Guest guest Posted January 25, 2000 Report Share Posted January 25, 2000 I *think* you'll be OK if you substitute " starch " for " carbs " when talking about or using Exchanges. I personally don't use them. I find them so confusing that I'm not able to figure out just what I *am*eating. And also, I find that the carb content is way high with exchanges for my system. I'd be on the ground constantly if I ate that way. --- But -- YMMV. I append a treatise on this subject (Exchanges) by Ron Sebol of the LC-Diabetes group. I copied (saved) it before I got tossed off that list for being a bit obtuse about a question (in Grant's opinion) and pig-headed about pursuing it. You can take it or leave it. Ron is a very studious student of diabetes. >Reply-To: Low Carb Diabetes Support List > >Sender: Low Carb Diabetes Support List > > >Subject: [LC-D] ADA exchanges: an editorial update >To: LC-DIABETES@... > > >Thanks to in Constable, NY, I have had the opportunity to look at >the recent revisions to the ADA food exchange list. Revisions that were >issued some ten years after the publication of the list I already had. I >have held off in commenting on ADA exchanges on the chance that the >conceptual errors in my early exchange list were later corrected. They >were not. > > >The essence of the ADA list is a more or less uniform 15 grams of carb >in the named portion (resolved to the nearest 1/4 cup) of the pure >carbs. >A meat exchange is defined as 7 grams of protein and of course that >equates >to a portion of one ounce. > > >Strangely, a milk exchange is 12 grams carb and 8 protein, for a total >of twenty. Equating the insulin cover of a meat exchange with a carb >exchange is itself erroneous. 15 grams of carb can produce as much >change in BG as 12 grams of glucose (e.g. rice) where 7 grams of protein >is equivalent to only 4.2 grams of glucose. That is only a mere 286% >error! The error is still considerable for the lower GI starches >relative >to protein. Even for greens, the error is not negligable. > > >The typical diabetic using insulin is usually given a diet, having a cap >determined by calories, of so many bread exchanges, so many vegitable >exchanges, so many meat exchanges, etc, on a per meal basis. They are >also told to take a fixed number of units of insulin to cover the >respective meal. The docs on the cutting edge allow patients to vary >the >dose in proportion to the total exchanges, rather than fixing exchange >total and dose. That latter method is the so called sliding scale. > > >The result of using the exchanges list is approximate control of BG with >a person being rather lucky if the average BG (calculated from an A1c >test) is as low as 150 mg/dl. The A1c equating to that average would be >roughly 7.0. Averages higher than 150 are not unusual with that >approach. >Many doctors seem to believe that to control any more tightly invites an >unacceptable risk of dangerous low sugar episodes and with >the exchanges approach to dosing that fear is more than justified. >However, with a >correct approach to dosing, an average of around 100 can be established >with less, not more, risk of a low sugar crisis. > > >The reason the exchanges approach effects only mediocre sugar control, >with significant remaining risk of diabetes complications, is >elementary. Or >perhaps I should say alimentery. All carbs, gram for gram, do not change >BG in the same amount nor do they all require the same insulin dose. > > >The study of glycemic index was, unfortunately, done on T2 diabetics. >With only the GI study provided as evidence, it is easy to dismiss the >GI >results as inapplicable to a T1. One would argue that if a carb >digests more slowly the T2 could better produce enough insulin to keep >up and >that would would, arguably, have nothing to do with what a T1 would find >necessary for the same food. They held to the notion that the T1 >would need the same insulin for all the GI items. Some years later than >the GI work an independant study was performed at an Australian >Medical School. They measured the total insulin elicited by foods along >with >the glucose area under the curve (the latter was all that the GI study >observed). Low and behold!! The total insulin data confirms that the GI >applies to T1 insulin dosing quite accurately. If one compares the >insulin index (defined in that study as a relative total insulin >normalized >to a bread portion for an isocaloric food input) to the glycemic index, >over all food items, they correlate with a .75 coefficient. If the one >super >high fiber item and the one super high fat item are eliminated from the >data, >and the corellation then recalculated (an exercise I did with the data >in the >Aussie study), the corellation jumps to .85. That is, accurate >prediction of required insulin, contrary to the quite reasonable >objections one might have raised to overgeneralizing from the GI work >alone, >is considerably aided by addressing the GI so long as one avoids >extending the calculations to abnormally high fiber and abnormally high >fat items. > > >Previously, I have provided an example of calculating a glucose >equivalent of a food from the GI and any food composition data base. >There was never any doubt in my mind about the superior results to be >derived from that more accurate method but I could not say that the >exchanges approach was a shabby second choice on the chance that it had >been updated and corrected in the nonce. Now, having seen their latest >and greatest, >and further encouraged by the objections to their approach in the form >of >a journal article one can, amazingly, access on the ADA web pages, I >now feel pretty comfortable in saying that using the ADA exchanges >premise produces excessive dosing error. > > >If one is ignorant of the presence of a chronic