carbohydrate counting and their effect in diabetes patients in riyadh city by: al burikan dalal –...

Carbohydrate Counting and Their Effect in Diabetes Patients in Riyadh City

By: Al burikan Dalal – Al shalabi Sabah Al shebil Noura – Al madani Dalal

Supervised by: Dr. Alorf Saada and miss: Al

Jawini Nouf

King Saud UniversityCollege Of Applied Medical Sciences

Department of community health sciencesClinical Nutrition

CHS439

Outline

• Interdiction

• Epidemiology

• Definition

• Pathophysiology

• Causes and risk factor

• Sign and symptoms

• Complication

• Diagnosis criteria

• prevention

• Management of diabetes

• Carbohydrate counting

Objective

• Find the benefit of carbohydrate counting in diabetic patients and it’s affect on controlling blood glucose level and glycosylated hemoglobin A1C.

• Compare between patients who use carbohydrate counting and the patients who don’t.

Interdiction

• Diabetes mellitus (DM) is now one of the most common non-communicable diseases globally.

• It is the fourth or fifth leading cause of death in most high-income countries.

• Complications from diabetes, such as coronary artery and peripheral vascular disease, stroke and diabetic neuropathy, etc...

• Diabetes atlas.org, [ internet]. Global Burden: prevalence and Projections, 2010 and 2030, ,[updated 2009 sep18,C21may,2011] available at (http://www.diabetesatlas.org/content/diabetes-and-impaired-glucose-tolerance)

http://www.diabetesatlas.org/glossary/term/9

Epidemiology


Figure 1: prevalence of diabetes in the world on 2010

Epidemiology (con..)


Figure 2: prevalence of diabetes in the Saudi Arabia on 2010

Definition

• Diabetes Mellitus is a syndrome characterized by abnormal insulin secretion, derangement of carbohydrate and lipid metabolism, and it is diagnosed by presence of hyperglycaemia.

• Diabetic people have bodies that do not produce or respond to insulin

• Without effective insulin, hyperglycaemia occurs, which can lead to serious complications and premature death.

• There are several types of diabetes and every type differs from the other.

• Type 1 it is usually occurs in persons younger than 30 years of age but can occur at any age

Definition (con..)

Definition (con..)

• previously known as insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes.

• It accounts for 5% to 10% of all diagnosed cases of diabetes. Persons with type 1 diabetes are dependent on exogenous insulin to prevent ketoacidosis.

• Type 2 occurs in persons older than 30 years of age, previously known as noninsulin dependent diabetes mellitus (NIDDM) or maturity onset diabetes

• The disease slowly progressive and the treatment necessary to control hyperglycaemia vary over time. Individuals are not dependent on exogenous insulin for survival but often require it for adequate glycemic control.

Definition (con..)

Mahan L.Kathleen, Escott – Stump Sylvia, Krause's Food & Nutrition Therapy, 2008 ,12 edition, medical nutrition therapy for diabetes and hyperglycemia of non diabetic origin , 765-805.

Pathophysiology

Type 1 diabetes mellitus:

• Is a catabolic disorder in which circulating insulin is very low or absent, plasma glucagon elevated, and the pancreatic B-cells fail to respond to all insulin-secretory stimuli. causing insulin deficiency.

Pathophysiology (con..)

Type 2 diabetes is characterized by :

• The combination of peripheral insulin resistance and inadequate insulin secretion by pancreatic beta cells.

• Which has been attributed to elevated levels of free fatty acids in plasma, leads to decreased glucose transport into muscle cells, elevated hepatic glucose production, and increased breakdown of fat.

Romesh Kh Type 2 Diabetes ardori, Mellitus, C Apr 25,2011, Medscape, Pathophysiology

Causes and risk factors

• Of type 1 diabetes Is genetic, autoimmune, or environmental factors.

• Type 2 diabetes include genetic, environmental factors, including a family history obesity, particularly intraabdominal obesity, physical inactivity, prior history of gestational diabetes, prediabetes, and race or ethnicity.

