Multiple Reading Insulin and Carbohydrates

English for Health Studies (OET)
Death to carbohydrate counting?

Adapted by IELI under Section VB of the Copyright Act 1968
Insulin therapy is an effective strategy for achieving glycemic control in patients with
type 2 diabetes. Although often neglected, it is important to use an appropriate diet
strategy to complement the insulin. Furthermore, a basic tenet of such therapy is that
insulin dosage and administration should be appropriate to balance diet and physical
activity in order to maintain normoglycemia.
In this issue of Diabetes Care, Bergenstal et al. (1) evaluated two strategies for
determining the appropriate dosage of mealtime bolus insulin. A simple algorithm that
adjusted bolus insulin dose based on weekly average of premeal glucose was compared
with an algorithm based on mealtime carbohydrate counting. The authors demonstrated
the equivalence of both the simple strategy and the more elaborate carbohydrate-counting
strategy in achieving glycemic control; almost one-half the participants in both groups
achieved an A1C <6.5%. Can patients with type 2 diabetes treated with basal:bolus
insulin succeed without adding the complexity of carbohydrate counting?
Carbohydrate counting has been around since the 1920s and became integral in managing
patients with type 1 diabetes after the landmark findings of the Diabetes Control and
Complications Trial (2). However, the efficacy of carbohydrate counting in type 2
diabetes is largely unknown. Potential barriers to carbohydrate counting include the time
and effort required for patients to count the carbohydrate content at each meal, patient
difficulties in understanding the strategy, and the availability of dietitians or appropriately
trained health care providers to teach patients.
The authors did not evaluate quality-of-life outcomes, and little is known about how
carbohydrate counting affects quality of life. Prior studies have demonstrated that, when
given a choice, patients opt to discontinue carbohydrate counting over other strategies
(3).
Further research is clearly needed on the optimization of carbohydrate counting in type 2
diabetes and also in assessment of the accuracy of patients' counting in the real world
setting.
It would appear that if similar levels of glycemic control can be achieved with few
adverse events by using a simple algorithm, then the simple algorithm may be a better
strategy for adjusting insulin. Additionally, the simple algorithm may be more feasible to
teach patients within underserved settings where a dietitian may not be available.
However, are there benefits to counting carbohydrates beyond glycemic control?
In examining the study's secondary outcomes, there is an apparent trend for the
carbohydrate-counting group to have less weight gain at the end of the 24-week period.
The carbohydrate group had a weight gain of 2.3% compared with a 3.4% increase in the
simple algorithm group.
The 1% difference in weight gain over 6 months did not reach statistical significance, but
the study was not adequately powered to test the significance of such a difference. What
would be the weight effects over a longer time period? Could the higher insulin dosage
used in the simple algorithm group cause greater weight gain? Weight gain is a well-
known side effect of insulin therapy, and previous studies demonstrate weight increases
of [less than or equal to] 21% in one year with some insulin regimens (4). Weight
management is a critical aspect of type 2 diabetes, and it will be important to evaluate
strategies to minimize weight gain while using insulin therapy. Reducing carbohydrates
can be an important strategy for improving glycemic control and weight loss.
Did the carbohydrate-counting group have a lower carbohydrate or caloric intake than the
simple algorithm group? The Look AHEAD (Action for Health in Diabetes) Trial, which
is evaluating the potential benefits of weight control in type 2 diabetes, found that the
three most common weight control strategies used by participants were increasing fruits
and vegetables, cutting out sweets, and eating fewer high-carbohydrate foods (5).
Counting carbohydrates may increase dietary awareness of the carbohydrates being
consumed and subsequently reduce carbohydrate consumption.
A greater number of patients in the simple algorithm group completed the study in
comparison with the carbohydrate-counting groups (91.2 vs. 79.6%), which may suggest
greater ease of compliance with the simple algorithm.
The overall adverse event rate was similar between the treatment groups, but reported
self-blood glucose monitoring < 50 mg/dl with symptoms was slightly more common in
the carbohydrate-counting than in the simple algorithm group. Although there was no
statistically significant difference in the rates of hypoglycemia with using either dosing
algorithm, the simple algorithm had 53 episodes of hypoglycemia in 19 patients, whereas
the carbohydrate counting group had 37 episodes in 19 patients. Although the reasons for
this are unclear, we question whether this reflects more real-time adjustment in bolus
insulin dose in the carbohydrate group rather than the weekly adjustment in dose in the
simple algorithm.
Insulin management continues to be complex and requires close monitoring both by

