Diabetes education case study: A man shows off carb counting skills by smartphone
A.E., age 34, has lived with type 1 diabetes for many years. He also faces the challenges of being out of work, without health insurance, and a single parent. A.E. hadn’t had much diabetes education to help him through his years with this complex condition. In January, his A1C, a measure of average blood glucose for the past two to three months, was high at 11 percent.
A.E. didn’t quite understand how his food choices and insulin could work together to keep his body fueled and his blood sugars on target. He was also trying to gain weight. Carb counting—estimating how many carbohydrate grams he would eat—and then dosing the appropriate amount of rapid-acting insulin were important skills for him to learn. These skills would help A.E. avoid taking too little insulin and having a high blood sugar after a meal, or taking too much insulin and going low after eating.
The Education Plan
I hoped to teach A.E. how to accurately estimate and count carbohydrate grams so he would be more likely to take enough, but not too much, insulin. I also wanted him to see that choosing nutritious food sources of carbohydrate and healthy fats and using extra rapid-acting insulin as needed would help him keep his blood sugars in range and meet his weight goal.
We met in person a few times to go over the basics. We discussed which foods are the main sources of carbohydrate, such as grains, starchy vegetables, fruit, dairy, and sweets. We also talked about general serving sizes of foods that equal 15 grams of carbohydrate each (such as one slice of bread or a half cup of apple slices). Then, A.E. had to go out and carb count in the real world.
He took photos of his meals and texted me his carb estimates. That way, A.E. could show me his understanding of advanced carb counting related to the food available to him. The hot dog plate photo (above) helped us talk about avoiding processed foods. I suggested he make this splurge only once or twice a month. I recommended adding a piece of fruit or a serving of vegetables to increase the nutrition, too.
Here’s a sample text from A.E.: “Sugar was 48 this morning—woke me up, so I had 4 oz. of Pepsi, got it to 90, then I had cereal-1/2 c., eggs, 2 pancakes, and 8 grapes—60 grams of CHO so I took 4 units.”
A.E. also noticed pretty quickly the foods that would spike his blood sugar—pizza, tortilla chips, and potatoes. This made for effective learning because he could see that he needed to use his carb-counting and insulin-dosing skills when choosing to eat these foods. As he texted, “I get so excited when 2 hours after meals I’m at 133 or 177.” The recommended level is under 180 mg/dl after a meal—A.E.’s new skills are effective!
Your diabetes educator may not be able to respond on the spot to photos and text messages, but consider bringing snapshots of a few meals to your next appointment. Sometimes, a picture is worth a thousand words when it comes to talking about your favorite foods, daily calorie and mealtime carbohydrate targets, and dosing insulin.
Laurie Stewart Mai, RN, CDE, is the program coordinator of the St. Vincent’s Mobile Health ADA-recognized outpatient diabetes program at St. Vincent’s Healthcare, Jacksonville, Fla.