Type 1 Diabetes continuing the conversation with Carbohydrate Counting

Part 2 of 3 in my series of Type 1 diabetes, body image and language.  Today we are going to talk carbohydrate counting...

Over the years in my role as a Registered Dietitian in an exclusively Type 1 diabetes facility I heard many stories from clients regarding their diagnosis and their lived experience with Type 1.  I always felt it was important for them to share their stories with me, if they chose to, because their lived experience with diabetes was different from that of another person’s and very different from what I read in textbooks.(Truly isn't every client different from the textbooks!?!?)  After a while I started to notice that I could almost pinpoint the decade that they were originally diagnosed by the way they talked about food.  Seriously, I could have had a carnival booth for this skill.  The foods they avoided, the way they timed their meals it all told a story of their lived experience with food.  Over the years there has been much change with how food was discussed in the diabetes world but overall I would say it has been very black and white, good and bad.  I would listen to clients say that they had never eaten cake (or cookies, or candy or a freezie) because they had diabetes.  Or that they knew fruit was bad for them (spikes blood sugars!) but that they just loved it.  I would sit there and listen to these stories and my heart would break.  Truly to have never eaten cake on their birthdays….all “because of diabetes”.    We would set goals such as “try a piece (or 2 or 3) of cheesecake”, “go out for ice cream”, “buy myself a birthday cake...and eat it”.  An interesting story that has stuck with me… a person discovered that they didn’t like cheesecake after finally trying it and realized they had spent 20 years being jealous of people eating cheesecake for no reason.

Usually this was where I ask if they would like to be introduced carbohydrate counting.  The idea being that you could count your carbohydrates and do a little math to determine the correct rapid acting insulin dose for that food.  What was most interesting to me was how these clients continued to skip the cake (or whatever foods were deemed bad) because they had spent so many years believing they could never eat that food.  It proved to me over and over again how ingrained these beliefs become.  Shame and fear when used as a motivator to monitor blood sugars and food intake creates negative relationships with food. Full stop...Regardless of disease of state- so why would it be different here.   Even though shame is not as common a motivator now (Or at least I am hopeful that others were at least similar to my experience) I often wonder how we can improve the way we talk and teach carb counting so that in 20 years another dietitian is not sitting there wonder "what the actual F*%^k where they doing in the 2010's?

Carbohydrate counting is currently the gold standard of matching food to rapid insulin.  There are many things wrong with this(in my opinion) but I am not going to address that today.  What I want to talk about is how we can teach carb counting in a way that might help keep a positive relationship with food.

For me this comes back to language (are you shocked..?).  If you read this first article in this series (please do if you haven't...kinda proud of it)  you would have seen how I talked about the language we use around bodies.  Carbohydrates are vilified in popular media. The poor carbohydrate has been tried in the court system of diet culture and is currently living out a life sentence in fad diet hell.   We blame it for weight gain, for acne, for mood, for the weather (I am sure that will come soon) and when you get diabetes it is the macronutrient we talk about the most.  We take all that diet stew you live in and talk about it even more.  And now you have to give your self an injection when you eat it so it physically can hurt you as well.  To top it all off an individual gets reinforcement that carbohydrates cause weight gain because they will gain weight after diagnosis and insulin is started.

If we take a step back, look at what we know about starvation and try to apply it to this conversation.  We know that when a body is starving it will do everything in its power to survive.  A great example is how the body will increase the drive to eat after restrictive eating.  Think of onset of diabetes as the restrictive time and then initiation of insulin as the time when being allowed to eat- on a cellular level not necessarily due to the clients own drive.  When we initiate insulin, and they start to feel better, there is often a dramatic increase in hunger as the body is trying to get all the energy it needs.  I have heard parents say of their children “I have never seem them eat this much”.  *Can we pause here just to reinforce the ideas that this is not the best statement to be saying to your child, teen, any other human...let them listen to their bodies and feed them!*  So back to my point-This can bring fear to the parents or clients themselves as there is a feeling of being out of control around food.  It is during this stage that carbohydrate counting if often taught.  So imagine.  We are teaching how to meticulously focus on food at a time when the body is still in survival mode.   This should come with warning bells.  This should be the time that we pull parents, guardians, partners to the side and explain how they will not help the build a positive relationship with food and carbohydrate counting if they become fixated too.  We need everyone on board with nourishing the body not obsessing over the body.

There are many different methods that are taught to carbohydrate count, I have never seen anyone teach it the same to be honest.  Due to the ability to be more precise with insulin doses now than in the past, I think that many decided it was best to get super precise with carb counting.  (please note I wasn't one of them) Lists of foods with carbohydrate amounts, scales that measure your food and tell you the carb amount- along with all the other macro and micornutrient as if you weren't overwhelmed enough, apps that can be used (for the forces of evil as well), labels to be read.  Often times I would hear that the first grocery shop after diagnosis took 2 hours because they read every label.  Image the stress at picking out cereal.  Instead of thinking "do I want the marshmallow one this week or not you have to read all the labels and to math to estimate a carb amount in serving sizes! All this fixation on carbs- sometimes forgetting that there are other macronutrients our bodies need- at a time when the body is recovering from starvation and parents (if diagnosis is in child or teen) are wanting to gain control.  I think as professionals at this time we need to talk about the micromanagement of food.  We need to be clear that there are many factors that will influence the absorption of food and in turn carbohydrates.  You can do the exact same thing 2 days in a row with diabetes and the outcomes will be different.  The body is so much smarter than the brain and it will do what it needs to do every day regardless of your plan.

As the initial dietitian in a newly diagnosed client you can help shape the relationship your client has with food-FOREVER. I am not trying to over emphasize this but it is true.  Ask any person who has type 1 diabetes and they can likely name the first nurse and dietitian they met or the one that changed their lives.   By using words that do not stigmatize foods such as free foods vs counted foods or saying “this food is bad for your blood sugars” can help.  By taking parents aside and discussing the need to not battle at the table over foods, have a backup plan for when a child refuses the potatoes at dinner that you already gave insulin for, and realize you cannot gain control of what you are going through by controlling the food.  Also to get parents to realize that this child is no different from their other children.  Everyone gets the ice cream or cake or the 2nd scoop of pasta. Type 1 diabetes is a difficult disease to live with (understatement I know).  There are so many factors that influence blood sugars that it is very easy to grasp onto the one that you think you can control the most.  That is why it is so important to create a positive experience with carb counting because it will continue to be the recommended method of dosing insulin until technology figures out how to do it for us.  Which may not be far off....

Until next time be Unapologetically you and I will be Unapologetically me