Instructions
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Complications of Advanced Carb Counting There are some potential issues with advanced carb counting that are worth discussing. These include insulin stacking (with a risk of severe hypoglycemia), an inadvertently high fat intake, inappropriate calorie intake, and severe insulin resistance or sensitivity.
What is Insulin Stacking? Insulin stacking occurs when a dose of rapid-acting insulin is given while a previous insulin dose is still in the patient’s system, doubling up the second dose on top of the first (stacking them up) with a potential for severe hypoglycemia. Insulin pumps are helpful in avoiding this as they can factor in active insulin in the patient’s system when calculating a bolus dose.
High Fat Intake As you know, the fat content of foods can slow their digestion and affect post-meal glycemia.(6) Insulin pumps use a square wave or dual wave bolus feature for this reason. A square wave bolus gives the entire bolus over a period of time, while a dual wave bolus gives part of the bolus at first, then the rest of the insulin over a period of time.
Inappropriate Calorie Intake Because advanced carbohydrate counting isn’t the structured approach to eating that some patients need, some may eat too many protein and fat calories, especially if they’re so focused on counting carbohydrates that they overlook the amount of protein and fat they’re consuming. However, patients practicing advanced carbohydrate counting tend to pay close attention to what they are eating, so this problem is not very common.
Insulin Resistance and Insulin Sensitivity Calculations of ICR and SF presented here could be considered as a way to more accurately adjust insulin doses for insulin-treated patients. However, these need to be used with caution as an inaccurate ICR and/or SF can result in hypo- or hyperglycemia. Therefore, there are a few rules of thumb to consider: 1) upon initial calculation of ICR and/or SF, err on the side of caution and base recommendations on a conservative dose of insulin; 2) promptly and frequently follow up after initializing or modifying any factor to assess for problems; and 3) modify factors based on blood glucose levels and patients’ experiences. Summary
By providing patients who have been diagnosed with prediabetes and diabetes with the tools and skills to implement carbohydrate counting, they can make appropriate food choices in an effort to keep their blood glucose under control. While many things affect the absorption of carbohydrates, it is the amount and distribution that most significantly affected blood glucose. Using the carbohydrate counting tool gives patients a measure of freedom in the meal choices they make, enabling them a better sense of control when it comes to foods eaten, serving sizes, and even the timing of meals. Counting carbohydrates does require the patient to accurately estimate the carbohydrate servings they eat. These are a skillset that can best be transferred through education and counseling by a Registered Dietitian/Nutritionist (RDN) or Certified Diabetic Care and Education Specialist (CDCES). And the additional tools of ‘Insulin to Carbohydrate Ratios’ and ‘Sensitivity Factors’ can help to refine the adjustment of insulin doses even further. The qualified clinician counselor can help the patient calculate a starting Insulin to Carbohydrate Ratio and Sensitivity Factor. Close follow-up with the patient is crucial to determine if further adjustments to those initial calculations are necessary. The bottom line? Carbohydrate counting is an effective, straightforward way for the patient to have better control over their blood glucose, reduce risks for the progression of diabetes and co-morbidities, and even match their insulin dosing to the foods eaten. Empowering patients with these tools can support their capacity and confidence to make smart meal choices on their own, and in their own time. |
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