CONTENTS

Introduction ………………………………………………………………….... 1

What are the sources of carbohydrate? …………………………………. 2

What is carbohydrate counting? ………………………………………….. 4

Different factors that affect the carb counting………………………….. 5

Types of Insulin………………………………………………………….….... 6

Insulin Sensitivity Factor (ISF) ……………………………………………. 9

Factors affecting the carb content of the food………………………….. 10

Nutritional Facts………………………………………................................. 13

Energy, Carbohydrate and Dietary Fibre of some common foods …. 14

Fat – Protein ratio……………………………….......................................... 18

How much control should we have on our blood sugars? …………… 18

Conclusion……………………………………………………………………… 19
 CARBOHYDRATE COUNTING
INTRODUCTION

The food we eat is composed of carbohydrate, fat, protein and various other micro

nutrients which are all essential for life. The main nutrient that affects the blood glucose

level is carbohydrate. In India, our staple food is mainly composed of carbohydrate

which includes cereals and starchy vegetables. In fact, 90 to 100% of the digestible

starches and sugar we eat appear in the blood as glucose within 15 minutes to 2 hours.

This booklet will help to assess the amount of carbohydrate you consume in a meal so

that you can accurately calculate the dose of insulin you need to inject prior to your

meals.

Carbohydrates

Carbohydrate is a macronutrient found in foods and beverages that forms the body’s

main source of energy. According to the American Diabetes Association (ADA) and

International Society of Pediatric and Adolescent Diabetes (ISPAD) guidelines, we

should obtain at least 50% of our daily calories from carbohydrate, 30% from protein

and 15-20% from fats. As carbohydrates are our primary source of energy,

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 substantially limiting its intake will force the body to utilize protein and fat as primary

sources of energy, leading to problems such as depletion of muscle mass and

decreased growth spurt in the children; it can also accelerate Diabetic Keto Acidosis

(DKA).

Low carb rotis and low carb cakes made of almond flour, flax seed flour etc. are

increasingly being promoted in the market. While dietary fibre is important for health, it

should be noted that excess intake can lead to constipation, Irritable bowel syndrome,

Osteoporosis etc.

What are the sources of carbohydrate?

1. Whole grains: ½ cup of rice or millets and 1 chappathi contain the same
amount of carbohydrate i.e.,15g. We often think that millets and chappathi are
low in carbs compared to rice and often over consume them. It is always better
to opt for minimally polished rice or unpolished millets (containing good amount
of fibre) compared to polished varieties.

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2. Starchy vegetables: Potato, Yam, Colocasia, sweet potato and tapioca
contain starch which is later converted into glucose.
3. Pulse and Lentils: Dhal varieties and whole grams like rajma, Channa and

green gram contain complex carbohydrates i.e., 1 cup of thick dhal contains 15-

18g of carbohydrate.

4. Dairy products: Milk contains a carbohydrate called lactose which gets

converted to glucose and galactose which can elevate blood sugar levels. i.e.,

1 cup of milk contains 12g of carbs.

5. Fruits: Carbs are also present in fruits like banana and mango in the form of

sucrose and fruits like apple and watermelon in the form of fructose. Fruits are

not harmful; it is important to know the art of exchanging with other

carbohydrate sources consumed on that particular day to prevent blood sugar

spikes. Fruits contain antioxidants, vitamins and minerals.

6. Direct sugars like honey, jaggery and table sugar provide empty calories

that gives 5g of carbs and 20Kcal in each tsp of serving.

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 What is carbohydrate counting?

Carbohydrate counting or Carb counting is a basic method used to count the amount

of carbohydrate in a particular meal in order to fix an insulin dose for that particular

meal.

This method helps to

1. Calculate the carbohydrate content and analyze the amount.

2. Calculate the insulin required to match the carbohydrate consumed.

3. Maintain the post meal blood glucose within targets.

4. Have a better control over diabetes.

The thumb rule is that 1 unit insulin covers 15g of carbohydrate, but this will vary from

individual to individual (and child to child). The Insulin- Carb Ratio known as ICR, is

high in young children and elderly people but low among teenagers. The ICR is

individualized and depends on one’s sensitivity to insulin, i.e., how many grams of

carbohydrates can be covered by 1 unit of insulin. Higher the ICR value, lower the

insulin requirement.

