients With Type 2 Diabetes Mellitus Lidia Guadalupe Compeán Ortiz, PhD Autonomous University of Tamaulipas, Tampico, Mexico Diane C. Berry, PhD, ANP-BC, FAANP The University of North Carolina at Chapel Hill Octelina Castillo Ruiz, PhD Eunice Reséndiz González, PhD Paulina Aguilera Pérez, MNS Elva Del Ángel Rivas, ME Autonomous University of Tamaulipas, Tampico, Mexico Hispanic patients with type 2 diabetes mellitus generally have poor glycemic control. Constant hyperglycemia in individuals with type 2 diabetes can cause microvascular and macrovascular complications that lead to early morbidity and mortality. Good glycemic control requires a balance between diet, exercise, and medication, but dietary balance is difficult to achieve for many patients. Of the macronutrients, carbohydrates mostly affect blood glucose levels. Basic carbohydrate counting, glycemic index, and glycemic load are important tools for patients to master to control their blood glucose levels. Los pacientes hispanos con diabetes tipo 2 suelen tener control deficiente de la glicemia. La hiperglicemia constante en los individuos con diabetes mellitus tipo 2 puede causar complicaciones microvasculares y macrovasculares que conducen a una morbilidad y mortalidad precoz. Un buen control de la glucemia requiere equilibrio entre dieta, ejercicio y medicamentos, pero el equilibrio en la dieta es difícil de alcanzar para muchos pacientes. De los macronutrientes, los carbohidratos son los que más afectan los niveles de glucosa en la sangre. Por lo tanto, el conteo básico de carbohidratos, el índice glicémico y la carga glicémica son herramientas importantes para que los pacientes controlen sus niveles de glucosa en la sangre. Keywords: carbohydrate counting; glycemic index; glycemic load; type 2 diabetes mellitus; carbohydrates; glycemic control
T
ype 2 diabetes mellitus is a major global public health concern. In 2000, approximately 366 million people older than the age of 20 years were diagnosed with type 2 diabetes. It is estimated that by 2030, that number will increase to 552 million worldwide
(International Diabetes Federation, 2011). In Mexico, approximately 10.6 million (9.2% prevalence in a population of 115,170,278) people older than the age of 20 years are currently diagnosed with type 2 diabetes. It is estimated that by the year 2030, the number of cases will 138
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DSM is achieved by seven elements of care outlined by the American Association of Diabetes Educators (AADE, 2011): (a) healthy eating, (b) being active, (c) monitoring, (d) taking medication, (e) problem solving, (f) healthy coping, and (g) reducing risk (AADE, 2011). Diabetes self-management education (DSME) and diabetes selfmanagement support (DSMS) are important elements in the care of individuals with diabetes (Haas et al., 2012). DSME and DSMS involve a long-term process of working with patients to develop the knowledge, skill, and ability to self-manage their diabetes in all aspects of their lives (Haas et al., 2012). In Mexico, several institutions have prepared health care professionals (doctors, nurses, and nutritionists) as diabetes educators to improve DSM. In the United States, a formal accrediting agency, the AADE provides certification for certified diabetes educators (CDEs) and board certified advanced diabetes management (BC-ADM). A CDE can be a clinical psychologist, registered nurse, occupational therapist, optometrist, pharmacist, physician, dietitian, nurse practitioner, physician assistant, exercise physiologist, or health professional with a master’s degree such as a social worker. A BC-ADM can be a registered nurse, registered dietitian, registered pharmacist, nurse practitioner, physician assistant, or a physician. As the diabetes epidemic increases in Mexico and the United States, it will be important to train more professionals in delivering DSME. It is particularly important for professionals to provide information on diet, with a focus on carbohydrate counting, glycemic index, and glycemic load to improve glycemic control in the general population and in the Hispanic population. This article focuses on providing health care providers working in family practice, primary care, and clinics with an understanding of carbohydrate counting, glycemic index, and glycemic load in patients with type 2 diabetes. Teaching carbohydrate counting and calculating glycemic index and glycemic load were skills reserved for CDEs and diabetes