*Mahan L.Kathleen, Escott – Stump Sylvia, Krause's Food & Nutrition Therapy, 2008 ,12 edition, medical nutrition therapy for diabetes and hyperglycemia of non diabetic origin , 765-805.

Causes and risk factors (con..)

• Lower serum creatinine was associated with an increased risk of type 2 diabetes.

Harita Nobuko, Hayashi Tomoshige, Kogawa Sato, Kyoko Nakamura, , Yoneda Takeshi, Endo Ginji, at al, Lower serum creatinine is a new risk factor of type 2 diabetes: The Kansai Healthcare Study, American Diabetes Association, December 15, 2008 ,1:3

Signs and symptoms

• frequent urination

• excessive thirst

• extreme hunger

• unusual weight loss

• increased fatigue

• irritability

• and blurry vision S.E. Inzucchi And Sherwin, Type 1 Diabetes Mellitus, in L. Goldman and D.Ausiello, 2008, 1727-47.

Complication of Diabetes, Diagnosis Criteria and Prevention

By: Al burikan Dalal

Outline

• Complication • Macrovascular

complications • Nephropathy • Ketoacidosis• Neuropathy • Retinopathy• Depression• Celiac disease

• Diagnosis criteria

• Prevention

Complication:Common complications resulting from uncontrolled diabetes include :

Macrovascular complications :• Coronary artery disease. • Peripheral vascular disease.• Cerebrovascular disease.

The reasons are prolonged, poorly controlled blood glucose level, which affect the lining of the body arterial walls. This increas the likelihood of furring up the vessels, atherosclerosis.

diabetes.org.uk [internet] Complications of diabetes uk, c2011, avelbile at: http://www.diabetes.org.uk/Guide-to-diabetes/ Complications

microvascular complications :

Nephropathy:nephropathy is a clinical syndrome characterized by excessive urinary albumin excretion, hypertension, and renal insufficiency. Half of patients with type 1 DM who have overt nephropathy will develop end stage renal disease (ESRD ) within 10 years and 75% within 20 years .

D. King, Keecia PharmD, D. Jones Jocelyn, PharmD, and Warthen Jessica, PharmD. Microvascular and Macrovascular Complications of Diabetes Mellitus , American Journal of Pharmaceutical Education 2005;

69 (5) Article 87.

Ketoacidosis:Sever hyperglycaemia also lead to dehydration and electrolyte imbalance. Hypoglycaemia can cause irreversible brain damage and coma.

diabetes.org.uk [internet] diabetes uk, c2011, avelbile at: http://www.diabetes.org.uk/Guide-to-diabetes/ Complications

Neuropathy

Diabetic peripheral neuropathy (DPN) is one of the most prevalent and complicated conditions to manage among diabetic patients. About 60% to 70% of people with diabetes have mild to severe forms of nervous system damage.impaired sensation or pain in the feet or hands.slowed digestion of food in the stomach.carpal tunnel syndrome.precursor for foot ulcers and other nerve problems.

Retinopathyretinopathy is the most frequent cause of new cases of blindness among adults aged 20-74 years. By the end of the first 2 decades of disease, nearly all patients with type 1 diabetes will have evidence of retinopathy. Nearly 20% of patients with type 2 diabetes will have retinopathy at the time of diagnosis of diabetes .

Depression :Among diabetic patients, the risk of depression is twice similar to people in the same age group without diabetes.

D. King, Keecia PharmD, D. Jones Jocelyn, PharmD, and Warthen Jessica, PharmD. Microvascular and Macrovascular Complications of Diabetes Mellitus , American Journal of Pharmaceutical Education 2005;

69 (5) Article 87.

Celiac disease

The incidences of type 1 diabetes and celiac disease are increasing rapidly. These autoimmune diseases often occur together, as 4.5% of subjects with recent onset type 1 diabetes also have celiac disease, and the coexistence is even more common in subjects with long- standing type 1 diabetes .