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Different factors that affect the carb counting:
The ICR changes from meal to meal and day to day. Generally, the requirement of

insulin is high in the morning, low in the afternoon and again high at night. There are

different factors affecting insulin requirements. Requirements are high during

1. Menstrual cycle

2. Puberty

3. Fever /any kind of infection

Increased physical activity affects the absorption of glucose leading to lower insulin

requirements.

Here are some examples of food items which provide 15 grams of carbohydrates.

Quantity that provides

Food items
15g of carbohydrate

Milk 5 cups

Idly 1 no.

Pongal 1/2 katori

Chappathi 1 no.

Rice 2/3 cup

Curds 5 katori

Sandwich 2 slices

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Before getting into the calculations of carbohydrate – Insulin Ratio (ICR) let us know

the types of insulin and how it works:

Generally, in a person without diabetes, insulin is released from the pancreas in two

patterns.

1. Basal Insulin or background insulin which is secreted around the clock to control

the blood glucose between meals.

2. Bolus Insulin or Prandial Insulin which is secreted whenever food is consumed

In people with diabetes, we generally try to mimic this basal and bolus insulin secretion
using different types of insulin:

Bolus Insulin

Breakfast Lunch Dinner

Basal Insulin

Above figure clearly shows the basal- bolus regimen in normal body

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Ultra-Rapid insulin like Fiasp, Rapid insulin like Aspart (Novorapid), Lispro (Humalog,

Eglucent R), Glulisine (Apidra) and Regular insulin like Actrapid, Huminsulin R,

Insugen R etc. are used as bolus insulin.

Intermediate insulin like neutral protamine Hagedorn (NPH) (Insulatard, Huminsulin

N, Insugen N) and Long-acting insulin like glargine (Lantus, Basalog), Degludec

(Tresiba) and Detemir (Levemir) are used as basal insulin. Intermediate insulin acts

for 12-16 hrs. and usually prescribed at morning and night by the treating doctor. Long-

acting insulin works for 24 hours and needs to be administered only once a day.

(Caution: Do not self-determine the type of insulin to be used as it need to be decided

by the treating doctor)

So, let’s get into the calculation of carb counting:

The basal insulin dose needs to be adjusted only using the fasting or 3 am blood

glucose value.

We generally determine ICR with 3 rules (rule of 350, 450 and 500).

1. Rule of 350 is for young children with a total daily dose (Basal + bolus

insulin) less than 10 units.

2. Rule of 450 is for Regular insulin

3. Rule of 500 is for Rapid and Ultra rapid insulin

Let’s make it more clear through an example.

If a child is on Inj.Fiasp 5………4……2...….4

Inj. Tresiba ……………….10

The Total Daily Dose (TDD) = 5+4+2+4+10 = 25 units/ day

As Fiasp is Ultra rapid insulin, rule of 500 is followed i.e., 500/ TDD will give the ICR.

Therefore;

500/25= 20g of carbohydrate

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That means, 1 unit of insulin covers around 20g of carbohydrate

Therefore, if a child takes a breakfast of 40 g of carbs, she/ he might need 2 units of

insulin at breakfast time.

i.e., 40/20 = 2 units

Again, as mentioned above regarding the factors affecting ICR, one needs to check

and monitor the sugars to know if the insulin dose was appropriate. One might not

master carb counting all at once. They need to practice it and might need multiple

cycles of trial and error to get on track. So, one has to keep working on it.

In the above scenario, the amount of insulin required for 40g of carbs is 2 units, that

can cover the blood sugars that is meant to be raised by the carbs alone. If the sugars

are persistently high, how the insulin dose is calculated?

For instance,

If the child with above insulin dose has a fasting blood glucose of 300mg/dl and takes

40g of carbohydrate for breakfast, how much insulin is required (as 2 units of insulin

won’t be adequate)? Here comes the role of insulin sensitivity factor.

