Food for Life Best Ideas Final

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Diabetes Best Ideas

By Alison Johnston and Anne Morrice



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Anne Morrice and Alison Johnston

The Diabetes Dietitians at GGC Children’s Diabetes Service are Alison Johnston, Lead Clinical Specialist Paediatric Dietitian (Diabetes),

Anne Morrice, Highly Specialised Paediatric Dietitian (Diabetes),

Jane Graham, Highly Specialised Paediatric Dietitian (Diabetes), and Janie Devine, Highly Specialised Paediatric Dietitian (Diabetes).

Approved by Yorkhill F.I.L.E.S. Committee March 2008 © Alison Johnston and Anne Morrice

C/-Greater Glasgow & Clyde Children’s Diabetes ServiceRoyal Hospital for Sick Children, Yorkhill, Glasgow. UK. G3 8SJ

www.diabetes-scotland.org/ggc

Extra copies may be purchased for £15 each.2nd Edition (revised) produced February 2010 / Planned review February 2013

All rights reserved. Alison Johnston and Anne Morrice assert their rights as set out in Sections 77 & 78 of the Copyright,Designs and Patens Act 1988 to be identified as the authors of this work, including commercially and

whenever any adaptation of this work is published or produced.

While all care is taken in the preparation of this publication, the authors and the Yorkhill Diabetes Service accepts no

responsibility for use outwith the Service’s guidance .



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What is diabetes? 5Diabetes and the principles of food. 6 What is healthy eating? 8 Types of food. 9Lower sugar choices. 13Foods that contain very little carbohydrate. 14Frequently asked questions. 15 What is an eating plan and why is it needed? 17 The eating plan - eating for a healthy life. 18Food containing 10g of carbohydrate. 19Eating plan - to start you off. 23How to keep a food diary. 24Food diary. 25Food labels. 26Ideas for meals. 32

Special occasions and eating out. 33Eating out - hints. 34 Average carbohydrate content of some eating out foods. 35 Your food and insulin working together. 36Calculating Insulin:Carbohydrate Ratios… 39Fibre. 42Glycaemic index. 43Hypoglycaemia. 44

Exercise. 47School. 51Illness. 52 Travel and holidays. 55 Toddlers. 57 Weight – the truth. 58

Contents





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Diabetes occurs when part of the body, called the pancreas, stops working

properly. The pancreas is a gland that lies behind the stomach. It makes many different substances, one of which is insulin. Insulin is produced in cells calledbeta cells, and enables the body to use sugar (or glucose) for energy. Insulin alsohelps the body to store glucose for use at a later time.

In normal health, the pancreas produces thecorrect amount of insulin to keep blood glucose

at the right level. Insulin works like a “key”,unlocking the “door” and allowing glucose topass from the blood stream into the cells of the body. Here it is used either to supply thecells with the energy they need, or to bestored away for use later.

In diabetes, the pancreas fails to makeenough insulin and unfortunately will sooner

or later stop producing insulin altogether. We

don’t yet know why, but the body’s immunesystem attacks its own pancreas beta cells until no

more insulin is produced.

Without insulin, the amount of glucose in the blood rises, and the body tries toremove the unused glucose in the urine. More urine is passed, and so the personneeds to drink more to replace the extra fluidlost. This is why in untreated diabetes,children frequently run to the toilet, feel very

thirsty and tired, and lose weight.

What is Diabetes?



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Now that your child has diabetes, you are likely to ask many questions. Some of

these will be about the kinds of foods that may be eaten, as food intake is a vitalpart of good diabetes care.

The eating plan for children with diabetes is simply healthy eating. Foods thatare good choices are the same foods that we should all be trying to eat. This canbe the opportunity for the entire family to adopt healthier eating habits.

Diet forms a major part of controlling diabetes. Most people think of a“diet” as a means of losing weight, but we use the term todescribe someone’s foodchoices and eating pattern.

All people should eathealthy foods, and this is

especially important forsomeone with diabetes. Ideally

this choice will include plenty of bread, potatoes, rice, and pasta, and at least fiveportions of fruit and vegetables every day. Amoderate amount of protein should also be eatenfor example, meat and fish, and only a smallamount of fats, oils and butter.

Your dietitian will work out an eating plan for you,and teach you how a healthy diet can help managediabetes. Foods don’t need to be weighed out, and“special” diabetic foods are not recommended. Sweetfoods can be included in the eating plan.

Diabetes and the Principles of Food



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Newly diagnosed childrentend to be extremely thirsty. Diet and low calorie

squashes or fizzy drinks may be taken freely as can water,

tea or coffee. This thirst willsettle once the blood glucose is

under control. Children may alsohave a huge appetite in the few

weeks after diagnosis. Don’t worry -this is quite normal. It is the body’s

way of regaining lost weight. The appetiteusually returns to ‘normal’ within a monthor so.

The diagnosis of diabetes can be an opportunity for all the family to look at their eating habits and adopt

healthier ones if necessary. The family can eat plenty fruitand vegetables and have grilled, boiled or baked foods in

preference to fried foods. Cutting down on fatty foods and sugary

foods is good for everyone.



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Some tips for healthy eating!

• regular meals: starting the day with breakfast.

• plenty of fruit and vegetables. Aim for a minimum of 5 portions of fruitand vegetables each day. These foods are rich in vitamins andantioxidants.

• snacks between meals should consist mainly of fruit.

• eat lots of starchy carbohydrates (around half the total calorieseaten should be from carbohydrate), especially those high in fibre.

• sweet foods are not forbidden and your dietitian will discuss how toinclude these in your diet.

• foods with a low glycaemic index (GI, see p39) should be encouraged asthese raise the blood glucose more slowly and fill you up for longer.

• small amounts of fatty and fried foods. Grilling, baking, or boiling are

healthier methods of cooking. Food labels can be misleading as foodsadvertised as being “Low Fat” are sometimes higher in sugar andcalories! The sugar content is often not the total carbohydrate content(refer to food labelling).

• monounsaturated fats e.g. olive oil and polyunsaturated fats e.g.sunflower oil and spreads made from these are a healthier option, butremember the calories are just the same as in butter or lard!

• include oily fish such as mackerel, sardines or salmon once or twice per

week.

• plenty of drinks, especially water.

• SALT intake should be kept to a minimum as too much is bad for yourhealth. It is unnecessary to add further salt at the table if it has beenused in cooking. The maximum amount of salt recommended for anadult is 6 g per day. Did you know that some packets of crisps containalmost 3 g? Many convenience and processed foods are high in salt.

What is healthy eating?





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Sugary Carbohydrate

• Sugar

• Sweets and chocolate

• Sugary drinks

• Jam, honey, marmalade

• Sugar-coated breakfast cereal

• Sweet puddings

Starchy Carbohydrate

• Bread, rolls

• Pasta

• Rice

• Potatoes

• Cereals (porridge, cornflakes)

• Lentils

• Beans

• Fruit

• Plain biscuits, oatcakes

Fat is very high in calories. Olive oil and margarine have the same caloriecontent as lard and butter. A gram of carbohydrate contains 4 calories of energy while a gram of fat contains 9 calories. This has big implications for daily calorieintake e.g. an apple and a bag of crisps each contain 10 g of carbohydrate but theapple has 50 calories while the crisps contain 150. For those watching their

weight remember a reduction in all types of fat is necessary. Look for lowercalorie and low fat alternatives.

CarbohydrateCarbohydrate is found in starchy and sugary foods, and all such foods areeventually digested into simple sugars.

It is better to have most of the carbohydrate in food as starches, particularly those with a low glycaemic index (p39) or high fibre starches, rather than sugars.Starchy carbohydrates are a good source of energy and help to make you feelfull for longer.

Sugary and sweet foods cause dental decay. Too much sugar in your diet is nothealthy.



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Fructose and lactose are other simple sugars, which have nutritional value and will raise the blood glucose. These can cause confusion when looking at foodlabels (p26).

Fructose

This is found in fresh, tinned and dried fruit and in natural fruit juice. Althoughthis will also increase your blood glucose level fruits contain healthy fibre, vitamins and antioxidants. This makes fruits a healthier alternative to othersugary snacks.