SIMELL SATU, HOPPU SANNA, SIMELL TUU, STÅHLBERG MARJA-RIITTA, VIANDER MARKKU,ROUTI TAINA, et al, Age at Development of Type 1 Diabetes– and Celiac Disease–Associated Antibodies and Clinical

Disease in Genetically Susceptible Children Observed From Birth,Diabetes Care , 2010 , 33 (4), 774-9.

Diagnosis criteria:

Diagnosis criteria for diabetes are summarized on table :

] American diabetic association executive summary ,standard of medical care in diabetes .2010 ,diabetic care ,33(51),54 ,510

In 2010 ADA added the glycosylated haemoglobin A1C > 6.5 % as another criteria for diabetes diagnosis.

For glycemic control A1C values are the standard indicators , It is determined by measuring the percentage of glycated hemoglobin . hemoglobin A1c (HbA1c) test is used to monitor long-term glucose control in people with diabetes. While daily blood sugar testing gives a picture of day-to-day fluctuations, the hemoglobin A1c test offers an overview of how well glucose has been controlled over the past 2 to 3 months.

Prevention of diabetes mellitus :Type 2 diabetes is largely preventable by taking several simple steps: 1. Promotion and evaluation of ‘healthy’ lifestyle programmes, which focus on the following aspects:Prevention and early treatment of overweight and obesity, optimum mean BMI for a population is in the range of 21–23 kg/m2.Consumption of a nutrient-dense diet, which is low in fat, particularly saturated fat ; (Saturated fat intake should not exceed 7% of total energy intake ), free sugars and and high in Non-starch polysaccharide( NSPs) .

-Active lifestyle, which includes regular physical activity of at least 1 hr/day, and vigorous activity, which is required to reduce the risk of developing type 2 diabetes .

2. Early identification of subjects at risk of developing type 2 diabetes.

3_ Healthy lifestyle programmes/interventions should focus on a life course perspective and not on a specific age group or developmental stage.J Mann2,NP Steyn1, , , N Temple4PH Bennett3, J Tuomilehto6P Zimmet5, , and A Louheranta , Diet, nutrition and the prevention of type 2 diabetes,2004, Public Health Nutrition,7(1A), 147–165

Herbs that Lower Blood Sugar:

There are several noteworthy herbs that are claimed to have blood sugar lowering effects.

Cinnamon Bark (Cassia Cinnamon):As little as ¼ to ½ teaspoonfuls can have a powerful effect in lowering blood sugar.Studies have shown that the addition of 1, 3, or 6 g of cinnamon to the diet led to significant decreases in blood glucose levels after 40 days. all three levels of cinnamon was similar in decreasing blood glucose in the range from 18 to 29%.

Alam Khan, Mahpara Safdar, Mohammad Muzaffar Ali Khan, Khan Nawaz Khattak,Richard A. Anderson, Cinnamon Improves Glucose and Lipids of People With Type 2 Diabetes, diabetes care, 2003, vol. 26 no. 12 3215-3218

Fenugreek (Trigonella foenum-graecum):

Fenugreek is effective for lowering postprandial (after meals) blood sugar. The applicable part of fenugreek is the seed. The active constituents include trigonelline, 4hydroxyisoleucine, and sotolon.

Klemens Jonathan, Herbs that Lower Blood Sugar,2006 .the online journal for the American association for integrative medicine ,3:5

Management Of Diabetes

Done ByDalal Al-Madani

428202721

Outline

• Medical management 1)Oral hypoglycemic agents 2) Insulin

• Nutrition management

• Educational management

Medical Management

1)Oral hypoglycemic agents:

a- stimulate insulin secretion from beta-cells.

b- decrease hepatic glucose production

c- improve insulin sensitivity

d- delays carbohydrate absorption.

e- enhances glucose dependent insulin secretion and suppresses postprandial glucose secretion.

f- decreases glucose production to prevent postprandial hyperglycaemia.