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ISF is defined as the extent to which one unit of insulin brings down the blood glucose

levels. It is calculated using the Rule of 1500/ 1800 (1500 for regular insulin and

1800 for rapid/ ultra-rapid insulin).

ISF= 1500/TDD or 1800/TDD

For the above instance, the insulin used is Fiasp (Ultra-rapid)

Rule of 1800 is followed

Therefore,

1800/TDD = 1800/25 = 72 mg/dl

i.e., 1 unit of insulin will bring down blood glucose by 72 mg/dl in the above child.

Let’s say the fasting sugar target of the above child was 120 mg/dl,

(The target blood sugar varies from individual to individual e.g. children with very

HbA1c should not target tight control straightaway as it may lead to relative

hypoglycemia or pseudo hypoglycemia).

We therefore need to bring the blood glucose down by 180 mg/dl, for which 180/72 =

2.5 units of insulin will be needed.

Therefore, the child will need a total of 4.5 units of insulin (2 units for the carbs

consumed + 2.5 units for the raised fasting sugar), to bring the post-breakfast

sugars under control.

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ISF can be used to correct the raised blood sugars and bring them under control

especially when you are on rapid or ultra-rapid acting insulin.

Caution:

• Do not over correct yourself as it might lead to hypoglycemia.

• It is necessary to keep a gap of 3 hours between the correction doses

• Always remember, the active insulin is already injected inside your body

FACTORS AFFECTING THE CARB CONTENT OF THE FOOD:

• Portion size: The amount of carbs changes according to the portion size of the

food consumed.

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• Ingredients: In a vast country such as India with different cultures and different

types of foods, the cooking style and food differs from house to house. For

example, in south India, Idli is made with rice and urad dhal whereas in north

India, Idlis are made by adding sooji and curd. Let’s take the simple example of

tea, as the proportion of milk: water in varies from kitchen to kitchen. So, it is

always better to have a check on the ingredients and calculate the carbs in

each of these.

• Glycaemic Index: Glycaemic index (GI) measures the speed at which food

gets digested and converted to glucose. Based on the GI, foods can be

classified as High, Medium and Low GI foods.

o High GI – Foods with carbohydrates that break down quickly during

digestion and release glucose rapidly into the blood stream tend to have

a high GI. This includes foods with a GI Score above > 70

o Medium GI – foods with a GI score of 56-69 belong to this category

o Low GI – Foods with carbohydrates that break down more slowly

releasing glucose more gradually into the bloodstream, tend to have

a low GI. This includes foods with a GI Score < 55

• Glycaemic load: is calculated as

GI x carbohydrate content of the food

100

Lower the glycaemic load of the food, less is the blood sugar spike. Certain

food items have high glycaemic content but less carbs. This lowers the total

glycaemic load of the food and it can therefore be included in the diet. Certain

foods like bananas have medium GI but the total carb content is high making

the glycaemic load high.

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 • Cooking methods: Generally steamed foods and fermented foods have higher

GI compared to other foods. A close monitoring of glucose through Continuous

Glucose Monitoring System (CGMS) / Ambulatory Glucose Profile (AGP)

capillary glucose meter can help us to assess the effect of these foods on blood

glucose and correct the insulin doses immediately. Adding fat, protein and fibre

to these foods can also help to blunt the sugar spike. Overcooked foods have

a higher GI.

• State of ripeness: Fruits like plantains, jackfruit etc. in the raw form have

resistant starch i.e., which cannot be converted into glucose and can therefore

be used in the diet.

Nutritional Facts:

It is very important to know the content of a food especially when it is in the form of

readymade packets. People often get misled by the front cover of various food packets

but the real information on the ingredients is found on the reverse of the food packet.

Always the food ingredients are listed in descending order of content. For example,

many “oats” biscuits available in the market contain little oats, which is therefore listed

as the fourth or fifth ingredient in the list whereas it has more amount of refined wheat

flour, which will be mentioned as the first item on the list. We are also misled by claims

like “zero cholesterol”, “zero carbs”, “zero trans fats” found on the food cover.

You can use the total carbohydrate values from the label for most foods. However,

because the 'Dietary Fibre' is not digested (and therefore contributes no glucose),

using the total value can cause you to overestimate the amount of glucose yielded by

high fibre foods. So, you have to subtract the grams of dietary fibre from the total

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 carbohydrate to find more precise value for foods that contain more than 5 grams of

fibre per serving.