There is no real advantage to buying granulated fructose as a sweetener as it isfairly expensive.

Lactose

This is found in milk and dairy products such as yoghurts, fromage frais and ice-cream. These foods will also raise blood glucose levels. They are important forproviding the body with protein and calcium.

What happens to carbohydrate?

When carbohydrate foods are eaten, they are digested and broken down to thesugar, glucose (blood sugar = blood glucose). The glucose is absorbed into theblood stream pushing the blood sugar levels up.

In normal health, the pancreas produces just the correct amount of insulin tobring the blood sugar back to the right level. Insulin works like a key, unlocking the “door” and allowing sugar to pass from the blood stream into the cells of

the body. Here it is used to supply the cells with the energy they need, or to bestored away for use later. Without insulin the glucose stays in the blood thenleaks out into the urine, so that the body doesn’t get the benefit of it. This is why in untreated diabetes, children frequently ‘run to the toilet’, feel very thirsty and tired, and lose weight.

To control diabetes insulin has to be given and attention paid to whatever foodsare eaten.



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Carbohydrate puts blood sugars UP

Insulin puts blood sugars DOWNSo remember ...

Usually insulin is made by the pancreas on a supply and demand basis - we makeonly as much as we need. When someone gets diabetes, instead of the pancreasmaking insulin, the insulin is given as an injection. Because the insulin is givenas a set dose, this needs to be balanced with a setamount of carbohydrate taken in the day because, once injected, the insulincan’t be inactivated or removed.

Injected insulin works throughout the day bringing the blood sugars down, so

the carbohydrates which raise blood sugar should be eaten regularly over theday, providing energy and keeping the blood sugar as near normal as possible.

It is important to eat regularly - 3 meals and 3 snacks throughout the day (unless youhave been advised otherwise) as this is more likely to result in blood glucoselevels within the target range (4-8 mmol/l). The effect of exercise is covered inits own section but, since exercise uses up energy (sugar), the amount being done has to be taken into account when planning the day.

Food Insulin

Exercise



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Low Sugar & Sugar-free Ideas Sugary Carbohydrates

PREFERRED OPTION RESTRICTSugar free diet drinks: water, low calorie flavoured water, low calorie/diet fizzy drinks, tea, herbaltea, coffee, low calorie squash, sugarfree milk shakes. Sugar free ice-lollies made with low sugar juice.

Sweetened drinks: squash, fizzy drinks, Lucozade, milk shakesyrups or milk shake powders.

Plain biscuits: Hobnobs,Garibaldies, fig rolls, digestives,crackers, oatcakes, rice cakes,cheese biscuits. Scones, pancakes,crumpets. Sugar-free gum.

Sweets, chocolate, peppermints,marzipan, sweet & chocolatebiscuits, iced buns, cakes, chewing gum.

Low sugar spreads: reducedsugar/low sugar jam or pure fruitspread, peanut butter, beef extract.

Jam, marmalade, lemon curd,syrup, honey, treacle.

Low-sugar and sugar free pudding:instant puddings, low sugarmousses, “low fat, low sugar”tinned milk puddings or in smallcartons e.g. custard, rice, sugar freejelly, tinned fruit in natural juice,fresh fruit, natural yoghurt and fruityoghurts, diet yoghurts, diet

fromage frais, low sugar ice lollies

Sweet puddings: sponge puddings,pies, tarts, cheesecake, trifle, instantand tinned puddings including custard and rice, jelly, thick ‘ncreamy yoghurt, fromage frais,tinned fruit in syrup, sweetenedcondensed milk, ice lollies

Cereals: a high fibre cereal e.g. any with wheat or bran in the name e.g.Bran Flakes, porridge, Shredded Wheat, Weetos and Weetabix.Other cereals: Special K, Cheerios,cornflakes, rice krispies.

Sugar coated breakfast cereal:frosted flakes, Coco Pops, Ricicles.

Non-sugar Sweeteners:

aspartame, sucralose, saccharine,acesulfame sweeteners.

Sugar including glucose, dextrose.

Low sugar choices



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FruitGooseberries, water melon, raspberries,lemons, black & red currants andblackberries.

VegetablesMost fresh, frozen or salad vegetables except potatoes, beans & pulses.

Soup

Homemade soup (without lentils and pulses, rice, pasta or potato), stock cubes.

Drinks

Water (tap or bottled), soda water, flavoured, low-sugar water, tea, coffee,sugar-free squash, sugar-free or diet fizzy drinks.

Miscellaneous

pepper, herbs, spices, garlic, curry powder, mustard, vinegar, Oxo, Bovril,Marmite, gelatine, food colouring, food essence, pickled onions, gherkins,sugar-free gum, sugar-free jelly.

These foods are low in carbohydrate and do not significantly cause a rise in

blood glucose. Remember that the foods that contain protein and fat only donot cause a rise in blood glucose either.

Foods that contain very little carbohydrate

lowcarbohydrate

foods



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What about sweets?

Sweets are not banned but can be eaten in moderation at certain times. The besttime to include sweets is before exercise when extra carbohydrate is needed or atthe end of a main meal when the other foods will slow down the rate of absorption of carbohydrate into the blood.

What type of milk should be used?

Milk is a good food. For babies, breast milk or modified infant formula (baby milk) should be used until 1 year of age. Thereafter full cream milk should bethe choice until the child is at least 2 years old. If the diet is well balanced, semi-skimmed milk may be introduced after this. Fully skimmed milk can be usedover the age of 5 years. Skimmed and semi-skimmed milk are lower in fat butjust as high in calcium as full cream milk.

What about artificial sweeteners?

These have a place. Sweeteners have made available many diet drinks andyoghurts. However, breakfast cereals, tea and coffee are best taken withoutsweeteners as they tend to encourage a sweet tooth. Some foods may taste better with a little added sweetener or fruit, such as stewed raspberries.

Sweeteners, such as the following, may be used:

• Aspartame e.g. Canderel or Nutrasweet

• Sucralose e.g. Splenda

• Saccharine e.g. Sweetex

• AcesulfameK e.g. Hermesetas Gold

Sweeteners can be used in stewed fruits, milk puddings anddrinks. Splenda can be used according to the directions incooking or baking. It is better to add other sweeteners aftercooking for best flavour. They are not as good for baking asthey have no bulk and the baking will not rise. To increase

Frequently asked Questions



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the fibre try using wholemeal flour, or half white flour and half wholemeal, andreducing the sugar in your usual recipes.

Remember that sweeteners such as fructose, mannitol and sorbitol may causediarrhoea and a sore tummy. These sweetners are not free of calories and can

raise the blood glucose level. Watch out for these sweeteners in many sugar freesweets and chocolates now commonly sold in supermarkets.

Why are “diabetic” foods not recommended?

How often should we speak with the dietitian?

As often as you like – they will always be pleased to discuss any aspects of food.Practical advice can be given on a whole range of things e.g. toddler food fads,fussy eaters or snack ideas.

Different stages of childhood merit different dietary considerations. The foodthat a toddler requires is different from a teenager’s nutritional needs. If theinsulin regimen is changed this will probably have implications for your diet. Itis important to see the dietitian regularly, who can review your eating plan and

modify it if necessary.

If you have any questions at any stage, please do not hesitate to contact yourdietitian.

• they are not necessary.

• they are expensive.

• they make people feel different. • some have a laxative effect, causing diarrhoea and tummy ache.

• remember some sweeteners can also raise the blood sugar level!

• they can contain carbohydrate and are often high in fat and calories.

• they often don’t taste as good as the food they are replacing.



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The eating plan for children and teenagers with diabetes is simply healthy eating

as outlined in page 8. The food for people with diabetes is the SAME as thatrecommended for everyone .

The purpose of the eating plan

Planning what you eat makes it easier for the injectedinsulin to keep blood sugars as near normal as possible.It helps avoid large swings in blood glucose. The aim is

to keep blood glucose between 4 and 8 mmol/l about80% of the time.

. Eating plans help babies, children and teenagers withdiabetes grow and develop normally. Sensible eating willreduce the risk of health problems in the future.

Your dietitian will help make out an individual eating plan,based on healthy eating and taking into account yourinsulin regimen, sex, age, weight, and activity levels.

The correct balance is very important.

