Carbohydrate counting as a strategy to optimize glycemic control in type 1 diabetes mellitus

ABSTRACT Objective: The objective of this study was to verify the impact of carbohydrate counting (CC) on glycemic control and body weight variation (primary and secondary outcomes, respectively) between consultations in patients with diabetes mellitus (T1D) followed at a tertiary hospital in southern Brazil in a public health system environment. We also sought to investigate CC adherence. Materials and methods: This retrospective cohort study included 232 patients with T1D who underwent nutritional monitoring at a referral hospital for diabetes care between 2014 and 2018. To assess primary and secondary outcomes, data from 229 patients, 49 of whom underwent CC during this period and 180 individuals who used fixed doses of insulin, were analyzed. The impact of CC on glycemic control was assessed with the mean glycated hemoglobin (HbA1c) level at all consultations during the follow-up period. Results: In the model adjusted for the most confounders (except pregnancy), the mean HbA1c was better in the CC group (8.66 ± 0.4% vs. 9.36 ± 0.39%; p = 0.016), and body weight variation was lower (0.13 ± 0.28 kg vs. 0.53 ± 0.24 kg; p = 0.024). Adherence to CC was reported in 69.2% of consultations. Conclusion: CC optimized the glycemic control of individuals with T1D, resulting in less weight variation than in the fixed insulin dose group, which indicates that CC is an important care strategy for these patients.

Carbohydrate counting in type 1 diabetes mellitus: dietitians' perceptions, training and barriers to use

Objectives A study was undertaken to determine the perceptions, training and barriers regarding the use of carbohydrate counting in the dietary management of type 1 diabetes mellitus (T1DM) among dietitians in KwaZulu-Natal (KZN). Design A cross-sectional, descriptive study was conducted. Setting Dietitians who were registered with the Health Professions Council of South Africa (HPCSA), and working in the province of KZN at the time of the study, were invited to participate. Methods Data were collected using a self-administered electronic questionnaire distributed through SurveyMonkey, an Internet-based survey programme. Results Dietitians agreed that carbohydrate counting was a useful dietary management approach for diabetes (p < 0.05) and that it was essential to manage T1DM (p < 0.05). However, they felt it was a difficult concept for patients with T1DM to understand (p = 0.001) and teaching it to patients was time consuming (p < 0.05). Although dietitians believed that there was a strong evidence base for teaching carbohydrate counting to patients with T1DM (p < 0.05), they indicated a need for further training or education in it (p < 0.05). Barriers to using carbohydrate counting included a lack of training, confidence and experience, financial resources, time, blood glucose records and poor patient motivation and patient illiteracy (p < 0.05). Conclusions Overall, dietitians who participated in the study had a positive perception towards the use of carbohydrate counting in the management of T1DM. However, further training needs to be addressed for carbohydrate counting to be used with confidence by dietitians in KZN to optimize their management of T1DM.

Effectiveness and safety of carbohydrate counting in the management of adult patients with type 1 diabetes mellitus: a systematic review and meta-analysis

Abstract Objective: This study aimed to evaluate the effectiveness and safety of carbohydrate counting (CHOC) in the treatment of adult patients with type 1 diabetes mellitus (DM1). Materials and methods: We performed a systematic review of randomized studies that compared CHOC with general dietary advice in adult patients with DM1. The primary outcomes were changes in glycated hemoglobin (HbA1c), quality of life, and episodes of severe hypoglycemia. We searched the following electronic databases: Embase, PubMed, Lilacs, and the Cochrane Central Register of Controlled Trials. The quality of evidence was analyzed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: A total of 3,190 articles were identified, and two reviewers independently screened the titles and abstracts. From the 15 potentially eligible studies, five were included, and 10 were excluded because of the lack of randomization or different control/intervention groups. Meta-analysis showed that the final HbA1c was significantly lower in the CHOC group than in the control group (mean difference, random, 95% CI: −0.49 (-0.85, −0.13), p = 0.006). The meta-analysis of severe hypoglycemia and quality of life did not show any significant differences between the groups. According to the GRADE, the quality of evidence for severe hypoglycemia, quality of life, and change in HbA1c was low, very low, and moderate, respectively. Conclusion: The meta-analysis showed evidence favoring the use of CHOC in the management of DM1. However, this benefit was limited to final HbA1c, which was significantly lower in the CHOC than in the control group.