Ingredient list and Nutritional Info of an oats biscuit where the proportion of oats is 14% and refined
wheat Flour (Maida) is 37%

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 Table: Energy, Carbohydrate and Dietary Fibre content of some common foods

Weight Energy Carbohydrate Dietary

FOOD NAME QUANTITY (g) (kcal) (g) fibre
(g)
Aappam 1 no 100 140 21.1 0.6
Adai-pulse bsed 1 no 80 421 50.6 6.6
Adhirasam 1 no 25 203 32.6 0.3
All jamun varieties
(rasagulla,rasamalai) 1 no 451 231 6.6 0.1
Amaranth & other leafy 1 Katori 160 150 12.3 7.3
vegetables
Aviyal-(mixed veg with coconut) 1 Katori 140 125 10.7 3.5
Bhajia / Masala vada / veg bonda 1 no 23 64 8.1 2.0
Bhatura / chola puri 1 no 75 194 29.9 1.1
Bhel /sev / dahi poori 1 Plate 100 224 34.7 5.7
Biscuits – salt 1 no 5 25 3.3 0.0
Biscuits - sweet 1 no 5 23 3.1 0.1
Bisibile bath / sambar bath 1 Bowl 350 371 63.5 8.0
Bread - white small 1 Slice 20 49 10.4 1.2
Bread and channa 1 Plate 210 179 33.0 3.4
Briyani - Chicken 1 Bowl 323 483 70.7 3.7
Briyani - Mutton 1 Bowl 340 516 71.7 4.4
Bun – plain 1 no 40 124 20.8 0.8
Burfi (coconut/groundnut/sesame) 1 no 19 97 9.6 0.8
Burger - Veg (cheese) 1 no 120 355 32.2 2.2
Buttermilk 1 Glass 150 23 0.8 0.0
Cabbage -Dry subji 1 Katori 98 116 10.7 4.8
Cake-cream / icing 1 no 40 156 21.1 1.1
Cake-plain, sponge 1 no 40 187 21.0 0.4
Carbonated beverages
(soft drinks) 1 Glass 200 93 23.3 -
Carrot -Dry subji 1 Katori 90 145 19.8 5.4
Cashewnut - Dry roasted 1 Tbsp 15 86 4.9 0.4
Chips -banana / potato / tapioca 1 Katori 10 53 6.1 0.5
Chips processed 1 Katori 10 54 5.1 0.4
Chocolate commercial 1 no 4 21 2.4 0.2
Chutney - coconut / groundnut 1 Tbsp 25 66 4.0 1.0
Chutney - onion / tomato / greens 1 Tbsp 23 31 2.4 1.0
Cookies (all types) 1 no 6 28 4.1 0.0
Corn flakes with milk 1 Bowl 325 302 49.9 3.0