Mahan L.Kathleen, Escott – Stump Sylvia, Krause's Food & Nutrition Therapy, 2008 ,12 edition

American Diabetes Association, Diagnosis and Classification of DiabetesMellitus, DIAGNOSTIC CRITERIA FOR DIABETES MELLITUS, 2007, Diabetes Care, 30( 1), S42-7

Medical Management (con..)

• 2) Insulin:

• a- Rapid – acting insulin.

• b- Short –acting insulin.

• c- Intermediate –acting insulin.

• d- Long acting Insulin.

Nutritional Management

• Total energy intake should be follows: more than 50% of carbohydrate, encouraging 30-35% of fat (less than10% saturated fat, less than 10% polyunsaturated fat, more than 10% monounsaturated fat).

In addition:

omega-3.

Fibers.

Antioxidants

Sweeteners

snacks.

Gaia Chiesa, Maria Antonietta Piscopo, Andrea Rigamonti, Angela Azzinari, Sonia Bettini,Riccardo Bonfanti et al, Insulin therapy and carbohydrate counting, Department of Pediatrics, Endocrine Unit, Scientific Institute Hospital San Raffaele, Vita-Salute University, Milan, Italy , 2005, Suppl. 3: 44-48

Other methods of nutritional management is meal planning:

Exchange Lists a booklet that contain list that group foods approximately the same number of calorie, carbohydrate, protein and fat.

The Diabetes Food Pyramidpyramid is similar to the USDA food pyramid. It is a pyramid in which a healthy diet means eating more grains, fruits, and vegetables, and less meat, sweets, and fats

The Plate System The method of using the plate system is by Pretending the plate divided in half. Then divide one of those halves into two equal sections. One-half plate = Non-starchy vegetables, one-fourth plate = 1 serving meat or other protein and the other, One-fourth plate = Bread/Grain or Starchy Vegetables.

Webmd[internet] 4 Systems for Diabetes Meal Planning[2011] available http://diabetes.webmd.com/features/4-systems-for-diabetes-meal-planning?page=3

Educational management:

physical activity.foot care.1)Foot examination2)Eliminate obstacles3)Toenail trimming4) Footwear.5)Exercise.6)Smoking.7)Diabetes control.

emedicinehealth.com, diabetic_foot_care,updated at 5 may 2011,available athttp://www.emedicinehealth.com/diabetic_foot_care/page6_em.htm

Done by :Sabah Al Shalabi

Carbohydrate counting

Out line

• Definition and History of Carbohydrate Counting

• Food Contain Carbohydrate

• Advantage and Disadvantage

• Teaching Levels of Carbohydrate Count

• General Ways to calculate carbohydrate

• Insulin-to Carbohydrate Ratio and Calculation

• The Glycemic Index

• Portions Size

• Food labelling

• Summary

Carbohydrate Counting

• It is an accurate meal planning system to help patient in monitoring blood glucose. It determine the right amount of carbohydrate grams that needed at each meal. Carbohydrate counting help in having more flexible food choices.

J. Davis Nichola Wylie-Rosett Judith , Carbohydrate Counting,diabetes care, 2008, 31 , (7), 1467-68American Diabetes Association, Nutrition Principles and Recommendations in Diabetes, Diabetes Care, 2009,32 s1) s36-s46(

history

• Carbohydrate Counting has been around since the 1920s.Began to receive attention in 1990 as method of controlling blood sugar,in 1994 ADA(American Diabetes Association) used carbohydrate counting as a meal method .

J. Davis Nichola Wylie-Rosett Judith , Carbohydrate Counting,diabetes care, 2008, 31 , (7), 1467-68

Food contain carbohydrate

• starchy foods like bread, cereal, rice, and crackers

• fruit and juice

• milk and yogurt

• dried beans like pinto beans and soy products like veggie burgers

• starchy vegetables like potatoes and corn

• sweets and snack foods like sodas, juice drinks, cake, cookies, candy, and chips

American Diabetes Assosition [internet],available at http://www.diabetes.org/foodand-fitness/food/planning-meals/carb-counting/

advantage and disadvantage

• Advantage :

• Some studies found improved in quality of life.