Optimum diabetes control is down to a good understanding of both the actionof insulin and of food eaten and how they react with each other.Regular blood glucose monitoring, interpreting this in relation to what you haveeaten and then acting upon the results is to date the best way of looking after

your diabetes.

Once this has been mastered within a usual day you can use your knowledge toadd variety and flexibility.

What is an Eating Plan and why is it needed?



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Your dietitian will work out an eating plan to suit you and your insulin.

You will soon know how to follow the eating plan by counting the amount of carbohydrate in foods eaten. For ease, foods are counted in 10 g carbohydrate(sometimes written as CHO) portions. Each portion does not contain exactly 10g of carbohydrate. It is sufficient to round up or round down to the nearest 10g, especially when you are working out carbohydrate from the information ontins and packets.

No one eats exactly the same each day. There are many factors that will affect

how much you eat from day to day, and many foods likely to be eaten areincluded on the next few pages.

If you are already eating healthily there should be no reason to makefundamental changes. However, if you think that the whole family could makeimprovements to their diets, now would be the ideal opportunity to make a new start. You may be asked to keep a food diary for the first few days so that thiscan be studied in conjunction with the blood glucose results and insulin doses.

You may also wish to use this to discuss your food choices with the dietitian.

The Eating Plan – eating for a healthy life



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This is a list of foods which contain 10 grams of carbohydrate, but if a

food label is available this will give you an accurate measure of thecarbohydrate content. Many foods vary in size and weight, so always check the label!

All spoon measurements are heaped.One level tablespoon is equivalent to 15 grams.

Bread Wholemeal or white ½ average slice Morning Rolls ½ average French stick 2 cm/1 inch Croissants ½ croissant Butteries (Aberdeen rolls) ½ roll Crumpets ½ small Scones ½ large/ 1 small Potato scones ½ triangle Scotch pancake ½ medium

Pitta bread1

/3 bread Chapati ½ medium Nan ¼ bread

Breakfast Cereal Bran Flakes 15 g / 3½ tablespoons Cornflakes 12 g / 4 tablespoons Weetabix, Shredded Wheat 1 biscuit

Porridge uncooked 15 g/ ½ oz/ 2 tablespoonscooked (with water) 45 g/1½ oz/4 tablespoons Rice Krispies 12 g / 5 tablespoons Muesli unsweetened 10 g / 1 tablespoon Weetos 13 g / 3 tablespoons Cheerios 13 g / 5 tablespoons Special K 13 g / 3 tablespoons

Flour Plain/self-raising 15 g / ½ oz / 1 tablespoon

Foods containing 10 grams of carbohydrate



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Rice and Pasta Rice (brown or white) cooked 35 g / 2 tablespoons Cous cous uncooked 15 g / 1 tablespoon Spaghetti uncooked 15 short strands

Spaghetti tinned 70 g /1

/3 small tin Pasta uncooked 14 g

cooked 40 g / ½ teacup Macaroni tinned 100 g / ½ small tin Ravioli tinned 70 g / 1/3 small tin Noodles uncooked 30 g

cooked 90 g

Biscuits Hobnob 1 Garibaldi 1 Fig Roll 1 Shortbread 1 Digestive 1 Crispbread wholewheat, rye 2 Crackers wholewheat, plain 2

Plain, Rich tea 2 Oatcake 1 triangle/2 round Rice cake 1 Matzos ½

Nuts Peanuts 100 g

Milk Whole all types 1 glass/ 200 ml/ 1/3 pint Yoghurt natural 1 small carton

Food for

Life !



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Vegetables

All vegetables contain some carbohydrate, but most have such a smallamount that they need not be counted. These should be counted…

Baked Beans in tomato sauce 2½ tablespoons Chickpeas tinned, drained 60 g Butter beans tinned 60 g Garden peas tinned 60 g Marrowfat peas tinned 60 g Kidney beans tinned 60 g Lentils dried 1½ tablespoons

cooked 2 tablespoons

Sweetcorn 4 tablespoons Corn on the cob ½ cob

Potatoes Boiled 1 small (egg sized raw) Chips 5 average Crisps 1 small pack (25 g) Roast 1 small (egg sized)

Mashed 1 scoop Sweet potato equivalent to 1 egg sized Jacket potato varies – see below *:* 1 small (90 g of jacket potato) 30 g carbohydrate

1 medium (180 g of jacket potato) 60 g carbohydrate1 large (270 g of jacket potato) 90 g carbohydrate (!)

Fruit

Some fruits are low in carbohydrate and need not be counted when takenin usual amounts (such as raspberries and water melon).

Apples eaten with skin 1 smallcooking 1 mediumstewed without sugar 6 tablespoons

Apricots fresh or dried 4 medium Banana ½ small

Cherries fresh 15 Dates 3



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Dried fruit:raisins,currants,sultanas 15 g Figs fresh or dried 1 large/ 2 small Grapefruit ½ large Grapes 10 large

Guavas fresh 1 Kiwi fruit 2 Mango fresh 1/3 large Melon (except watermelon) ¼ Nectarine fresh 1 medium Orange 1 large Paw-paw ¼ Peach fresh 1 medium

Pear eaten with skin 1 medium Pineapple fresh 1 slice

tinned/natural juice 2 rings Plums dessert fresh 2 large/ 4 small Prunes dried 3 medium Satsumas 2 Sharon fruit ½ Strawberries 10 Tangerines 2

Fruit Juice Unsweetened fruit juice 1 small glass/ 100 ml Tomato juice 250 ml

Miscellaneous and Convenience Soup thick all types 1 ladle/ 150 ml Fish fingers grilled 2

Pizza

1

/3 snack size Sausage grilled 2 average/ 1 slice Sausage roll 1 very small White/black pudding 2 slices Haggis 4 tablespoons Waffle 1 average Potato Smiley Faces 4 Scotch meat pie 1/3

Ice cream 1 scoop Chicken nuggets 4 average (check label)



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Your dietitian will help you with this page.

Time Carbohydrate (g)

Breakfast

Morning Snack

Lunch

AfternoonSnack

Dinner

Evening Snack

Bedtime Snack

Total:

Eating plan – to start you off…



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Primary School boy taking insulin 3 times a day

Meal Time Food CHO (g) TotalBreakfast

7.452 Weetabix

200mls milk ½ small banana

Low calorie squash

20 10 10 0

40

Morning

Snack

10.20 1 packet crisps 20 20

Lunch 12.30 1 roll spread,

ham , tomato diet yoghurt small apple

Hobnob Low calorie drink

20 0 0

10 10 10 0

50

AfternoonSnack

15.15 15g box of raisins

1 small pancake spread

10

10 0

20

Dinner 17.30 1 ladle of thick soup ½ slice bread

Mince 2 scoops of potato

carrots and frozen peas

1 scoop of ice-cream

sugar free jelly glass of water

10 10 0

20 0 0

10

0 0

50

EveningSnackSupper 20.30 1 large slice of toast

cheese 20

0 20

Total: 200 g We suggest you

copy the following pageto make your own records.

Please note that it is not necessary to keep a food diary every day!

How to keep a Food Diary



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Meal Time Food CHO(g) TotalBreakfast

MorningSnack

Lunch

AfternoonSnack

Dinner

Evening

Snack

Supper

Total:

Food diary



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A food label gives information about the product, telling us what ingredients areused. The food label of Special K lists the ingredients as:

• rice • wheat

• sugar

• wheat gluten

• dried skimmed milk

• salt

• de-fatted wheatgerm

• barley malt flavouring

• vitamin C

• niacin

• iron

• vitamin B6

• vitamin B2

• vitamin B1

• folic acid

• vitamin D • vitamin B12

The ingredients are listed in order of weight. You can see there is more rice thansugar in this product.

A label also provides nutritional information in a table. It will tell you how muchcarbohydrate is in the product and allows you to compare foods and choose ahealthier, high fibre, low sugar or low fat food. For example:

Breakfast Cereal Per 100 g Per 30 g serving with 125 mlssemi-skimmed milk

Energy 373 kcals 171 kcalsProtein 16 g 9 g Carbohydrate

of which sugarsstarch

75 g 17 g 58 g

29 g 12 g 17 g

Fat 1 g 2.5 g

Food labels



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Remember that these figures are per 100 grams. Some labels will state theinformation per serving or per item but if not, you will need to work out theamounts from the weight of the item.

