My four year old son is on an insulin pump, I have also been on an insulin pump for 10 years, and I have found that carb counting is just one-third of the puzzle for calculating insulin. Most of us realize that 15 grams of an apple does not give the same blood sugar results as 15 grams of a banana. It seems that insulin/carb ratios need to vary depending on glycemic index, and how much fat and protein are with each meal. Why isn’t this information taught? It seems like dietitians would like us to believe that all carbs are treated the same, as long as, the grams are the same. It seems that doctors believe that it is not the white submarine sandwich ( even though we carb counted correctly) that caused the high but something else. It seems as if we are behind the times since some countries only use glycemic index. Could this be because most doctors do not know the relationship between fat, protein, carb, and glycemic index for insulin dosing per meal?

You raise an interesting and very controversial topic which is debated all the time in the diabetes world. The American Diabetes Association began to recommend carbohydrate counting over exchanges in 1997 because it was simpler and easier for people to follow and can be very beneficial. Many people could not or would not follow the exchange system. With this change came the premise: A sugar is a sugar is a sugar, and glycemic index was not included in the equation. In other parts of the world such as Australia, glycemic index is very popular and highly regarded.

Everyone’s diabetes is different and some people have to work harder to get the same results than others. For example, some people have to include the carb content of non-starchy vegetables such as broccoli in their insulin dose and others are not that sensitive. It sounds like you are very sensitive to insulin and very attuned to the differences in how some foods break down into glucose. You have learned how combining carb with protein and/or fat changes the rate of the breakdown and hopefully use that information to your advantage. Not all people living with diabetes are willing to do all of this work and would rather keep it simple and just estimate carb content and take the appropriate amount of insulin for the total grams consumed for that meal. I congratulate you for your efforts and wish I had more patients like you!

JS
Additional comments from Dr. Larry Deeb:

I think we all know that different foods affect everyone differently, even with the same carb count. We teach patients to learn about this and individualize treatment. That said, what you discuss is very complex. Many patients cannot understand let alone use it. One must take advantage of strength and weakness in each patient. If you overwhelm, nothing will happen and patients give up. I encourage the very best understanding and individual attention to management. Work with your child’s diabetes.

LD
Additional comments from Dr. David Schwartz:

You are very correct, and, if you search some of my other responses to similar questions on this website, you will see that I agree that not all carbs are created equal. 15 grams is 15 grams is 15 grams but the rate of digestion, concurrent food intake, etc makes the absorption and availabilty variable. This is part of the so-called glycemic index.

Why is it not taught? I don’t know. It probably is now, but we do so in stages. The basic concepts of carbohydrate counting need to be very familiar and the skills quite good before you start the nuances.

Imagine a family, recently diagnosed with a pre-schooler that may not have the advantage of your experience and knowledge base, and then start the diabetes education, and needing to assimilate all the skills of insulin administration, glucose checking, hypoglycemia reactions and treatment, activity, meal planning, sick days, etc. So fundamentals are given at first onto which this foundation is built other levels.

DS
Additional comments from Lois Schmidt Finney, diabetes dietitian:

Good question. I think the dietary recommendations may be evolving into something that will try to deal with those issues in the near future. We have found that each person has his own insulin to carb ratio that varies at different times of day and also can vary with the different types of carbohydrates, so we have to use ballpark figures. Of course blood glucoses done after meals will also vary with the premeal blood glucose, amount of insulin given and possible location of the injection (if not using a pump), other foods in the meal, and any illnesses, stresses and activity.

If everyone would do multiple blood glucose checks in a day and track that with the content of their meals, they would have some useful info, but it is for that food with that person. This is not the most helpful, but I hope you can see the challenges here.

LSF