increase to 31.8 million (Gutiérrez et al., 2012). In the United States, approximately 25.8 million people older than the age of 20 years are diagnosed with type 2 diabetes, and by 2030, this number is projected to increase to 50.1 million (American Diabetes Association [ADA], 2014; Boyle, Thompson, Gregg, Barker, & Williamson, 2010). Diabetes is currently the leading cause of death in Mexico (Secretaría de Salud, 2007) and the seventh leading cause of death in the United States (Hoyert & Xu, 2012) secondary to microvascular and macrovascular complications. There are currently 50.7 million Hispanics in the United States, and 33 million of these are of Mexican heritage; 19.8 million are newly immigrated with limited English proficiency (Motel & Patten, 2012; Pew Hispanic Center, 2009). By 2050, it is projected that the Hispanic population will exceed that of non-Hispanic Whites in the United States (Centers for Disease Control and Prevention, 2009; Motel & Patten, 2012). Thus, it is essential to improve glycemic control to reduce the complications associated with diabetes both in Mexico and among Mexican Americans. Diabetes self-management (DSM) is critical to decrease morbidity and mortality caused by microvascular and macrovascular complications (ADA, 2014). Approximately 95% of people with diabetes are diagnosed with type 2 diabetes (ADA, 2014). Type 2 diabetes involves a complex interplay between hyperglycemia, hyperinsulinemia, and alteration in the metabolism of carbohydrates, lipids, and proteins (ADA, 2014). A primary objective of diabetes control is optimal glycemic control to prevent microvascular and macrovascular complications (ADA, 2014). Optimal glycemic control is defined as a preprandial (fasting) blood glucose between 70 and 130 mg/dl; peak postprandial (1–2 hr after meals) blood glucose less than 180 mg/dl; and a glycosylated hemoglobin (HbA1c) level less than 7% (ADA). Figure 1 shows the conversion of blood glucose to HbA1c levels.
4% .. 50–80 5% ..... 80–115 6% ........ 115–150 7% ............ 150–180 Value of A1c (Goal less than 7%)
8% ................ 180–210 9% .................. 210–245
Blood glucose (Goal: Half or more testing in the optimal range).
10% ..................... 245–280 11% ....................... 280–310 12% .......................... 310–345 13% .............................. 345 and more
Figure 1. Relationship between blood glucose levels and glycosylated hemoglobin. American Diabetes Association. (2014). Clinical practice recommendations. Diabetes Care, 37, S14–S67. 139
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nurses predominately in patients with type 1 diabetes. However, with the global epidemic of type 2 diabetes, health care providers working with Hispanic patients need to understand these concepts to help their patients with type 2 diabetes learn to be aware of carbohydrates and what they eat and that the timing of what they eat affects overall glycemic control (Gonçlaves Reis & Dullius, 2011; Martins, Ambrosio, Nery, Aquino, & Queiroz, 2013; Varela, Vega, & Valenzuela, 2012; Zipp, Roehr, Weiss, & Filipetto, 2010). Many patients diagnosed with type 2 diabetes transition to basal and bolus insulin regimes within several years of diagnosis for improved glycemic control (Meneghini, 2013).
glucose production by activating glycogenolysis and gluconeogenesis (Nelms et al., 2010). Blood glucose can come either from ingestion of carbohydrates or from glycogen stores (Nelms et al., 2010). Hormones such as insulin, glucagon, growth hormone, and cortisol are necessary for glucose levels to remain stable (Nelms et al., 2010). Foods that are rich in carbohydrates stimulate production of insulin, which transports glucose into the cells within 60–90 min after ingestion to avoid postprandial hyperglycemia (Nelms et al., 2010). The excess glucose is stored as glycogen (Nelms et al., 2010). In diabetes mellitus, there is a deficiency of insulin production or the insulin does not act efficiently (ADA, 2014). Excessive blood glucose that cannot be absorbed by fat cells and muscle accumulates in the bloodstream, causing hyperglycemia (ADA, 2014). Patients with diabetes who understand healthy eating, carbohydrate counting, glycemic index, and glycemic load are in a better position to self-manage their blood glucose levels. Unfortunately, many patients of Hispanic heritage in both Mexico and the United States have received inadequate DSME (Golden et al., 2012; Gonzalez, Berry, & Davison, 2013). In Mexico, patients often have difficulty gaining access to health care providers trained to deliver DSME (Compeán-Ortiz et al., 2010; Golden et al., 2012). In the United States, many Mexican American patients have difficulty with access because of lack of health insurance and because of a lack of trained bilingual diabetes educators (Gonzalez et al., 2013).