The following is an example of how to work out the carbohydrate content of a

food from the label:

A 150 g tub of diet yoghurt contains 7 g of carbohydrate per 100 g.150 g of yoghurt has one and a half times the amount of yoghurt in 100 g.

so there will be one and a half times the amount of carbohydrate,so there will be one and a half times 7 g of carbohydrate,

so there will be 1½ × 7 = 10.5 g of carbohydrate.

Round this down to 10 g of carbohydrate in a 150 g yoghurt tub.

It is the total carbohydrate that you need to count, not the “of which sugars” value. The “of which sugars” tells you how much of the total carbohydrate isfaster acting sugar. Ideally, most often, the “of which” sugars value should be aslow as possible (aim for one third of the total carbohydrate for foods eatenregularly).

Exceptions to this are foods containing fruit (fructose) and or milk (lactose) as

these are “good natural” sugars and will result in the “of which sugars” being high. An example of this is fruit yoghurt.

Many foods, such as biscuits and puddings, are labelled “low sugar” or “low infat”. It is worth investigating and trying these.

The “traffic light” food labelling system, although useful, can be misleading. Thecoloured area for sugar refers to the total sugar content of the product not thetotal carbohydrate content.

• Don’t panic! Food labelling can sometimes be confusing … check with yourdietitian if you need some help interpreting a label.

Remember!Look at the labels on tins and packets too. Round up and round down to thenearest 10 g of carbohydrate. If you do not know the carbohydrate content of the food then make an educated guess based on the amount and type of food.

For example a waffle may be less carbohydrate than a pancake of a similar size.Don’t miss out!



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There are different ways to work out how much carbohydrate is in the food you

eat. This includes using the: -• “Foods containing 10g of carbohydrate” food list (page19)• Nutrition Information Table on tins and packets - eating the suggested

portion• Nutrition Information Table on tins and

packets – working out the amount fromyour own portion.

Using the “Food for Life” foodlist

The “Foods Containing 10g of Carbohydrate” list tells you theamount of a food that contains 10g of carbohydrate. The amounts aregiven in handy measures, that is, using

spoons and scoops, and in some cases arealso in weights.

Example

You want to have a bowl of Special K with 1 glass (200ml) of semi-skimmedmilk for breakfast. Using a tablespoon you find out that the bowl you havepoured out has 12 level tablespoons of Special K in it.

To work out the carbohydrate content look up the food list. This tells you that: -6 tablespoons of Special K = 10g of carbohydrate so12 tablespoons of Special K = 20g of carbohydrate

1 glass (200ml) of milk = 10g of carbohydrate

So the total carbohydrate in the bowl is 20g + 10g = 30g carbohydrate.

Carbohydrate counts



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Using the Nutrition Information Table on tins and packets - eatingthe suggested portion

Nutrition information on food packaging usually gives the total amount of

carbohydrate value of the food or drink per 100g or per 100mls. It then givesthe amount of carbohydrate per serving or per portion. From the amount perportion or serving it is easy to see how much carbohydrate you will be eating.Remember though this will only be correct if you eat the same portion that itrecommended on the packet or tin.

Using the Nutrition Information Table on tins and packets -working out the amount from your own portion

1. Look at the nutrition information table on the food label.

Special K

Nutrition Information per 100g Energy 397 kcalProtein 6g Carbohydrate

of which sugarsof which starch

82g * 35g 47g

Fat 5g

* Note: it is the total carbohydrate amount that will be needed for thecalculation (highlighted here in bold) not the ‘of which sugars’ or ‘of whichstarch’ amount.

This tells you that there are 82g of carbohydrate in 100g of Special K. You may not want to eat 100g of Special K so you have to: -

2. Weigh your normal portion of Special K e.g. 45g. (This is the amount or weight of Special K and not the amount of carbohydrate in the portion of cereal.)

3. To find out how much carbohydrate is in your portion you need to divide the

amount in 100g of the food by 100. This will tell you how much carbohydrate isin 1g.



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amount of carbohydrate in 100g ÷ 100 × weight of port ion

= carbohydrate in your portion

∩∩

Then you need to multiply this by the number of grammes in your portion. This will be the amount of carbohydrate in your portion.

1. Divide the amount of carbohydrate in 100g by 100

82 ÷ 100 = 0.82

Remember an easy way to divide by 100 is to move the decimal point 2 places tothe left.

0.8.2. = 0.82

2. Then multiply this by the weight of your portion

0.82 x 45 = 36.9

3. Your portion of Special K has 36.9g of carbohydrate in it (or 40g rounded upto the nearest 10g).

Hints and Tips

• Remember is it the ‘total carbohydrate’ that you are counting not the ‘of which sugars’ or ‘of which starches’.

• Many of the nutrition information tables found on food packets andtins will not only give the amount of carbohydrate per 100g of theproduct but also the amount per serving or per portion e.g. per biscuit,per ½ tin or 30g bowl. If this is given then it is easy to see how muchcarbohydrate is in the suggested portion. Be careful this may not be theportion you want to eat.

• For foods such as rice, pasta and noodles check whether the amount of carbohydrate per 100g is for the cooked or uncooked weight of thefood as this makes a big difference to the correct answer.



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• If you have worked out the carbohydrate content of a food from the weight and using a food label put it onto your usual plate and so thatyou know what this looks like and you don’t have to weigh this foodevery time. However, it is a good idea every now and again to go back and check.

• It is useful to keep scales, a calculator, a pen and paper in the kitchen to work out the carbohydrate content of foods and jot down those thatyou eat often. Many scales now will measure in grammes.

• Add up the carbohydrate content of each food in your meal and thenround the total up or down to the nearest 10g of carbohydrate to find

out how much carbohydrate you will be eating altogether in your meal.



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Feeding a family can be expensive, but there are many dishes that are easy to

prepare, tasty and relatively cheap. Here are some ideas for meal times…

Convenience foods need not be bad foods. Tins and packets can be used to make a healthy meal

- try a packet of soup followed by beans on toast. Jars of ‘Cook-In Sauces’ can be added to pasta, meat or vegetables

- add to tuna, ham or chicken and vegetables. Baked potatoes can be made quickly if you have a microwave

- they are tasty with baked beans, chilli or tuna.

Tinned soups are quick and can be high in fibre- try lentil, pea and ham, and vegetable soup.

- soups can be served with French bread, crusty bread or rolls. Nutritious meals needn’t always be hot

- what about sandwiches or rolls with egg, tuna, lean meat, chickenor cheese and salad?

- have you tried filled mini pitta breads?- you could finish off with yoghurt, fromage frais or fruit.

Kidney beans or butter beans in mince or stews give extra fibre. Use plenty of rice, pasta and potatoes

- potato in ‘micro chips’ or waffles is expensive and high in fat. Frozen vegetables are just as nutritious as fresh ones. Buy fruit and vegetables that are in ‘season’ as they’ll cost less.

Ideas for Snacks

You can have plenty of variety when planning daily snacks. At school, quick snacks are often wanted - while crisps are convenient, they are also high in fatand salt. Much healthier options include fruit, cereal bars, or raisins. Minipackets of biscuits can be useful, but try not to fill up with too many.

Toast, sandwiches, rolls, pitta bread, scones, pancakes, crumpets, fruit loaf,crackers and oatcakes (with low-sugar jam) are all good. What about a variety of fruit, yoghurt, or even cereal? Porridge, other breakfast cereals and wholemealtoast with low-sugar jam can make great bedtime snacks.

Ideas for meals



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Eating plays an important part in

almost every social event there is. Think of birthdays, Christmas,

Easter, or even a day out withoutfood!Learning to live with diabetesmeans joining in all of these

activities, planning around them andmost of all enjoying them.

Special Occasions

Here are a few tips:

• Remember that eating well most of the time means that treats can beincluded some of the time.

• Remember that parties can be ‘strenuous exercise’ with lots of games and

dancing. Encourage savoury foods like sandwiches, chicken nuggets,cocktail sausages, crisps - but a treat can be included such as cake, achocolate biscuit or a few sweets.