• improved glycaemic control.

• reduction in mean body weight.

• reduction in total daily dose(TDD) of insulin .

• reduction in A1C% in patient using carbohydrate counting.

Kawamura T. The importance of carbohydrate counting in the treatment of children with diabetes. Pediatric Diabetes 2007: 8 (Suppl. 6): 57–62.

Disadvantage

• Other studies shown that using carbohydrate counting is a possible reasons for weight gain because patient’s lack attention to protein and fat intake.

Kawamura T. The importance of carbohydrate counting in the treatment of children with diabetes. Pediatric Diabetes 2007: 8 (Suppl. 6): 57–62

Teaching level of carbohydrate counting

• Is based on increasing level of complexity:

• First level is (basic),

• Second level is (intermediate)

• Third level is(advanced)

• All three levels is about controlling portions to monitor blood glucose.

American diabetes association , Diagnosis and Classification of Diabetes Mellitus, diagnostic cartieria for diabetes malitues , 2007, Diabetes Care, 30( 1), S42-7

General Ways to calculate carbohydrate

• Carbohydrate Counting has two ways to be calculated:

• 1-Counting the carbohydrate in grams, a specific amount of carbohydrate grams at each meal.

• 2-Counting carbohydrate servings size. That’s means 1 Carbohydrate Serving is a portion of food that contains 15 grams of carbohydrate, about the amount in a slice of bread , a medium apple ,one-half cup of corn.

American Diabetes Association, Nutrition Principles and Recommendations in Diabetes, Diabetes Care, 2009,32 s1) s36-s46(

• The use of insulin dose according to their correction factor(amount of blood glucose in (mg/dl) lowered by 1 unit), carbohydrate factor( the amount of carbohydrate in a portion of food) and,insulin/carbohydrates ratios (match insulin to the amount of carbohydrate)

Kawamura T. The importance of carbohydrate counting in the treatment of children with diabetes. Pediatric Diabetes 2007: 8 ( 6): 57–62..

insulin-to carbohydrate ratio

• Is by knowing how much carbohydrate is covered by unit of insulin, usually expressed as U: C

Kawamura T. The importance of carbohydrate counting in the treatment of children with diabetes. Pediatric Diabetes 2007: 8 (Suppl. 6): 57–62.Warshaw Hope, Karen bolderman,practical carbohydrate how to teach guide for health professionalas,ada,2nd edition,2008,chapter 6

ICR calculation

• ICR is calculated by various methods :

• The First basic method is ,For example, if the person ate 75 g of carbohydrate.

• 1 unit of insulin/15 g (or 1 serving) of carbohydrate

• 75/15=5 units of rapid or short-acting insulin .

• This is written as a 1:15 insulin-to-carbohydrate ratio.

• Second method:

• called the rule of 500.This method is use to determine ICR, based on TDD(total daily dose)

Kulkarni karmeen,carbohydrate counting:a practical meal-planning option for people with diabetes,2005,clinical diabetes,3(23),120-22

• E.g.:

• basal insulin dose: 8 units twice daily

• bolus insulin dose:5 units pre-breakfast.

• 6 unit pre-lunch

• 7 unit pre-dinner.

• TDD=8+8+5+6+7=34 units.

• 500/34= 14.7~15.

• ICR is 1 unit to 15 grams of carbohydrate, 1:15.

The Glycemic Index

• The Glycemic Index (GI) it is a scale that ranks carbohydrate-rich foods by how much they raise blood glucose levels.

• High GI

• Medium GI

• Low GI

Foster-Powell K , Holt SHA, Brand-Miller JC. International table of glycemic index and glycemic load values Am J Clin Nutr. 2002;76:5-76Photo:http://www.glycemicindex.com/

Portions size:• It is by knowing the measuring equipment and

portions control tools that people must learn how to use it. People should have measuring equipment at home and use it regularly: measuring cups (liquids-solid),measuring spoon(tea-table),food scale to provide features the gram weight of the food.