PHYSIOLOGY OF CARBOHYDRATE METABOLISM Nutrition is a process that maintains the biochemical characteristics, composition, and function of tissues, organs, and body systems (Esherick, Clark, & Slater, 2013). Intermediary metabolism is the conversion of food at the cellular level (Whitney & Rolfes, 2011). This begins with the absorption of nutrients and ends when nutrients are used at their maximum capacity (Sizer & Whitney, 2013). Appropriate nutrition is an essential aspect of diabetes care and includes a balance of carbohydrates, proteins, fats, vitamins, and minerals (Sizer & Whitney, 2013). Carbohydrates are the nutrients that mostly affect blood glucose levels and are therefore strong predictors of glycemic response (ADA, 2014; Sizer & Whitney, 2013). Carbohydrates are chemical compounds composed of carbon, hydrogen, and oxygen and they are the main source of energy in the human diet (Sizer & Whitney, 2013). They are classified as monosaccharides (glucose, galactose, and fructose), disaccharides (sucrose, lactose, and maltose), oligosaccharides, and polysaccharides (starch; Sizer & Whitney, 2013). Digestion of carbohydrates begins in the mouth and continues in the stomach by the action of enzymes that produce simple compounds such as glucose, galactose, and fructose (Sizer & Whitney, 2013). Simple forms of nutrients (glucose, fatty acids, and amino acids) are available in the first hours (0–3) after food intake (the immediate postprandial or absorptive period; Nelms, Sucher, Lacey, & Roth, 2010). These nutrients then cross the intestinal wall and pass into the bloodstream, which takes them to the liver, muscle, fat, and other organs where they are either used to produce energy or are stored as energy compounds (glycogen and triglycerides; Nelms et al., 2010). In normal conditions, the production of insulin by the pancreas increases during this period so that the glucose transported by the bloodstream can pass into muscle and fat cells. During periods of fasting (postabsorptive period), pancreatic insulin secretion drops and an increase in glucagon secretion occurs (Nelms et al., 2010). Both conditions generate an increase in hepatic
HEALTHY EATING Healthy eating is extremely important for those with diabetes. Glycemic control cannot be achieved by patients who do not adhere to a healthy eating plan, even if they take medications and exercise regularly (Mechanick et al., 2012). Healthy eating is influenced by complex processes that include conditions, culture, and customs (Mechanick et al., 2012). The typical diet eaten by Hispanic patients in Mexico and the United States contains highcarbohydrate foods such as corn, flour, rice, and beans, and often, beverages high in sugar (Nelms et al., 2010; Sizer & Whitney, 2013). Nutrition education can provide a strong foundation on which to build a healthy balanced diet resulting in improved glycemic control. Patients should be taught basic carbohydrate counting, glycemic index, and glycemic load at a literacy level and in the language they feel most comfortable learning in.
Basic Carbohydrate Counting Basic carbohydrate counting is essential for patients with type 2 diabetes who are controlled with diet and physical activity, with or without oral diabetic medications. This method can also be used by patients with type 2 diabetes treated with oral medications that are starting insulin. 140
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TABLE 2. Conversion From Grams of Carbohydrates to Portions of Carbohydrates
To learn basic carbohydrate counting, three steps are suggested: (a) identify which foods contain carbohydrates, (b) determine how many servings of carbohydrates there are in each food serving, and (c) identify the total amount of carbohydrate consumed in each dish (portion). Other factors that affect blood glucose, such as the medications used (oral hyperglycemic agents or insulin), physical activity, illness, and stress, must also be considered (ADA, 2014; Nelms et al., 2010; Sizer & Whitney, 2013). Step 1: Identify Which Foods Contain Carbohydrates. Foods may contain carbohydrates, protein, and fat; however, carbohydrates have the greatest effect on blood glucose levels (Nelms et al., 2010). The amount of carbohydrates consumed and the type of carbohydrates (simple or complex) affects blood glucose levels (Sizer & Whitney, 2013). Simple carbohydrates are easily and quickly absorbed into the bloodstream and include dextrose, fructose, maltose, white sugar, corn syrup, honey, and turbinado sugar (Sizer & Whitney, 2013). Complex carbohydrates are slowly absorbed into the bloodstream and include starches, glycogen, and cellulose and nutritional compounds composed of multiple monosaccharide (simple sugar) building blocks (Sizer & Whitney, 2013). Carbohydrates are found in bread, tortillas, corn, flour, rice, pasta, cereals, potatoes, legumes, fruits, juices, milk, yogurt, candy, and desserts (Table 1). It is important to recognize that some foods do not contain carbohydrates or contain minimal amounts; their main nutrients are proteins or fats (Sizer & Whitney, 2013). Protein foods include meats, such as beef, chicken, turkey, and fish;
Total Carbohydrates (g)
Quantity
Corn tortilla 6 in.