• It is easier to give sugar free or diet drinks to everyone.• Many parties are held in fast food chains or children’s play centres and the

food does tend to be more savoury than sweet i.e. fish fingers, chickennuggets, burger and chips. This can be added into the day’s meal plan.

• Sugar free jelly can be used on its own or as an ingredient in sugar freepuddings e.g. trifle or jelly whip.

• Christmas wouldn’t be Christmas without Christmas Dinner! If dinner ismid-afternoon have a snack at lunch time. Most children are very excitedand active on Christmas Day and will need extra food, not to mention being up early too. Once a year they can eat what they like and enjoy it.

• Party bags filled with balloons and small toys are preferable to lots of sweets. Presents or prizes of sweets should be, where possible, discouraged -ask relatives or friends to give a favourite novelty or comic instead.However, any sweets received can be kept and eaten before exercise or after

a main meal.

Special occasions and Eating out



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Give some prior thought to eating out - it need not upset diabetic control.

Hints for eating out • Carbohydrate amount should be approximately the same as that taken

usually, unless more activity is involved. For example, you may need to eatmore if you are having a meal before skating or football.

• If you are on fast acting insulin at the time when you are due to eat, thisallows flexibility. With experience you can learn to adjust the insulin tomatch the food e.g. have a little more fast acting insulin with additionalcarbohydrate.

• If dinner is going to be much later than usual, insulin should be given at thenormal time, followed by a snack. Dinner can then be taken later in theevening – you are simply swapping dinner and an evening snack.

• Always keep to diet or low sugar drinks.

Many of the larger chain eating places provide nutritional information either asleaflets or on web sites.

Eating Out - Hints



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Average Carbohydrate content of some“eating out” foods

Food Style Food Type Carbohydrate (g)

Fast Foods • Hamburger & roll 30

• Quarterpounder + roll 30 - 40

• Cheeseburger + roll 30

• Chickenburger + roll 40

• Carton of chips (small) 20

• Cartons of chips (large) 40

• Chicken nuggets x 4 10

Chinese Food • Fried rice - portion 3 tbs = 10 g carbs

• Boiled rice - portion 3 tbs = 10 g carbs

• Noodles cooked weight 30 g = 10 g carbs

• Chow mein portion 60• Sweet and sour 60

Fish & Chips • Fish in batter 10

• Pie 30

• Chips 30 → 50

• Sausage in batter 10

Indian Food • Very thin chapati (saucer) 10• Chapati 30

• Nan bread 40

• Curry - most varieties 10

• Rice portion 80

Italian Food • Pizza (saucer size) 30

• Large pizza (dinner plate) 70



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Your eating plan and your insulin regimen will be arranged to suit your lifestyle.

You will be encouraged to eat healthily and no foods are banned. Having morefrequent injections of insulin or using an insulin pump allows for greaterflexibility in carbohydrate amounts and the timing of meals than for those ontwo or three insulin injections.

2 or 3 Insulin Injections Daily

The action of the insulin requires that you eat regularly i.e. three meals withsnacks in between at approximately the same time each day.

To maintain growth and an ideal weight, healthy eating means that about half of your total calorie intake (all the food you eat!) should be carbohydrate. Thedietitian will assess your present intake, and in accordance with your age, height, weight and activity level, this will be used to suggest amounts of carbohydratefor you to follow at each meal and snack time every day.

Basal Bolus (4 or more injections daily)

The basal (long acting) insulin continually works in the background and isunrelated to the food you eat. This is usually given once or twice daily.

The bolus (short acting) insulin deals with the carbohydrate eaten, and is given with meals and larger snacks. It is usually needed three or four times a day.Snacks containing a small amount of carbohydrate may not require a bolusinjection. Larger snacks (certainly more than 20 g) usually need insulin.

The advantages of basal-bolus insulin therapy are:

• it allows more flexibility with the timing of meals.

• the amounts of carbohydrate eaten can vary to suit appetite and situation.

• blood glucose more easily controlled when sweeter foods are eaten.

• there is no need for large snacks between meals (healthier).

• it allows easier management of diabetes and sport.

• it is easier to deal with unpredictable and erratic eating patterns.

• it allows lifestyle freedom to fit in with friends, family and activities.

Your food and insulin working together…



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The disadvantages of basal-bolus insulin therapy are:

• it may encourage missing meals, particularly breakfast (unhealthy).

• it can encourage eating too many sweets (unhealthy).

• you can eat lots and match this with lots of insulin. This is OK occasionally but if done frequently will result in becoming overweight.

Pump Therapy

Pumps provide a way of giving insulin continuously. Bolus doses are givensimply by the press of a button to match all carbohydrate food eaten – including all snacks; even if only 10 g of carbohydrate!

Bolus doses of insulin can be delivered either as one dose given immediately orover a period of up to 1-2 hours. This can be staged to match the type of mealeaten, or the situation. Meals with a high fat content take longer to be digestedand the insulin can be given over a longer period to achieve better blood glucoseresults. If a meal is spread over a prolonged period spreading the bolus will bemore effective.

Eating Out

It can be difficult to estimate carbohydrate contents of meals when eating outand decide the appropriate dose of bolus insulin. It may be better to give a bolusof insulin to cover the starter and main course before eating, and then take asecond bolus afterwards if you wish dessert.

Meals with a High Fat Content

Some meals are high in fat (e.g. fish & chips, Chinese, Indian or Italian meals).High fat foods should be limited as part of a healthy eating plan. However,

occasionally it is fine. Fat slows down the digestion of a meal and you may findthat blood glucose levels rise gradually over a few hours.

With fatty meals a bolus of insulin may reduce the blood glucose too quickly,risking an early hypo followed by a high reading. This is because the bolusinsulin has finished working before the food has finished being digested andglucose continues to be released into the bloodstream. Some find that bloodglucose tests carried out after the meal show that the blood glucose is high. A

good effect can be achieved with multiple injections (2 smaller boluses of insulin with a high fat meal, one before and one after eating).



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About half of the daily insulin will be given as basal (long acting background)insulin and the other half as bolus (short acting with food) insulin. However, this varies from person to person.

Following discussion with the dietitian you will

probably have started off on a setamount of carbohydrate for eachmeal and snack. In the early days itis crucial to keep to this, as this willbe used along with blood glucoseresults to calculate the insulin tocarbohydrate ratio (ICR) for eachmeal. To achieve the best possible

results it is important to check theblood glucose before and 90 minutesafter meals. The before meal results

tell you if your basal insulin is adequateand the after meal tests tell you if the

bolus insulin is adequate.

It is important to:

• establish the correct basal dose before adjusting the bolus doses. The basalinsulin should be adjusted to achieve target blood glucose results in the firstinstance and then establish the correct bolus doses.

• establish the correct bolus dose for each individual meal as a differentproportion of insulin may be required at different times of the day. Forexample most (but not all) people require a larger proportion of insulin withbreakfast than for later meals.

• remember that the amount of carbohydrate in meals and snacks greater than10-20 g should be counted.

Remember to also look at the Basal-bolus insulin section(Pages I 11 - I 23) in the Patient Held Record (red folder).



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Step 1

Once the blood glucose results are in the target range you can then work out theinsulin carbohydrate ratio. Results in the target range will be achieved by following your eating plan, by testing blood glucose levels and altering theinsulin doses appropriately. Add all the doses of insulin together in the day toreach the total daily dose.

18 units basal (50%)

• Total daily insulin 35 units 17 units bolus (50%)

Meal Carbohydrate Bolus insulin dose● Breakfast 40 g 6 units

● Mid-morning snack 10 g * 0 units

● Lunch 50 g 5 units

● Mid-afternoon snack 10 g * 0 units

● Dinner 60 g 6 units

● Supper 20 g 0 units

* snack sizes can be reduced or left out using basal bolus insulin regimen.

None of the snacks in this example are over 20 g carbohydrate and so do notusually need a bolus of insulin to be given.

Step 2

Look at each meal to work out the insulin:carbohydrate ratio (ICR).

Remember this may not be the same for each meal.

• Breakfast 40 g carbohydrate requires 6 units of insulin therefore each 10 g carbohydrate requires 1.5 units of insulin.