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 Weight Energy Carbohydrate Dietary
FOOD NAME QUANTITY (g) (kcal) (g) fibre
(g)
Dhal / chutney powder 1 Tsp 5 17 2.8 0.7
Dhal fry 1 Katori 150 167 21.6 5.5
Dosa 1 no 58 102 20.1 1.4
Doughnuts1 no4518119.9 0.5
Dried fish - gravy / curry / fry 1 Tbsp 11 48 0.9 0.5
Egg – curry 1 no 60 59 1.5 0.8
Egg - omlette 1 no 82 133 3.2 0.7
Egg(whole) - boiled, 1 no 43 74 NULL 0.0
poached
Fish – fry 1 Piece 42 106 1.1 0.5
Fish - gravy / curry 1 Katori 153 132 7.1 2.0
French fries- 20 pieces 1 Plate 653 512 9.4 2.3
Fruit juices - sweetened 1 Glass 200 153 37.4 2.7
Fry - Chicken 1 Katori 116 321 7.3 2.6
Goose berry 1 no 10 6 1.4 0.7
Gravy Mutton 1 Katori 140 186 5.4 2.5
Groundnut roasted 1Tbsp 15 86 4.0 1.2
Halwa-cereal based
(wheat, rava, maida) 1Tbsp 20 123 18.9 0.4
Ice cream - plain (small) 1Cup 125 259 29.5 0.9
Idiappam / Rice noodles 1 no 40 70 15.0 0.2
Idly 1 no 50 78 16.7 0.9
Jam - mixed fruit 1 Tsp 5 14 3.4 0.1
Jambu 1 no 10 6 1.4 0.3
Jangiri 1 no 35 133 12.4 0.5
Kebab - Chicken 1 no 50 151 2.8 1.1
Kesari / sheera 1 Katori 125 286 46.3 1.3
Kootu - vegetables 1 Katori 128 131 19.5 4.3
Ladoo / jilebi 1 no 55 205 27.0 1.3
Lassi - sweet 1 Glass 200 197 26.0 0.0
Legumes - gravy (all 1 Katori 172 153 17.9 6.9
varieties)
Lichis 1 no 50 31 6.8 0.6
Mango(S=3) 1 no 140 104 23.7 2.5
Meduvada / plain bonda 1 no 37 113 10.9 2.4
Milk - 3% & 4% 1 Glass 200 107 7.0 0.0
Milk sweets (milk kova / 1 no 98 332 43.0 0.5
basundi)

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 Weight Energy Carbohydrate Dietary
FOOD NAME QUANTITY (g) (kcal) (g) fibre
(g)
Murrukku / chakli 1 no 20 84 12.6 1.1
Mushroom -Dry subji 1 Katori 130 67 7.4 1.7
Musk melon(S=3) 1 Slice 150 26 5.3 1.2
Mysore pak / mohan dhal 1 no 40 191 11.5 2.4
Noodles - Veg 1 Bowl 320 457 73.9 5.6
Oothappam 1 no 63 148 21.3 1.0
Other veg & gourds
(ladies finger,brinjal etc.,) 1 Katori 126 89 11.3 4.1
Paavbaji 1 Plate 120 572 85.66 .9
Paneer masala 1 Katori 175 255 9.7 3.7
Paniyaram 1 no 30 69 10.6 0.8
Papad 1 no 7 37 3.0 0.9
Paratha -stuffed 1 no 87 265 42.2 2.1
Pasta - Macroni / Sphagetti - 1 Bowl 270 284 42.9 5.0
Veg
Payasam - Cereal based 1 Katori 175 227 35.8 0.3
Payasam - Pulse based 1 Katori 150 253 34.0 2.4
Pesarattu 1 no 75 140 19.6 5.9
Phulkas (without oil or ghee) 1 no 30 77 15.6 2.7
Pistachio 1 Tbsp 20 125 3.2 2.1
Pizza - Veg 1 Slice 100 268 29.0 2.2
Plain yoghurt /curd 1 Katori 150 90 4.5 NULL
Plantain raw -Dry subji 1 Katori 150 372 24.7 6.0
Poli- Dhal 1 no 40 168 19.6 1.4
Pomegranate(S=6) 1 no 120 78 17.4 4.1
Pongal 1 Katori 165 295 46.9 4.1
Pongal-sweet 1 Katori 150 223 40.7 1.2
Poori / Any masala poori 1 no 23 70 9.8 0.7
Popcorn / cheese corn puffs 1 Katori 10 38 7.8 1.4
Porridge - cereals / gruel 1 Bowl 315 169 32.6 1.8
Potato -Dry subji 1 Katori 83 163 19.8 1.5
Potato masala 1 Katori 155 159 28.1 2.9
Prawn, Crab - Fry 1 Katori 150 452 3.7 2.0
Puddings, souffle, custard 1 Katori 138 277 41.6 0.3
Puff - Veg 1 no 95 264 21.3 3.0
Puffed rice - Roasted with 1 Katori 15 46 8.8 0.3
masala