Efectividad del conteo de hidratos de carbono para el control metabólico de niños con diabetes mellitus tipo 1: revisión sistemática / Effectiveness of carbohydrate counting for metabolic control of children with type 1 diabetes mellitus: Systematic review

El conteo de hidratos de carbono como intervención terapéutica en pacientes con diabetes mellitus tipo 1 (DM1) desempeña un importante papel para obtener el nivel óptimo de glucemia posprandial, que se demuestra con los correctos niveles de hemoglobina glucosilada (HbA1c). Sin embargo, las recomendaciones para niños con DM1 se basan en revisiones narrativas de la evidencia disponible. Nuestro objetivo fue evaluar mediante una revisión sistemática la eficacia del conteo de hidratos de carbono sobre el control metabólico de niños con DM1. Se realizó la búsqueda en Pubmed, Google Académico y el registro de ensayos controlados de la colaboración Cochrane, CENTRAL. Se desarrolló una búsqueda desde enero del 2000 hasta septiembre del 2015. Se identificaron 5 ensayos elegibles, de 261 estudios potencialmente relevantes; 2 ensayos clínicos fueron incluidos. La calidad de los estudios en general no fue adecuada. Los 2 estudios incluidos concuerdan en la reducción de los niveles de HbA1c con la técnica del recuento de hidratos de carbono, como medida de control metabólico. En general, los demás parámetros medidos mostraron resultados contradictorios sin diferencias significativas, a excepción de la lipoproteína de alta densidad en uno de los estudios, que fue más alta en el grupo intervención. Aunque el conteo de hidratos de carbono es una técnica prometedora en el control metabólico para niños con DM1, la evidencia encontrada en esta revisión no es suficiente para recomendarla.

Carbohydrate counting as a therapeutic intervention in patients with Diabetes Mellitus type 1 (DM1) plays an important role in obtaining an optimal postprandial glucose level, which is demonstrated with the correct levels of glycosylated haemoglobin (HbA1c). However, recommendations for children with DM1 are based on narrative reviews of the available evidence. Our objective was to evaluate the effectiveness of carbohydrate counting on metabolic control of children with DM1. This study was a systematic review. The search was conducted in PubMed, Google Scholar, and controlled trials of the Cochrane collaboration (CENTRAL), published from January 2000 to September 2015. Five eligible trials out of 261 potentially relevant studies were identified, which include two trials. The quality of the studies was generally poor. The two studies included agreed on the positive impact of carbohydrate counting in reducing HbA1c levels as a measure of metabolic control. In general, the other parameters measured showed conflicting results with no significant differences, except for the high density lipoprotein in one study, higher in the intervention group. Although carbohydrate counting is a promising technique for metabolic control in children with type 1 diabetes, the evidence found in this review is not enough to recommend it.

Nutritional Management and Carbohydrate Counting for Patients with Type 1 Diabetes Mellitus / 임상당뇨병

Carbohydrate counting is a prudent meal planning approach for patients with type 1 diabetes mellitus (T1DM), especially those undergoing multiple daily injections or continuous subcutaneous insulin injections. Carbohydrate counting can make food planning flexible and enjoyable, but limitations exist. This article focuses on how to educate T1DM patients in Korea on carbohydrate counting and how to overcome the limitations of carbohydrate counting.

Avaliação do padrão alimentar de indivíduos com diabetes tipo 1 que realizam contagem de carboidrato em uma unidade de saúde pública de Brasília-DF / Evaluation of the dietary patterns of individuals with type 1 diabetes who use carbohydrate counting at a public health facility in Brasília-DF