• Lunch 50 g carbohydrate requires 5 units of insulin therefore each 10 g carbohydrate requires 1 unit of insulin.

• Dinner 60 g carbohydrate requires 6 units of insulin

therefore each 10 g carbohydrate requires 1 unit of insulin.

Calculating Insulin:Carbohydrate Ratios…



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Now that this has been established you can vary the amounts of carbohydrateeaten according to appetite and situation and adjust the insulin doseappropriately.

Be aware that your insulin requirements are constantly changing so you will need

to continue to carry out regular blood glucose testing and fortnightly 8-pointprofiles to adjust your ratio as necessary. This will ensure blood glucose resultsstay in the target range and result in a good HbA1c at clinic!

Some things to think about …• It is essential to carry out regular blood glucose tests before and 90 minutes

after food (8 point profile) once or twice a month to check your ICR’s are working out. The ICR ratio will probably change as you grow.

• Smaller snacks usually do not require bolusinsulin, but this varies from person to

person. Regular blood glucose testing is theonly way to check this.

• When more than 50 grams of carbohydrate are eaten at one time, a

lower ICR may be needed for the extracarbohydrate. The ICR for extracarbohydrate is usually around half of the ICR for the first 50 grams.

• For example, if a 50 gram mealusually needs an ICR of 1 unit of insulin per 10 grams carbohydrate, ameal of 70 grams carbohydrate needs:

• 1 unit per 10 grams for the first 50grams (5 units) of the carbohydrate,

plus

• a further half a unit per 10 grams for theremaining 20 grams (1 unit).

• Therefore a meal of 70 grams carbohydrateneeds a total insulin dose of

6 units.



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• The total carbohydrate content will determine the insulin dose however theglycaemic index and the fat content may affect the way this is given.

• It takes longer for the glucose from foods that have a low glycaemic index(p39) and/or a high fat content to reach the bloodstream. It may help to

split this bolus insulin dose, giving half before food and the remainderafterwards. Alternatively, some may find delaying the entire dose until theend of the meal achieves better blood glucose results.

• The amount of insulin and the time it is given may vary depending on thesituation.

• When eating out you may give sufficient insulin to deal with the maincourse but then decide to have dessert. You can then have extra

insulin to cover the additional carbohydrate at the end of the meal.

• Toddlers often vary the length of time they take to eat and the amount eatenmay be different from meal to meal so it may be safer to calculate, and givethe insulin dose after food.

• Activity should be considered when deciding on thefinal bolus dose to be given. Here is anexample:

• If lunch is usually 50 grams of carbohydrate with an ICR of 1unit per 10 grams carbo-hydrate, the usual dose of insulin will be 5 units.

• If playing football after lunch, and youknow that this usually reduces your bloodglucose much more than on other days, it might be a goodidea to reduce the insulin dose to just 3 units – you may notneed to eat extra carbohydrate before and during the game.

• Other options include eating more carbohydrate but taking the usual dose of insulin (5 units), or doing a little of both -eating a little more and taking a little less insulin (for example, just 4 units).

• Above all, do not be afraid to experiment with small adjustments - check theblood glucose readings and keep notes. Everyone is different! This is how

you will find out what is right for you.



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Fibre is the part of plant foods not broken down in the body. It is found incereals, vegetables, fruits and pulses (such as beans and lentils). Fibre keeps the

body healthy. Drink plenty water when following a high fibre diet.

There are two main types of fibre - soluble and insoluble.

Soluble fibre is beneficial in the way our bodies deal with sugars and fats and isfound in: oats

lentilspeasoranges

This means that oatcakes, porridge, lentil soup, peas and oranges are excellentcarbohydrate foods.

Aim for at least 5 portions of fruit and vegetables every day.

Ways to increase fibre intake…

Benefits of dietary fibre: improved blood sugars

less constipation

feel satisfied for longer

reduced bowel problems & heart disease risk (in later years).

Include some foods from this table every day …

• wholemeal, granary, soft grain bread, white bread with added fibre

• wholemeal pasta

• brown rice

• wholemeal biscuits, oatcakes, muesli biscuits, digestives, Hobnobs, fig rolls, garibaldies,

• porridge, oat cereals, bran flakes, muesli, shreddies, weetabit

• potatoes cooked in their skins (baked or boiled)

• oranges, tangerines, satsumas

Fibre



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Glycaemic Index (GI) is something you may have heard about. It gives an

indication of how quickly carbohydrate containing foods are broken down into

glucose and absorbed into the blood stream.Different carbohydrates affect blood glucose levels in different ways. Somecause the blood glucose level to rise higher and quicker than others. The foodsthat are absorbed into the bloodstream quickly are known as high glycaemicindex (high GI) foods. Foods that are absorbed more slowly are called low glycaemic index (low GI) foods.

Once you have mastered the day-to-day carbohydrate counting you may wish toconsider the GI of the carbohydrates eaten. To achieve the best possible bloodglucose results, include as many low GI foods as possible.

Lower GI foods help you feel fuller for longer. This may be very useful if youare watching your weight. These foods also generally help to improve the fatlevels in your blood, which is great for your heart and circulation.

There are many sources of information on glycaemic index. These includebooks, leaflets and web sites. To access many of these, just enter “glycaemicindex” into an internet search engine, such as Google, MSN Search, or Yahoo!.

A detailed list can be found on the internet this way. One such site is found at: www.glycaemicindex.com. Some GI’s may surprise you!

Low GI Medium GI High GI

• apples, oranges

• pears, peaches

• beans, lentils, barley

• pasta (durum wheat)

• sweet potato• porridge

• custard

• milk

• All bran, Special K

• Sultana bran

• pineapple

• honey, jam

• shredded wheat

• Weetabix

• ice cream• new potatoes

• pitta bread

• couscous

• basmati rice

• glucose

• water melon

• white and brownbread

• brown rice• white rice

• cornflakes

• baked potato

• mashed potato

Glycaemic index



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We describe the amount of sugar (also known as “glucose”) in the blood by

describing what amount of solid (glucose) is dissolved in what amount of liquid(blood). This is known as the “concentration” of glucose in the blood, and here we describe it as an amount (millimoles, or “mmol” for short) in a certain volume (a litre, “l”). A typical result would be written in this form:

5.6 mmol/l.

Good diabetes control relies on balancing the blood glucose concentrationincrease from the regular intake of food at meals, with the blood glucoseconcentration reduction brought about by insulin.

In those without diabetes, the body automatically adjusts the amount of insulinproduced to match the blood glucose concentration resulting from the food weeat. For someone with diabetes, we have to achieve this balance by matching appropriate doses of injected insulin to the food we plan to eat each day.Exercise plays an important part, too, but we will discuss that later…

Ideally, 4 out of every 5 blood glucose results should be between 4 and 8mmol/l, but sometimes the blood glucose will fall below 4. We call this a

“hypo” …

Hypoglycaemia

Food Insulin

Exercise



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What’s a “hypo”?

The word “hypo” is an abbreviation of the word, “hypoglycaemia”, which itself is made up from several smaller Greek words…

• Hypo - “Under”

• glykys - “sweet” = “Under – sweet – blood”

• haima - “blood”

This literally refers to “low blood sugar” – too low to provide the body with enoughenergy to carry out its normal functions. We

usually start to feel the ill-effects of a low blood glucose when it falls below 4 mmol/l. We refer to any blood glucose lower than 4as a “hypo” (which is short for

“hypoglycaemia”!).

We have all felt the early signs of a hypo, whether we have diabetes or not – the hunger,

the mild tummy ache, and maybe even slight

dizziness. This happens whenever it has been a whilesince our last meal or snack, and our own blood

glucose concentration has fallen a little low.

What are some of the causes of a “hypo”?

As discussed above, blood glucose moves out of the target range when thebalance between food, insulin and exercise is upset. Situations when this might

occur include:• Not eating enough carbohydrate

• Being late for, or missing a meal or snack

• Taking too much insulin

• Taking insulin at the wrong time

• Extra exercise and too little food

• Food not absorbed (such as when ill with vomiting and/or diarrhoea)

There usually is a reason, but a hypo may happen without an obvious cause.