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 Weight Energy Carbohydrate Dietary
FOOD NAME QUANTITY (g) (kcal) (g) fibre
(g)
Puttu - Rice 1 Katori 90 250 50.4 1.7
Ragi adai / roti / dosa 1 no 651 702 2.6 4.0
Rasam 1 Katori 125 26 3.5 0.7
Rava idly 1 no 50 77 10.5 0.6
Rice - plain fried / jeera 1 Bowl 290 335 58.1 2.2
Rice cooked (parboiled) 1 Bowl 250 288 65.8 1.3
Rice flakes with milk and 1 Katori 150 139 26.5 0.0
sugar
Rice -mixed (lime / tamarind /
tomato rice) 1 Bowl 273 395 75.2 3.0
Rice- Veg / pulao/ biriyani 1 Bowl 305 427 68.1 5.1
Salad - Veg 1 Katori 120 33 6.8 2.3
Sambar - Plain (no coconut) 1 Katori 153 113 16.6 4.2
Sambar lunch (with coconut) 1 Katori 160 142 16.0 5.3
Samosa /cutlet - Veg 1 no 98 250 32.4 2.5
Sev (pakoda/ mixture/
boondhi/ 1 Katori 48 227 21.6 3.4
ompodi/ bhujia)
Son papadi 1 no 25 134 15.2 NULL
Soup - Mutton 1 Bowl 300 146 2.6 0.9
Soup - Non cream 1 Bowl 300 105 15.5 3.5
Tender coconut water 1 Glass 200 48 8.8 2.2
Upma bread 1 Katori 115 308 39.3 5.9
Upma plain (vermicelli / 1 Katori 160 292 40.5 2.2
semolina)
Upma rice flakes 1 Katori 154 321 52.7 2.7
Veg kurma 1 Katori 155 162 9.9 4.3
Yam, colocasia, sweet
potato -Dry subji 1 Katori 143 215 33.2 6.1

Note: For detailed and better pictorial representation of a wide variety of food items
along with calories and all nutritional facts, refer to the “Dr. Mohan’s Atlas of Indian
Foods”.

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We have a misconception that fats and proteins cannot elevate the blood sugars but

the fact of the matter is that they do tend to raise the blood sugars, albeit much later

than carbohydrates. If you consume a food containing 20g of fat and 30g protein, you

might need a correction bolus of insulin in the later part of the day.

For example, when someone eats a cheese burst pizza at dinner, the blood sugars

tend to rise by midnight and you can observe elevated fasting sugar the next day.

HOW MUCH CONTROL SHOULD WE HAVE ON OUR BLOOD SUGARS?

Often, parents are concerned about the elevated blood sugars that occurs once or

twice a day. Everyone wants tight control which leads to over correction of the blood

glucose, as also to anxiety among parents and children. What one should keep in

mind, is that to achieve an HbA1c of 7% or less, one should keep their blood sugars

between 70-180 mg/dl for 70% of the day. Occasional high or low sugars can be

ignored, thereby enabling enjoyment of life without the constant fear of diabetes.

REMEMBER!! DIABETES SHOULD NEVER RULE YOU; YOU SHOULD RULE

YOUR DIABETES.

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CONCLUSION:

Type 1 diabetes is a deficiency; it’s the deficiency of insulin, like any other deficiencies

this can also be managed with the right amount of insulin. For that, we need to closely

monitor the sugars and we should understand our requirements of insulin, and the

response to various foods, moods and physical activity. The day you master this, is

the day you win over diabetes. Then, you are a hero/heroine, with insulin power.

Reference:

1. “Dr Mohans’s Atlas of Indian foods” by V. Sudha, Dr. V.Mohan,

Dr.R.M. Anjana, Mrs. Kamala Krishnaswamy.

2. “Dr Mohan’s Handbook of Diabetes Mellitus” by Dr. V. Mohan,

Dr.R.M Anjana, Dr Ranjit Unnikrishnan

3. Diet in diabetes simplified: Your Personal Diabetes Nutrition Coach by

Sheryl Salis

4. Healthy eating and carbohydrate counting for children and adults with
type 1 diabetes. Indian Foods - Edition 1, 2021. ISPAD & Life for a
Child. Authors: Sheryl Salis, Anna Pham-Short, Carmel Smart, Cecile
Eigenmann, Graham Ogle.

We thank the support given by Hinduja Foundation for the Type1 Diabetes in
India (TIDI) Project

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