erratic dosing error, >one would look at meal response BGs and say " my response to insulin is >very erratic so there is no reason to use any complicated calculation >method " . >Wrong!!! The response only appears to be erratic because the dose is >right at some meals and way wrong at others. Of course the BG is all >over the map when the dose is rarely correct. There is every reason to >expect that insulin responses would be considerably more stable, and >sugar averages lower, if the dose was correctly calculated. In my case, >in a year and a half, I have not seen any evidence of variation of >insulin responses day to day. In fact, things are so stable and >predictable I have been able to measure the impact on insulin resistance >of hydrochlorothizide (2.7:1), monopril (1.08:1), fish oil caps (1.7:1), >changes in body weight (100% per 15% weight change), chromium >picolonate, >vanadium sulphate, etc, all by watching my dose adjustments. I also see >no evidence of dose absorption variation even for 25 units. While I >can't >prove it, I suspect that Bernstein's assertion that insulin absorption >varies 30% shot to shot was influenced by his omission of GI in his >considerations of carb dosing. Had he said he saw that 30% when the SAME >FOODS WERE EATEN, I could buy it. Because he didn't fix food with >respect to >that observation, his assumed uniformity of dosing for a given gram >weight >of carb had to be a factor that introduced scatter in his BG results. > > >I just had to speak up about this ADA exchanges list dosing error issue >and the other example of a consequence of omitting GI because: > Exchanges are still in common use > > > Application of ADA exchanges leads to poorer sugar control than is >otherwise possible > > > Erratic dosing accuracy encourages more frequent and more severe hypo >episodes > > > Erratic accuracy of dosing discourages attempts to attain better >control >by application of more exotic calculations by producing an incorrect >perception of >erratic resonses to insulin that would, if valid, make dose fine tuning >an exercise in futility > > > erratic control frustrates the attempts of a T1 to sort out personal >responses to >drugs and foods via home BG testing > > > >Ron At 01:01 PM 1/25/00 -0600, you wrote: > > >Hi everyone......wow there sure were alot of posts about carbs versus low >carbs....and I sure appreciate everyone's input. Ok now I'm not sure >about this terminology yet....so about the Carb Exchanges...uhhhhhh not >sure what you mean by that. It does say that in this big book the >diabetes dietician gave us in the hospital...explaining which foods were >carbs....and that 15 grams of carbs is worth about 80 calories...and the >protein involved and then goes to other starches and tells you the same >about them, and then the veggies and so on, but........... >Ok..let me tell you what this sheet says that she gave us >for example..breakfast 2 carbs, 0-1 oz protein, 1 fruit, 1 milk, 1 fat, >and he can have black coffee. Lunch....2-3 carbs, 2-3 oz protein, 1 >vegetable, 1 fruit and a beverage..iced tea >Dinner...3 carbs , 2-3 oz protein, 1 fruit, 1 fat and iced tea again. For >a night time snack if he needs one she told us to limit it to 15-20 grams >of carbs and be at or under 100 calories. > >Now I was under the impression that he HAD to have this much at each >meal, to keep his sugar and his insulin in balance ? Warren never used >to eat breakfast..he still doesn't like eating anything first thing in >the morning but now he forces himself to. And he doesn't have a veggie at >lunch...he kinda saves them for dinner, and he does usually try to have >one or two that are low in carbs....or a salad on the side..he does love >veggies so he is lucky there. If he wants peas or corn or beans...we >limit him to half a cup of only one...and then a salad maybe as well. As >for potatoes or rice...the dietician said he could have 1 cup of either, >as long as he counts that as 2 carbs...sometimes he doesn't finish them >all though...and makes sure he eats all the meat and veggies. >I guess we must be doing something right, cause I called the dr with his >sugar readings this morning for the past 3 days and he called back and >told us not to change a thing...just keep doing what we're doing : ) . > >Toni...thats EXACTLY what the dr told Warren...he still is making his own >insulin but his body is not using it correctly, thus the need for the >insulin injections, as he also is a type 2 diabetic. > >Susie...he doesn't snack unless he starts to shake...then he goes for a >juice or the glucose tablets or some cookies...whatever is available. He >does have a snack at night before bedtime, made up of one carb....which >seems to be working since his last 3 morning sugars have been almost >identical at 110, 110, and 114, so this is working for him. The dietician >told us about the low fat cheese which I did buy and only using canola >oil which we did anyway, I now buy the leanest meat I can find and like I >said....no problem getting him to eat ANY veggie..he loves them all !! >He's determined to keep this under control...not only so he doesn't have >problems later on in life ( he's 48 now ) but so that he keeps his kidney >functioning and won't have any problems with it either. > >I can't thank you all for the help you've been sharing with us these past >few days....this is just all still very new to us, it seems I learn >something everyday, and then tell Warren as soon as he gets home from >work. > >And you just KNOW I'm going to have more questions : ), so thanks in >advance !! > > >________________________________________________________________ >YOU'RE PAYING TOO MUCH FOR THE INTERNET! >Juno now offers FREE Internet Access! >Try it today - there's no risk! 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