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Features of hypoglycaemia

Grade Signs and Symptoms Treatment

Mild • shaky

• dizzy • hungry

• feeling sick

• headache

• paleness

• behaviour change

• 60 mls Lucozade Original or

• 3 glucose tablets Both treat hypos most quickly,but if none are available a sugary drink will do e.g. coke,lemonade.)

• after 10 minutes follow with 10grams of slow-acting carbohydrate or

• meal or snack if due. * Moderate • needs help

• unaware of hypo

• confused

• uncooperative

• nauseous

• appears “drunk”

• treatment as for a mild hypo (seeabove) if able and if there is norisk of choking, or

• 1 tube of Glucogel, wait 10minutes, and then treat with 10grams of slow-acting carbohydrate (as above).

Severe • unconscious • may be fitting

• Glucagon injection. • once rousable, give 1 tube of

Glucogel.

• follow the above with treatmentas for a mild hypo.

* If hypo when you are supposed to allow a 30 minute gap between taking insulin and eating take your glucose treatment and EAT IMMEDIATELY!

Principles of management• Check blood glucose - if unable to, treat as though hypo anyway. Some

people may feel hypo when the blood glucose is over 4mmol/l. This isNOT hypoglycaemia and glucose should NOT be given.

• Treat quickly.• Consider possible causes and record details: prevention’s better than cure!• Hypo treatment does NOT count as part of a meal or snack.• Remember that hypo features vary.•

Everyone with responsibility for caring for the child should know how tolook after a hypo (including family, friends, teachers, baby-sitters, etc.)



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Exercise is good for you, for all sorts of reasons!

Let’s look at some of the benefits of exercising…

The benefits far outweigh the risks!

Having diabetes is no reason to side step exercise. In fact, it should probably be

prescribed like insulin! What is important is to try and avoid hypoglycaemia.Extra activity uses up the body’s glucose, and causes it to fall - UNLESS youstart exercising with high blood glucose, when lack of insulin may result inketones and cause you to become unwell (see illness).

How do you avoid hypos? The eating plan is designed to cover a

day’s usual activity, balanced with theday’s insulin dose.

Extra exercise means using extraenergy, and so requires eating more carbohydrate or reducing the fastacting insulin dose. A lot of peoplefind that a combination of reducing

their insulin dose and eating extra works well.

If eating extra carbohydrate to coveractivity, this is a great time to include faster

acting carbohydrates e.g. chocolate or sweet foods.

Benefits of Exercise

Exercise…makes you feel good

improves your circulationmakes for a healthy heartreduces fats in your blood

lowers blood glucoseis a good way of socialising with friends

helps control weightimproves insulin effectiveness

Exercise



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What is extra activity?

This depends on the individual - everyone is different. It may depend on:• how active a person is usually • how long the activity lasts• how much effort a person puts into sport

Some examples include:

• A person cycles 2 miles to school every day This is not extra exercise.

• One hour of gym, or disco dancing This is extra exercise/activity

• Staying up hours later than usualThis is extra exercise - you use up moreglucose than if lying in bed!

Having diabetes is no bar to:- discos, all sortsof dancing, swimming, basketball,football, cycling, hockey, running,aerobics, PE at school, judo,karate, skiing - even climbing Mount Everest! - butremember to speak to your Diabetes Team before leaving for Nepal…they will want to go with you!

When to eat extra?

The best time to eat extra carbohydrate is just before exercise. You can also add this to the meal or snack beforehand,but games and other activities so often happen withoutplanning that this may not be practical.If the exercise is unplanned take additional food during or afterwards. With prolonged exercise like cross-country

running, or dancing all night, extra food may be necessary before, during and afterwards.

Always carry a hypo remedy when exercisingas you are more likely to become hypo at this time.

Glucose tablets and Lucozade are handy.



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Strenuous activity can not only lower the blood glucose at the time but also formany hours thereafter - by making the body more sensitive to insulin - so doEXTRA blood glucose tests.

How much extra?

Again, this depends! By experimenting and checking the blood glucose you willbecome the expert on how much you need for various situations.

10 g of carbohydrate is usually enough for mostactivities, but for hard or fast sports like

skiing or climbing, up to 40g might be

needed.

It’s trial and error really - check the bloodglucose after exercise and …

• If between 4 and 8 … Brilliant! Just enough carbohydrate to balance theexercise and the day’s insulin.

• More than 8 … A little less carbohydrate or more exercise next time.

• Less than 4 … Treat the low blood glucose immediately, and remember too eat more the next time!o Take a little less insulino Eat a little more and take a little less insulin!

Keep good records of your activity and blood glucose results so that you canlearn quickly from experience.

N.B. You may also have adjusted your insulin before exercise so keep a note of this too.



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What to take?

For a quick boost of energy, fun size chocolate bars and chocolate biscuits areuseful. If you need more than 10 g extra, take 10 g as a sugary food, and the restas a slower acting, starchy food (such as bread, fruit, cereal bars or biscuits). This

will keep your blood glucose from rising and dropping quickly.

Try not to overdo the extra food, as this will affect your overall diabetes controland exercise performance. If staying up late take the extra food asa slower acting starchy food.

Remember…

• Extra carbohydrate is just that - over and aboveusual meals and snacks.

• Extra exercise needs extra carbohydrate(and/or less insulin).

• Always carry glucose tablets or Lucozade orsome other hypo remedy. The risk of a hypo isgreater at this time.

• Carry some identification with you.• Tell your friends you have diabetes, and how to

deal with hypos.

They may see hypo warning signs before you do!• Hard. prolonged exercise can make insulin work

better. This can lead to a lower blood glucose (and apossible hypo) well after the exercise is finished, up to 16 hours afterwards,so as well as reducing fast acting insulin, you may also need to reduce yourlong acting insulin.

• The amount of food for each activity may differ: Work out how much isright for you.

• Regularly taking too much food will affect your overall control.• Blood glucose tests show you the effect of food and exercise but this may

not always be possible (such as on a ski slope!)• Don’t exercise if you are unwell – you are more likely to make ketones.• If you take part in serious, competitive sport and train hard and often, you

will need a specially tailored plan. Speak to the Diabetes Team.• You also may get useful advice from the internet www.runsweet.com or

www.childrenwithdiabetes.com/sports/

• Most importantly enjoy your sport!



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Children spend a lot of their time at nursery, primary and secondary school. It is

important that teachers know about diabetes, and how to deal with any situationthat may arise. The Diabetes Team will contact the nursery/school and givethem all the appropriate information.

Take in a ‘First Aid Kit’ in a box to nursery or school. This should be kept in theclassroom. It should contain:

• glucose tablets• Lucozade

• plain biscuits• fun size snack bars

It is important to plan meals and snacks:

Morning snack time should be when the whole classhave a break. Check “ideas for snacks” for ideas.

At lunchtime, there are several options, but wherepossible continue with arrangements as before - don’tchange things just because of ‘diabetes’.

A home lunch isn’t always possible, and if your childdidn’t come home for lunch before being diagnosed withdiabetes, they won’t have to come home for the midday meal now.

School lunches now offer a wide variety of suitable foods. Primary Schools tendto send home menus in advance therefore suitable choices can be discussed

amongst the child, the family and the school. Packed lunches are an option if preferred.

Many older children and teenagers like to visit the local shops for lunch withtheir friends. However, it’s all too easy to end up having chips or a roll andsausage every day. It would be better to have rolls filled with cold meat, chicken,tuna or cheese and fruit instead - at least most of the time.

School trips or holidays may need a little more thought but should pose no real

problems. The Diabetes Team will be happy to discuss any aspects of diabetes inthe school.

School



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At some stage, all children will get colds, sore throats, viruses, tummy bugs and

vomiting illnesses. There is no reason why a child with diabetes should becomeunwell any more often than a child without the condition, but they certainly aren’t immune to all the usual childhood illnesses.

Illness will probably affect blood glucose results and your appetite. The body responds to the stress of illness by increasing the amount of glucose in theblood. The body’s metabolic rate increases, and therefore so does its need for anadequate energy supply. Normally the pancreas gland would simply produce

more insulin in this situation, but for someone with diabetes, they have toincrease the insulin amount themselves, by injecting increased doses.

