Reflections on carbohydrate counting: walking in our patients’ shoes

Abstract

As a diabetes team in a busy acute trust we decided to embark on carbohydrate counting for one week to enable us to walk in our patients’ shoes. The group comprised two dietitians and four diabetes specialist nurses. We all either teach people to carbohydrate count on a regular basis or come across numerous patients who are carbohydrate counting within our clinical settings. We wanted to experience what it is like to carb count on a day-to-day basis. We used the same carbohydrate counting diaries that we give to our patients, and we all agreed on a start date after the December festive period. The general feeling was that we all started off quite positively weighing out our carbohydrates and diligently writing down the figures. We all used a 1:10 ratio and so also included in our diaries what our hypothetical insulin dose would have been. Soon, though, we all began to look for short cuts – that is, estimating the carbohydrate content, sticking to the same foods to make life easier or using package foods which already had the carb content worked out. We soon realised what a huge commitment carbohydrate counting is and how frequently we might graze/snack throughout the day – and how difficult this would be to manage if we had to check blood glucose levels, calculate carbohydrates and give insulin every time we wanted to snack. Feedback from the group highlighted that we not only avoided eating out or home-cooked meals because it was easier to manage the carbohydrates that way, but we also began to analyse what and how much we were eating. You could quite easily start to become a bit obsessed by how much carbohydrates are in foods or start avoiding foods as you didn't want to admit to eating them. It certainly does put a different perspective on eating and food; this must be quite a hard balance for someone with type 1 diabetes. We have included some quotations from the team's personal reflections to highlight the difficulties faced while doing this task: ‘It helped me to understand the difficulties and time commitment needed for people to do carbohydrate counting.’ ‘I did find it time consuming and I found I was starting my meal a good 5 minutes after everyone else.’ ‘This has given me a new appreciation for the time and effort my patients have put in to managing their diabetes, not just for the week as we have done, but every day for the rest of their lives.’ ‘I realised that I underestimated the amount of carbs in certain foods.’ ‘I was definitely able to empathise with patients who pursued this method to best control their glucose levels. Furthermore, I could relate with patients’ initial hesitation when they were asked to present their food diaries.’ Everyone who participated in the carbohydrate counting exercise found it extremely useful in understanding how our patients feel. It should also be noted that we only carried this out for five days, and did not have the additional tasks of having to perform blood glucose monitoring and insulin administration which would make the process even lengthier. It made us aware of the pitfalls of carb counting and why patients may struggle with this on a long-term basis. It allowed us to be aware of the difficulties around snacking/eating out and home-cooked meals and how this may impact on our patients’ day-to-day lives. We think it is important to note that carbohydrate counting would not necessarily suit every patient with type 1 diabetes, and putting the appropriate patients forward for training is imperative for success.