Warshaw Hope, Karen bolderman,practical carbohydrate how to teach guide for health professionalas,ada,2nd edition,2008,chapter 6 the photos:http://www.afb.org/seniorsite.asp?SectionID=66&TopicID=303&DocumentID=3256http://bestpinaymom.com/cgi-sys/suspendedpage.cgi

http://www.afb.org/seniorsite.asp?SectionID=66&TopicID=303&DocumentID=3256

• First: Hand

Warshaw Hope, Karen bolderman,practical carbohydrate how to teach guide for health professionalas,ada,2nd edition,2008,chapter 6The photo:httptipsonweightloss.blogspot.com200810portion-size-by-hand.html

• Second: Eye

• help people train their eyes to judge portions. Used in the supermarkets, at the bakery, and at the restaurant.

Food labelling

• 1- the serving size.

• 2- grams of total

• carbohydrate . fiber, sugar,

• polyols (sugar alcohol)

http.totallyhowto.comjonis-cuisine201102how-to-read-food-labels

Recommendation

• Patient with type1 and type 2diabetes is preferred to use carbohydrate counting to monitor blood glucose level and to reduce the complication that sync with uncontrolled blood glucose level.

• Diabetes patient should fallow healthy life style by keeping BMI in the normal range between 18.5-24.9 kg/m2 , increasing physical activity level, monitor fat intake, and increase fiber intake.

Recommendation (con..)

• Encourage the patient to follow up to chick on his regulating of cho count diet method and monitoring lab result (FBS, A1C)

• Educate patient about portion sizes and food labelling to help in carbohydrate counting diet method use.

summary

• There is several ways to control hyperglycaemia by medications, exercise and diet changes. Carbohydrate counting is a very important diet method used in diabetic patient to control blood glucose and improve the quality of life and decrease the severity of the complication .

• Using carbohydrate counting, in conjunction with the intensive insulin allow more flexibility in the timing and frequency of meals, the amount of carbohydrate eaten at meals and snacks, and management of physical activate.

References :• Diabetes atlas.org, [ internet]. Global Burden: prevalence and Projections, 2010 and 2030,

,[updated 2009 sep18,C21may,2011] available at (http://www.diabetesatlas.org/content/diabetes-and-impaired-glucose-tolerance)


• Mahan L.Kathleen, Escott – Stump Sylvia, Krause's Food & Nutrition Therapy, 2008 ,12 edition, medical nutrition therapy for diabetes and hyperglycemia of non diabetic origin , 765-805.

• Romesh Kh Type 2 Diabetes ardori, Mellitus, C Apr 25,2011, Medscape, Pathophysiology

• Harita Nobuko, Hayashi Tomoshige, Kogawa Sato, Kyoko Nakamura, , Yoneda Takeshi, Endo Ginji, at al, Lower serum creatinine is a new risk factor of type 2 diabetes: The Kansai Healthcare Study, American Diabetes Association, December 15, 2008 ,1:3

• S.E. Inzucchi And Sherwin, Type 1 Diabetes Mellitus, in L. Goldman and D.Ausiello, 2008, 1727-47.

• diabetes.org.uk [internet] Complications of diabetes uk, c2011, avelbile at: http://www.diabetes.org.uk/Guide-to-diabetes/ Complications

• D. King, Keecia PharmD, D. Jones Jocelyn, PharmD, and Warthen Jessica, PharmD. Microvascular and Macrovascular Complications of Diabetes Mellitus , American Journal of Pharmaceutical Education 2005; 69 (5) Article 87.

http://www.diabetesatlas.org/content/diabetes-and-impaired-glucose-tolerance

http://www.diabetesatlas.org/content/diabetes-and-impaired-glucose-tolerance

• diabetes.org.uk [internet] diabetes uk, c2011, avelbile at: http://www.diabetes.org.uk/Guide-to-diabetes/ Complications

• D. King, Keecia PharmD, D. Jones Jocelyn, PharmD, and Warthen Jessica, PharmD. Microvascular and Macrovascular Complications of Diabetes Mellitus , American Journal of Pharmaceutical Education 2005; 69 (5) Article 87.