OBJETIVOS: Avaliar o comportamento alimentar e o perfil de indivíduos com DM1 que realizam contagem de carboidratos e o risco de desenvolver complicações cardiovasculares. MÉTODOS: Estudo transversal analítico com amostra de conveniência composta por 23 indivíduos com DM1, em insulinização intensiva, atendidos em unidade de saúde pública, que aplicavam a contagem de CHO no tratamento. Por meio de entrevista, obtiveram-se informações sobre dados socioeconômicos e comportamento alimentar. Medidas antropométricas (peso, altura e circunferência da cintura) também foram aferidas e classificadas conforme o gênero e a faixa etária. RESULTADOS: Verificou-se que a maior parte da amostra aplicava corretamente o método de contagem de CHO. A maioria apresentou ingestão adequada de alimentos dos grupos dos CHO, vegetais, proteínas de origem animal e vegetal, óleos e gorduras, quando comparada ao preconizado pelo Guia Alimentar para a População Brasileira. Também foi apontado pela maioria um consumo de alimentos integrais em frequência diária ou semanal (2 a 4 vezes). Em contrapartida, o consumo de laticínios e frutas foi insuficiente entre grande parte dos participantes. Constatou-se que 39% da amostra apresentava algum de grau de excesso de peso, conforme Índice de Massa Corporal, e em 43% identificou-se risco para doenças cardiovasculares conforme medida da circunferência da cintura. CONCLUSÃO: A abordagem da alimentação saudável deve ser prioritária no tratamento, no intuito de minimizar complicações principalmente cardiovasculares e contribuir para adequado controle glicêmico. É relevante que se ofereça treinamentos periódicos multidisciplinares, independente do tempo de aplicação da técnica de contagem de CHO, para aprimoramento desta. Serviços especializados em DM1 devem oferecer orientações para prevenção de ganho de peso excessivo, principalmente da obesidade abdominal.

OBJECTIVES: To evaluate the eating behavior and the profile of individuals with type 1 diabetes (T1DM) and the risk of developing chronic complications. METHODS: An analytical cross-sectional study with a convenience sample consisted of 23 individuals with type 1 diabetes, who needed Intensive insulin therapy and were treated at a public health unit in which carbohydrate counting was used in the treatment. Through interviews, information on socioeconomic data and feeding behavior was obtained. Anthropometric measurements (weight, height and waist circumference) were also taken. RESULTS: It was found that most individuals of the sample correctly applied the carbohydrates counting method. For the majority of the sample, food intake was found adequate when compared with that recommended by the Dietary Guidelines for Brazilian population (Guia Alimentar para a População Brasileira), in regard to the groups of carbohydrates, vegetables , proteins of animal and vegetable origin , oils and fats . Most of the sample had a daily or a 2 to 4 times a week intake of whole foods. In contrast, consumption of dairy products and fruits was insufficient among most participants. It was found that 39 % of the sample had some degree of overweight, as measured by the body mass index, and 43.4 % of the sample had a waist circumference higher than the recommended value. CONCLUSION: Helping individuals with T1D is essential in maintaining an appropriate body weight and in preventing abdominal obesity. This should be coupled with a balanced diet, which is essential in the treatment in order to minimize long-term complications and aids achieving good glycemic control. It is crucial to offer periodic training to ensure correct application of the carbohydrate counting method.

Controle glicêmico de diabéticos tipo I com contagemde carboidratos: uma revisão da literatura / Glycemic control in type I diabetics with carbohydrate counting: aliterature review

Objetivo: avaliar o controle glicêmico de indivíduos com diabetesmellitus tipo 1 em tratamento intensivo e que realizam contagemde carboidrato.Método: Trata-se de uma pesquisa bibliográfica em que foramutilizadas as bases de dados online LILACS, SciELO, BIREME. Nabusca inicial foram considerados como palavras-chave os termosdiabetes mellitus, contagem de carboidratos, alimentação e automonitorização.No total foram utilizados 25 artigos.Resultados e Discussão: O diabetes é uma doença crônica e seutratamento é de extrema importância para manutenção dos níveisglicêmicos dentro dos padrões de normalidade para prevenção daspossíveis complicações provenientes desta patologia. O consequentetratamento inclui terapia nutricional, estimulo à pratica da atividadefísica, administração de insulina e automonitorização. Coma utilização do método de contagem de carboidrato aliado a insulinizaçãointensiva viu-se que há diminuição nos níveis de hemoglobinaglicada, dos níveis glicêmicos e maior adesão ao tratamento, jáque ela permite maior flexibilidade nas escolhas alimentares.Conclusões: A automonitorização glicêmica, alimentação equilibrada,contagem de carboidratos e aplicação das doses de insulinabasal-bolus, podem contribuir para um melhor controle glicêmico,prevenindo ou reduzindo episódios de hiperglicemia ou hipoglicemiae suas complicações. Porém são necessários mais estudos direcionadospara esta área...