Without an increase in the amount of insulin injected during illness, the body will be unable to use carbohydrate properly, and so will start to use its alternativeenergy supply – fat. This only provides a short term solution, as the result of using fat as an energy source is that ketones are produced. These acids steadily poison the body, making the person with diabetes even more ill, and only insulin will halt this situation developing.

Care must be taken at a time of illness, however, as the blood glucose may fallduring a vomiting illness or if the child has diarrhoea, even as the body

Illness



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Never stop insulin and Never stop carbohydrate!

continues to produce ketones from the consumption of fat. In this case, and any time someone with diabetes becomes ill, it is essential to check blood glucoseresults often, and also to test the urine or blood for ketones. Keep a record of the results and follow “The Sick Day Rules” advised by your team.

Seek advice from the Diabetes Team whenever you are uncertain or concernedin any way.

Do not wait for the Diabetes to get out of control.

Remember the golden rule:

It is important to always have insulin andcarbohydrate every day, even during illness whenappetites are poor and even if you are on a basalbolus insulin regimen. As mentioned above, youusually need more insulin during illness. Carbohydrate is needed to stop the body using

its fat stores as a source of energy, and insulin isthen essential to prevent the ketones forming.

During minor illness, the usual diet may betolerated but if the child feels unable to eat asnormal, carbohydrate may have to be given in adifferent form – as simple, sugary carbohydrates

or fluids. A vomiting illness can be a cause for realconcern. Contact your Diabetes Team if the child is

vomiting to the extent that all fluids are being brought back.

Remember, always seek medical advice if concerned in any way, and alwayscheck for ketones when unwell, even if the blood glucose is normal or low.

Remember to also look at the What to do when Unwell section(Pages G 04 - G 05) in the Patient Held Record (red folder).



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Can’t face food?

If usual foods cannot be eaten, replace the usual carbohydrate amount in thediet with sugary carbohydrates or fluids that will be more easily tolerated.

Here are some ideas for providing 10g portions of carbohydrate:

Items providing 10 g of Carbohydrate Amount required

• Lucozade 60 mls/ 2 oz

• Fruit juice -orange/apple ½ glass/ 100 mls

• Coke-not diet ½ glass/ 100 mls

• Other fizzy drinks 1 cup/ 150 mls

• Milk 1 cup/ 200 mls

• Glucose tablets 3 tablets

• Blackcurrant drink eg Ribena 1 tablespoon undiluted

• Ice lollies Check label

• Ice cream 1 scoop

• Fruit yogurt- not diet ½ pot

• Sweetened milk pudding 2 oz

• Boiled sweets 2

• Thick soup

1 ladle

• Jelly (not sugar free) 3 level tablespoons

• Sugar, jam, honey or syrup 2 teaspoons

Tips

• Sugary foods and drinks may be necessary to ensure sufficient carbohydrateis taken.

• Many children prefer to drink than eat when unwell.

• If fluids are all that can be managed, sip them slowly throughout the day - little and often is best.

• Let the gas go out of fizzy drinks as it may upset the stomach further.• Encourage low calorie/sugar free drinks including water, in addition to any

fluids used to provide carbohydrates. This prevents dehydration, and willhelp to “flush out” ketones and excess sugar.

• Never cut down on carbohydrate but if you feel unable to eat your usualmeals and snacks divide the total daily carbohydrate into 10g portions

spread throughout the day.



55

With a little forward planning, travel should pose no problems, whether just

going into town or on holiday abroad.

Follow the advice given in the Patient Health Record regarding insulin.

Travel Tips Early Starts

If making an early start it may be necessary to

take an extra snack after getting up, especially if everyone is excited. Children who aretravelling very early, but just go into the carand go back to sleep will not need extracarbohydrate.

Insulin and breakfast can be given at theusual time, even if this means eating rollsor sandwiches in the car or bus.

Taking food with you can be easier thanfinding an eating place at the right time.

Travel Abroad• A letter is available from the Team outlining the need to take injection

devices such as pens or syringes and insulin through customs.

• Check holiday insurance cover.

• Carry some form if identification e.g. SOS Talisman or Medic-alert

• Take double the supplies that are needed, and divide them through yourcarry-on luggage, as a precaution against loss or breakage.

• Take care of insulin while on holiday. Never expose it to temperatureextremes. Insulin should be kept cool, but not frozen, and not too hot.

Travel & Holidays



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• Never pack insulin into luggage going into the hold of a plane as it willfreeze and be ruined. When travelling in a hot country, insulin can be carriedin a cool bag or in a vacuum flask which has been cooled overnight in afridge.

• Most countries have low calorie drinks available, but it may be useful to takea bottle of low calorie squash. Make this up with bottled water or check thatthe local tap water is suitable for drinking. Beware of ice cubes in drinks asthese may be made using local water!

• Peel fresh fruit and avoid raw vegetables and salads washed in local water.

• A change of climate may change activity levels e.g. hot weather may makesome want to swim all day - and need extra carbohydrate, OR others may want to sunbathe. To find out the effects on the diabetes, check blood

glucose regularly.

Check list for air travel

• Carry hypo remedy (in hand luggage).

• Carry carbohydrate containing food to cover delays and smaller meals.

• Don’t order a “diabetic meal” from the airline - it may not contain sufficientcarbohydrate.



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Food fads and food refusal in this age group are common. It may be thought of

as ‘normal’ behaviour at this stage, even though worrying and frustrating forparents. When a child has diabetes, concern about eating problems isunderstandably greater. If there are problems with food they may be resolved by a change in insulin regimen.

These pointers may be helpful:

• Children grow and thrive without being ‘told’ how much to eat.Don’t worry if you feel they are not eating enough - they usually are!

Chat with your dietitian if you are concerned.

• Following rigid meal patterns and snacks does not work. Finger foods canbe useful through the day (such as pieces of fruit, toast ‘soldiers’ and smallsandwiches). Small plates of well-presented foods can be attractive totoddlers. Offer food regularly during the day.

• A child will never respond to force feeding. Although it will be difficult atfirst, try to play down the emphasis on food. Usually falling blood glucose

will promote hunger and make the child eat.

• Avoid using sweet foods or sugary drinks to “make up” the carbohydrate.Children soon learn that food refusal means a sweet drink or chocolatebiscuit!

• Offer a variety of foods - not just the carbohydrate. The overall balance of the diet matters too.

• Breakfast can be a difficult time. Try cereals, milk, toast or even yoghurt orunsweetened fresh fruit juice. Some children may at first only take a drink of milk, and then eat in half an hour or so.

• Glucogel can be a useful hypo remedy for low blood glucose in this agegroup.

• Toddlers are growing and constantly changing. At this age a regular review of food intake and insulin dose is particularly important.

Talk to the dietitian about any problems you may have about food.

Toddlers



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It is important for everyone to be the correct weight

for height. Being the appropriate weight for heightimproves general health, and helps you feel goodabout yourself. The balance between food andinsulin is important. Occasionally the insulin dosesrise too high and to prevent hypos, overeating results in extra weight. This will be picked up atclinic when your height and weight are plotted andthe appropriate advice given.

What weightshould I be?

It is fashionable to bethin - overly thin infact. This trend is worrying because

many children andteenagers - bothmale and female -can have a distorted view of their weight. They can feeloverweight when they are not. Your dietitian willgive you an idea of what an

acceptable weight for you is.

For growing children who are a kilo or two overweight, it isbest to let weight “mark time”, and they will in effect slim down,

as they grow taller. This can be done by adjusting food intake and activity level.

Some teenagers find themselves a little overweight, especially if they are notdoing as much activity as they used to. Find a sport or activity that appeals -

even walking is good for you. Other teenagers just feel overweight but are in fact

Weight – the Truth



an ideal weight; it’s just that their body changing shape and they don’t have themedia’s stereotype of a model figure.

Remember carbohydrate contains 4 kcals per gram, butfat contains 9 kcals per gram!!!

Speak to the dietitian if you feel that you are eating more than you would like to because you have beentold to do so.

A regular review of insulin and eating plan by yourdiabetes team is a good idea. A different insulin

regimen may be advised that will help control your

weight.

Feel free to discuss any concerns or queries you may haveat any time with the diabetes dietitian or another team

member.

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Food for Life Best Ideas Final