• SIMELL SATU, HOPPU SANNA, SIMELL TUU, STÅHLBERG MARJA-RIITTA, VIANDER MARKKU,ROUTI TAINA, et al, Age at Development of Type 1 Diabetes– and Celiac Disease–Associated Antibodies and Clinical Disease in Genetically Susceptible Children Observed From Birth,Diabetes Care , 2010 , 33 (4), 774-9.

• American diabetic association executive summary ,standard of medical • care in diabetes .2010 ,diabetic care ,33(51),54 ,510

• J Mann2,NP Steyn1, , , N Temple4PH Bennett3, J Tuomilehto6P Zimmet5, , • and A Louheranta , Diet, nutrition and the prevention of type 2 diabetes,2004, Public Health

Nutrition,7(1A), 147–165

• Alam Khan, Mahpara Safdar, Mohammad Muzaffar Ali Khan, Khan Nawaz Khattak,Richard A. Anderson, Cinnamon Improves Glucose and Lipids of People With Type 2 Diabetes, diabetes care, 2003, vol. 26 no. 12 3215-3218

Klemens Jonathan, Herbs that Lower Blood Sugar,2006 .the online journal for the American association for integrative medicine ,3:5

American Diabetes Association, Diagnosis and Classification of DiabetesMellitus, DIAGNOSTIC CRITERIA FOR DIABETES MELLITUS, 2007, Diabetes Care, 30( 1), S42-7

Gaia Chiesa, Maria Antonietta Piscopo, Andrea Rigamonti, Angela Azzinari, Sonia Bettini,Riccardo Bonfanti et al, Insulin therapy and carbohydrate counting, Department of Pediatrics, Endocrine Unit, Scientific Institute Hospital San Raffaele, Vita-Salute University, Milan, Italy , 2005, Suppl. 3: 44-48

Webmd[internet] 4 Systems for Diabetes Meal Planning[2011] available http://diabetes.webmd.com/features/4-systems-for-diabetes-meal-planning?page=3

emedicinehealth.com, diabetic_foot_care,updated at 5 may 2011,available athttp://www.emedicinehealth.com/diabetic_foot_care/page6_em.htm

. Davis Nichola Wylie-Rosett Judith , Carbohydrate Counting,diabetes care, 2008, 31 , (7), 1467-68American Diabetes Association, Nutrition Principles and Recommendations in Diabetes, Diabetes Care, 2009,32 s1) s36-s46(

• Kawamura T. The importance of carbohydrate counting in the treatment of children with diabetes. Pediatric Diabetes 2007: 8 (Suppl. 6): 57–62.

• American Diabetes Association, Nutrition Principles and Recommendations in Diabetes, Diabetes Care, 2009,32 s1) s36-s46(

• Kawamura T. The importance of carbohydrate counting in the treatment of children with diabetes. Pediatric Diabetes 2007: 8 (Suppl. 6): 57–62.

• Warshaw Hope, Karen bolderman,practical carbohydrate how to teach guide for health • professionalas,ada,2nd edition,2008,chapter 6

• Kulkarni karmeen,carbohydrate counting:a practical meal-planning option for people with diabetes,2005,clinical diabetes,3(23),120-22

• Foster-Powell K , Holt SHA, Brand-Miller JC. International table of glycemic index and glycemic load values Am J Clin Nutr. 2002;76:5-76

• http://www.glycemicindex.com

• Warshaw Hope, Karen bolderman,practical carbohydrate how to teach guide for health professionalas,ada,2nd edition,2008,chapter 6

• http://bestpinaymom.com/cgi-sys/suspendedpage.cgi

• Warshaw Hope, Karen bolderman,practical carbohydrate how to teach guide for health professionalas,ada,2nd edition,2008,chapter 6

• http.totallyhowto.comjonis-cuisine201102how-to-read-food-labels

carbohydrate counting and their effect in diabetes patients in riyadh city by: al burikan dalal –...

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