1 piece
Flour tortilla 10 in. Cooked beans
¹⁄³ piece ¹⁄³ cup ½ cup
Whole or skim milk
1 cup
Evaporated whole milk
½ cup
Cooked pasta
½ cup
Cooked lentils
½ cup
Small apple
1 piece
Papaya
1 cup
Banana
½ piece
Cereal w/o sugar
1 cup
Cereal w/sugar
¾ cup
Cooked rice
0–5
0
6–10
½
11–20
1
21–25
1½
26–35
2
36–40
2½
41–50
3
51–55
3½
56–65
4
66–70
4½
71–80
5
Sizer, F., & Whitney, E. (2013). Nutrition: Concepts and controversies. Belmont, CA: Cengage Learning.
eggs; tofu; cheese; and nuts (Sizer & Whitney, 2013). Fat foods include cooking oil, butter, margarine, salad dressings, cream cheese, and cream (Sizer & Whitney, 2013). Proteins and fats do not have much effect on blood glucose; however, it is important not to consume excess amounts because they promote weight gain and obesity (Sizer & Whitney, 2013). Sugar-free foods or foods with a small amount of carbohydrates (⬍5 g of carbohydrate per serving) such as coffee, sugar-free gelatin, spices, sugar substitutes, unsweetened teas, and water also have almost no effect on blood glucose levels (Sizer & Whitney, 2013). Dietary calories should be approximately 50%–60% carbohydrates, 10%–20% protein, and 25%–30% fat in patients with diabetes without complications (Sizer & Whitney, 2013). Step 2: Determining How Many Servings of Carbohydrates Are in Each Food Serving. A portion of carbohydrates is defined as the amount of food that contains 15 g of carbohydrates (Sizer & Whitney, 2013). Tables 1 and 2 show selected foods that are equivalent to one portion. The total carbohydrate number includes starches, natural sugars, added sugars, and fiber (Sizer & Whitney, 2013). Total grams of carbohydrates are included on the nutrition food label on packaged food. Total grams of carbohydrates can be found for nonpackaged foods on websites in both English and Spanish. Total carbohydrates for chain restaurants can be found on the restaurant website many times in English and Spanish. The ADA publishes The CalorieKing Calorie, Fat, & Carbohydrate Counter and The Diabetes Carbohydrate & Fat Gram Guide, which are very helpful to patients learning carbohydrate counting. There are also free applications that can be downloaded for iPads, iPod touches, tablets, and smart phones.
TABLE 1. Examples of Foods Equivalent to One Portion of Carbohydrates Food
Portion
Note. The size of the cup is approximately 240 ml. Sizer, F., & Whitney, E. (2013). Nutrition: Concepts and controversies. Belmont, CA: Cengage Learning. 141
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Nutrition Facts Portion size Refers to the size of the portion (serving) per package. For each bar eaten, the amount of nutrients on the label is consumed.
Serving size 1 bar (25g) Servings per container 2 Amount per serving Calories: 93 Protein 1.9g Total fat 1.7g Saturated fat 0.6g Monounsaturated fat 0.5g Polyunsaturated fat 0.5g Cholesterol 0g Transfat 0g Sodium 115 mg Total carbohydrate 17.4g
Servings per container Refers to the amount of portions (servings) the package contains.
Total carbohydrate Amount of total carbohydrate in grams per serving.
Dietary fiber 1.8g Sugars 6.7g Folic Acid 8% RDV*
Other nutrients Should be low-fat and high-fiber.
*Recommended Daily Value for Mexican Population
Figure 2.
Example of a food label.