Objective: To evaluate glycemic control in subjects with type 1diabetes on intensive treatment and perform carbohydrate counting.Methods: This is a literature in which we used the online databasesLILACS, SciELO, BIREME. The initial search were consideredas keywords terms diabetes, carbohydrate counting, diet and self--monitoring. In total 25 articles were used.Results and Discussion: Diabetes is a chronic disease and itstreatment is extremely important for keeping blood glucose levelswithin normal limits for prevention of possible complicationsfrom this disease. The consequent treatment includes nutritionaltherapy, the practice of physical stimulation, insulin and self-monitoringactivity. Using the carbohydrate counting method combinedwith intensive insulin regimen was seen that there is a decreasein glycated hemoglobin, blood glucose and increased treatmentadherence levels, as it allows greater flexibility in food choices.Conclusions: The blood glucose monitoring, balanced diet, carbohydratecounting and application of doses of insulin basal-bolus,may contribute to a better glycemic control, preventing or reducingepisodes of hypoglycemia or hyperglycemia and its complications.However, more studies directed to this area are needed...

Tratamiento con múltiples dosis de insulina y conteo de hidratos de carbono: su relación con el aumento de peso, frecuencia de hipoglucemia y control glucémico en una población de adultos con diabetes tipo 1 / Effect of multiple-dose insulin therapy and carbohydrate counting on weight gain, frequency of hypoglycemia and glycemic control in an adult population with type 1 diabetes / Tratamento com múltiplas doses deinsulina e contagem de carboidratos: Sua relação com o aumento de peso,frequência de hipoglicemia e controle glicêmico em uma populaçãode adultos com diabetes tipo 1

La insulinoterapia intensificada con conteo de hidratos de carbono es actualmente considerada la mejor herramienta terapéutica disponible para los diabéticos tipo 1. Sin embargo, con su empleo aún es difícil alcanzar las metas de control glucémico propuestas en los consensos y se le atribuye promover tanto el aumento del peso como la prevalencia de hipoglucemias. Objetivo: Describir una población de pacientes diabéticos tipo 1 con insulinoterapia intensificada. Material y métodos: Estudio descriptivo, de corte transversal, con pacientes diabéticos tipo 1 con insulinoterapia intensificada y diferentes niveles de aplicación del conteo de hidratos de carbono, que se atienden en la Sección Diabetes Tipo 1 de la División Nutrición del Hospital de Clínicas “José de San Martín”, que hayan concurrido a la consulta por lo menos 1 vez en el período comprendido entre julio de 2011 a julio 2012 y que los datosa registrar pudieran rescatarse de la historia clínica. De la HC se obtuvieron los siguientes: sexo; edad; peso; talla; índice de masa corporal (IMC); tipo de tratamiento para la diabetes; nivel de entrenamiento en el conteo de hidratos de carbono; frecuencia de hipoglucemias; valor de hemoglobina glicosilada (HbA1c), antigüedad de la enfermedad, años de seguimiento. En el análisis estadístico se obtuvo la media y el desvío estándar (DS) utilizando la versión 17.0 del programa estadístico SPSS. También se obtuvieron los porcentajes de presentación de cada variable. Resultados: Se obtuvieron datos de 34 pacientes: 7 hombres y 27 mujeres. La media de IMC de la población fuede 24.28 kg/m2. El 97,28% de las pacientes...