patients and their physicians. Bergenstal et al. (1) have developed an algorithm to
simplify the management of insulin regimens containing basal and mealtime insulin.
Patients with type 2 diabetes may achieve glycemic targets with a simple basal:bolus
insulin algorithm without the added burden of counting the carbohydrate content of each
meal. Giycemic control, however, is one of many aspects of diabetes management, and
we need to be mindful of other important aspects including weight control and risks of
hypoglycemia. Bergenstal et al. have certainly initiated the impetus for us to examine the
relevance of carbohydrate counting for insulin dosing in type 2 diabetes, but carbohydrate
counting may have a life for more than just medication adjustment.
Answer the following questions based on the article.
1. What according to Paragraph 1 is often neglected?
a) Insulin therapy
b) Type 2 diabetes
c) a diet strategy
d) physical activity
2. In the first method, the dose of medication is adjusted based on levels of
a) bolus insulin
b) premeal glucose
c) an elaborate strategy
d) calorie counting
3. The second method is based on
a) levels of bolus insulin

b) levels of premeal glucose
c) an elaborate strategy
d) calculating the amount of carbohydrates consumed
4. Overall, the first method was found to ____________ the second method.
a) be more effective than

b) be as effective as
c) be less effective than
d) reduce the effects of
5. Which of the following is NOT a drawback of the carbohydrate counting method?
a) Time and effort required

b) Complexity of the method
c) Availability of health services
d) Weight gain in patients
6. Which of the following is NOT a future focus of this research?
a) The effect of carbohydrate counting on quality of life

b) The effectives of the simple algorithm over other methods of calculating doses.
c) The use of carbohydrate counting in managing Type 1 diabetes
d) The use of carbohydrate counting in managing Type 2 diabetes
7. Which reason does the author give as a cause of weight gain in diabetes Type 2
patients?
a) consumption of carbohydrates
b) poor glycemic control
c) insulin therapy
d) high calories intake
8. Of the three types of weight control methods mentioned, which is more likely to lead
to a reduction in consumption of carbohydrates?
a) eating more fruit and vegetables

b) cutting out sweets
c) insulin therapy
d) counting carbohydrates
9. More patients in the simple algorithm group
a) monitored their own insulin levels

b) completed the study
c) recorded weight loss
d) preferred the simple algorithm method
10. Fewer patients in the carbohydrate counting group
a) suffered hypoglycaemic episodes

b) completed the study
c) recorded weight loss
d) preferred the simple algorithm method
Answers
1. c
2. b
3. d
4. b
5. d
6. c
7. c
8. d
9. b
10. a

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English for Health Studies (OET)

Death to carbohydrate counting?

Insulin management continues to be complex and requires close monitoring both by

1. What according to Paragraph 1 is often neglected?

2. In the first method, the dose of medication is adjusted based on levels of

3. The second method is based on

a) levels of bolus insulin

a) be more effective than

5. Which of the following is NOT a drawback of the carbohydrate counting method?

a) Time and effort required

6. Which of the following is NOT a future focus of this research?

a) The effect of carbohydrate counting on quality of life

a) eating more fruit and vegetables

9. More patients in the simple algorithm group

a) monitored their own insulin levels

10. Fewer patients in the carbohydrate counting group

a) suffered hypoglycaemic episodes

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