Patients must understand that the nutritional information provided on food labels is per serving (Figure 2). Therefore, the carbohydrate gram information will need to be adjusted to their portion size. Fiber is not broken down or absorbed by the body; therefore, the grams of fiber can be subtracted from the total carbohydrate grams because fiber does not affect blood glucose levels. Registered dietitians or certified diabetes educators should be consulted to establish each patient’s individual carbohydrate needs. Step 3: Identifying the Amount of Carbohydrates in Each Dish. It is important to recognize that the amount of carbohydrates each person needs is based on factors such as height and weight; amount of physical activity; and the person’s state of health, diabetes medications, and glucose levels. In general, women require 3–4 servings of carbohydrate at each meal (45–60 g) and men require 4–5 servings (60–75 g) at each meal (Sizer & Whitney, 2013). It is also necessary to have snacks two to three times a day, with 1–2 servings of carbohydrates (15–30 g), which will help to control blood glucose (Sizer & Whitney, 2013). Helping patients understand how to read a food label is instrumental to their success in basic carbohydrate counting. The food label provides information on portion size, the number of calories per serving, and other nutrients, such as fat and protein per serving (see Figure 2). It is important to review with patients the way to read a food label. First, examine the portion size. Second, examine how many portions in the package. Third, examine the total amount of carbohydrate per portion. Fourth, examine the other nutrients to make sure this is a low-fat and highfiber food. If the food portion has 5 g or more of fiber, subtract half the grams of fiber from the total number of carbohydrates (Sizer & Whitney, 2013).
To correctly calculate the amount of carbohydrates that a food contains using the food label is an important skill for health care providers to learn and teach their patients. For example, if a food label reports that a portion has 17 g of carbohydrates per portion (see Figure 2), and two portions are eaten, then the patient should multiply by 2 and will be consuming a total 34 g of carbohydrates.
Glycemic Index The glycemic index is also important for individuals with diabetes to be aware of as they make dietary choices (Table 3). The glycemic index is a ranking of how much a carbohydrate raises blood glucose level as compared to pure glucose (Craig, 2012; Sizer & Whitney, 2013). A glycemic index ⱕ55 is considered low; between 56 and 69 is considered medium; and ⱖ70 is high (Craig, 2012; Sizer & Whitney, 2013). Glycemic index values are determined by researchers who give 10 individuals a portion of food that contains 50 g of carbohydrate; the researchers test blood glucose levels before the food is consumed and at set times for up to 2 hr after consumption (Craig, 2012; Sizer & Whitney, 2013). Then on another day, researchers give the same individuals 50 g of glucose that is equal to 50 g of carbohydrates and measure blood glucose levels at the same time; the two sets of measurements are then compared (Craig, 2012; Sizer & Whitney, 2013). The glycemic index of foods varies slightly from person to person and depends on whether a food is eaten alone or with other foods (Craig, 2012; Sizer & Whitney, 2013). Consuming a carbohydrate along with protein and fat may have a lower glycemic index than eating a carbohydrate alone (Craig, 2012; Sizer & Whitney, 2013). In addition, how a food is prepared, how ripe a food is, and how quickly an 142
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TABLE 3. Glycemic Index, Serving Size, and Glycemic Load in Spanish and English Glycemic Index (1–100)
Tipo de Alimento (type of food)
Serving Size (grams)
Glycemic Load (per serving)
Pan y productos horneados (breads and baked products) Pastel de plátano con azúcar (banana cake with sugar)
47
60
14
Pastel de plátano sin azúcar (banana cake with no sugar)
55
60
12
Pastel con merengue (cake with frosting)
42
111
24
Bagel (bagel)
72
70
25
Pan de trigo entero (whole wheat bread)
71
30
9
Pan de pita (pita bread)
68
30
10
Tortilla de maíz (corn tortilla)
52
50
12
Tortilla de harina integral (wheat tortilla)
30
50
8
Bebidas (drinks) Coca Cola
63
250 ml
16
95 ⫾ 10
250 ml
40
Jugo de manzana sin azúcar (apple juice with no sugar)
44
250 ml
30
Gatorade
78
250 ml
12
Jugo de naranja sin azúcar añadida (orange juice with no added sugar)
50
250 ml
12
Jugo de Naranja Tampico (orange tampico)
Cereales (cereals) All-Bran
55
30
12
Corn Pops
77
30
20
Cornflakes