Intensive insulin therapy, together with carbohydrate counting, is currently considered the best therapeutic strategy for the management of type 1 diabetes mellitus (DM1). However, goals of glycemic control proposed by consensus are still difficult to achieve with this therapy,which has also been associated with weight gain and increased hypoglycemia. Objective: To describe a population of patients with DM1, who were treated with intensive insulin therapy. Material and methods: This descriptive, cross-sectional study included type 1 diabetics who underwent intensive insulin therapy and used different levels of the carbohydrate counting method. All these patients were attending the Type 1 Diabetes Section of the Nutrition Division at the“José de San Martín” Clinical Hospital and they made at least one follow-up visit between July 2011 and July 2012. Only those with complete medical records were included in the study. The following information wastaken from their medical records: sex, age, weight, height, body mass index (BMI), treatment for diabetes, training level in the carbohydrate counting method, frequency of hypoglycemia, glycated hemoglobin (HbA1c) value, duration of the disease, number of follow-up years. The statistical analysis was performed using SPSS 17.0 software, mean and standard deviation (SD) values were calculated. Also the percentages of each variablewere calculated...

A insulinoterapia intensificada com contagem de carboidratos é atualmente considerada a melhor ferramenta terapêutica disponível para os diabéticos tipo 1. No entanto, com seu emprego ainda é difícil alcançar as metas de controle glicêmico propostas nosconsensos e atribui-se a tal terapia promover tanto o aumento do peso quanto a prevalência de hipoglicemias. Objetivo: Descrever uma população de pacientes diabéticostipo 1 com insulinoterapia intensificada. Material e métodos: Estudo descritivo, de corte transversal, com pacientes diabéticos tipo 1 com insulinoterapia intensificada e diferentes níveis de aplicação de contagem de carboidratos, que são mencionados na Seção Diabetes Tipo 1 da Divisão de Nutrição do Hospital de Clínicas /"José de San Martín/", que tenham ido à consulta pelo menos 1 vez no período compreendido entre julhode 2011 a julho 2012 e que os dados a registrar pudessem ser resgatados da história clínica. Da HC foram obtidos o seguinte: sexo; idade; peso; altura; índice de massacorpórea (IMC); tipo de tratamento para diabetes; nível de treinamento na contagem de carboidratos; frequência de hipoglicemias; valor de hemoglobina glicosilada (HbA1c), antiguidade da doença, anos de seguimento. Na análise estatística obteve-se a média e o desvio padrão (DS) utilizando a versão 17.0 do programa estatístico SPSS. Também foram obtidas as porcentagens de apresentação de cada variável. Resultados: Foram obtidos dados de 34 paciente ...

The Meal Management of Korean Type 2 Diabetes Patients Using Carbohydrate Counting

Carbohydrate(CHO) counting is a meal planning approach used with diabetic patients that focuses on carbohydrate as the primary nutrient affecting post-prandial glycemic response. However, it has not been used in meal management of diabetic patients in Korea. CHO counting can be used by clients with type 1 and 2 diabetes. The purpose of the study was to determine the barriers to utilize the CHO counting when three levels of CHO counting were educated to type 2 diabetic patients who started continuous subcutaneous insulin infusion (CSII) therapy by nutrition lectures and counseling. And the CHO-to-insulin ratios were determined for the individual patients who followed the carbohydrate counting as a meal management, and the factors to influence the CHO-to-insulin ratios were selected through the stepwise regression analysis. Twenty- four subjects were received three lectures, and one or two nutritional counseling for a month. The average age of the subjects was 50.7 years, and the duration of diabetes was 9.4 years. Their body mass index (BMI) was 21.5 kg/m2. The difficulties of using CHO counting were 1) confusing the CHO exchange system to diabetic food exchange system, 2) lack of basic nutrition and not distinguishing nutrients such as CHO, fat and calorie, and 3) lack of motivation to make effort to count and record the amount of carbohydrates eaten. Nutritional counseling replenished the nutrition education and made patients practice CHO counting. Average CHO-to-insulin ratios at breakfast, lunch and dinner were 4.1+/-3.3, 2.9+/-2.6 and 2.9+/-3.0units/23g of CHO, respectively. CHO-to-insulin ratios were influenced by gender, age, BMI, post-prandial blood glucose levels and post-prandial c-peptide levels. The effective education and nutritional counseling of CHO counting can make CHO counting applicable to type 2 diabetic patients as meal management for improving glycemic control with less hypoglycemic episode.