93
30
23
Maíz dulce (sweet corn)
60
150
20
Arroz blanco (white rice)
89
150
43
Galletas graham (graham crackers)
74
25
14
Vanilla wafers (vanilla wafers)
77
25
14
Galletas (shortbread)
64
25
10
Helados (ice cream)
57
50
6
Leche entera (whole milk)
41
250 ml
5
Leche descremada (skim milk)
32
250 ml
4
Yogur bajo en grasa (low fat yogurt)
33
200
11
Manzana (apple)
39
120
6
Plátano (banana)
62
120
16
Uvas (grapes)
59
120
11
Naranja (orange)
40
120
4
Durazno (peach)
42
120
5
Pera (pear)
38
120
4
Sandía (watermelon)
72
120
4
Granos (grains)
Galletas (cookies)
Frutas (fruits)
(Continued) 143
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TABLE 3. Glycemic Index, Serving Size, and Glycemic Load in Spanish and English (Continued) Glycemic Index (1–100)
Tipo de Alimento (type of food)
Serving Size (grams)
Glycemic Load (per serving)
Granos y frutos secos (beans and nuts) Frijoles negros (black beans)
30
150
7
Garbanzos (chickpeas)
10
150
3
Cacahuates (peanuts)
7
50
0
Macarrones (macaroni)
47
180
23
Macarrones con queso (macaroni and cheese)
64
180
32
Espagueti (spaghetti)
46
180
22
Hojuelas de maíz (corn chips)
42
50
11
Papas fritas (potato chips)
51
50
12
Galletas saladas (pretzels)
83
30
16
51
80
4
Pastas (pasta and noodles)
Bocadillos
Hortalizas (vegetables) Chícharos (green peas) Zanahorias (carrots)
35
80
2
Patata hervida blanco (boiled white potato)
82
150
21
Camote (sweet potato)
70
150
22
Yam (yam)
54
150
20
Atkinson, F. S., Foster-Powell, K., & Brand-Miller, J. C. (2008). International tables of glycemic index and glycemic load values. Diabetes Care, 31(12), 2281–2283. For example, one ripe 7-in. banana provides about 10 g of carbohydrates and has a glycemic index of 62. Therefore, the glycemic load is about 6 because 62 ⫻ 10/100 ⫽ 6.2. A glycemic load between 1 and 10 is considered low, a glycemic load between 11 and 19 is considered medium, and a glycemic load 20 or above is considered high (Craig, 2012; Sizer & Whitney, 2013).
individual eats it play a part in the glycemic index of a food. For example, a banana that is green and underripe has a lower glycemic index than an overripe banana. In addition, how foods are cooked determines glycemic index. A white potato that is slightly undercooked and firm will have a lower glycemic index than a white potato that is cooked until soft and granular. Hence, it is important for persons with diabetes to learn how they respond to different carbohydrates and how they respond when they eat carbohydrates in combination with other foods. An individual’s blood glucose level immediately before a meal may also affect the glycemic index of a food. If an individuals’ blood glucose level is low prior to a meal, then the glycemic index of the food usually goes up; but when an individual’s blood glucose level is high prior to a meal, then the glycemic index of a food may be lower (Craig, 2012; Sizer & Whitney, 2013).
CONCLUSION Basic carbohydrate counting, glycemic index, and glycemic load are important for individuals with diabetes to learn to better manage type 2 diabetes. Many Hispanic individuals in both Mexico and in the United States have poor DSM, resulting in increased morbidity and mortality. Health care providers can help this population understand that the amount and type of carbohydrate eaten affect blood glucose levels. Monitoring carbohydrate intake is a key strategy in achieving glycemic control, and the use of the glycemic index and glycemic load may provide additional benefit. That is, individuals who choose carbohydrates that have a low to medium glycemic index may lower the overall glycemic load of their meals, thereby improving blood glucose levels.
Glycemic Load Glycemic load takes into consideration the amount of carbohydrate in the food that is consumed and the glycemic index of the food (see Table 3). An individual can calculate the glycemic load of a food by multiplying the glycemic index value by the number of grams of carbohydrate and then dividing by 100 (Craig, 2012; Sizer & Whitney, 2013). 144
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ACKNOWLEDGMENTS. This article is the result of research supported by the Ministry of Public Education through the Programa de Mejoramiento al Profesorado (PROMEP UAT-EXB 199) in the Nursing School at the Autonomous University of Tamaulipas in Tampico. Correspondence regarding this article should be directed to Lidia Guadalupe Compeán Ortiz, PhD, Autonomous University of Tamaulipas, Campus Tampico, Avenida Universidad, Boulevard López Mateos S/N, Tampico, Mexico. E-mail: lcompean@uat. edu.mx
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