May 2015

Dear (Editor):
As the cost of healthcare becomes more and more of a public-wide concern, it
has never become more potent that we as a nation take responsibility to reduce
these expenses. One strategy is to prevent future health complications in one of our
nations largest at-risk populations older adults. Within this group, diabetes
mellitus is a leading cause of secondary medical issues. Every year there are a
multitude of admissions that could have been prevented with the proper diabetes
management. This studys focus was to compare the two common methods of
carbohydrate counting, a standard tool used in diabetes management, to see what
method older adults were utilizing more and which was associated with more
accurate carbohydrate estimations. The hope of this study was by understanding
which method resulted in higher accuracy levels, healthcare professionals would be
able to improve their overall efficiency in how they serve the geriatric population.
This study was done as a requirement for the Aramark Distance Learning
Dietetic Internship for the 2014-2015 year. Permission to conduct this study was
granted under the Main Line Healths International Review Board. This study hopes
to provide as a base for future studies to investigate the efficiency and
effectiveness of the various methods of carbohydrate counting. This study was
conducted within Riddle Memorial Hospital located in the suburbs of Philadelphia,
Pennsylvania. Your consideration for this manuscript is appreciated.
Sincerely,
Christine Bannon
Dietetic Intern
Aramark Healthcare Distance Learning Dietetic Internship
1068 W Baltimore Pike
Media, PA 19063

Research Practice and Innovation

A Focus on the Older Adult Population: A Comparison of the Methods of
Carbohydrate Counting for Diabetes Management
Word Count: 3,712

A Focus on the Older Adult Population: A Comparison of the Methods of

Carbohydrate Counting for Diabetes Management

Christine Bannon
Dietetic Intern
Aramark Healthcare Distance Learning Dietetic Internship
1068 W Baltimore Pike
Media, PA 19063
Christinebannon27@gmail.com

A Focus on the Older Adult Population: A Comparison of the Methods of

Carbohydrate Counting for Diabetes Management
ABSTRACT
With the geriatric population on the rise, it has never been more important
that the healthcare industry cater their services toward this ever expanding group.
One of the more common and costly health risks this group is facing is diabetes
mellitus with millions diagnosed and facing secondary complications. Minimal
amounts of literature has been written on comparing the two methods of
carbohydrate counting, a standard tool for managing diabetes. The focus of this
study was to compare carbohydrate counting methods to see which of the two was
more efficient for older adults to use. To determine this, a questionnaire was
developed asking older adults to estimate the amount of carbohydrates of various
foods. Subjects were recruited from an outpatient diabetes management class. A
total of twelve questionnaires were filled out using whichever carbohydrate
counting methods subjects felt comfortable using. Results from the seven-week
study showed that while two-thirds of subjects utilized the one-gram increment
method, the exchange system was associated with higher accuracy (57.5%)
compared to the one-gram increment method (35%). In addition with only
accounting for the open-ended portions of the questionnaire, subjects using the
exchange system method were within a closer proximity of the actual carbohydrate
amount in foods than those using the one-gram increment method. Comments from
the questionnaire revealed challenges older adults face with both methods and
need to be consider when teaching this population how to manage their diabetes.
Limitations and suggestions for future studies are discussed.
INTRODUCTION

Riddle Hospital is a community 250-bed hospital located in the suburbs of

Philadelphia, Pennsylvania. The vast majority of its patients come from surrounding
nursing homes and care facilities. Because of this, staff interacts with many from
the geriatric community, a population that is currently seeing its share of
exceptional growth. According to the 2010 United Status census, the Northeast has
the highest percent of older Americans ages 65 and older than any other region at
14.1% (1). In fact, between 2000 and 2010, the rate of the older American
population in the Northeast increased (15.1%) more than that of the total U.S.
population put together (9.7%) (1). The county that Riddle Hospital is located in is of
no except of these statistics with 14.25% of its population aging 65 years old and
older (2).
As the older population continues to grow and the cost of healthcare is
increasing anally, its never been more important to address the health needs of
this group. Because aging is associated increase rates of comorbidities (3),
healthcare professionals need to develop strategies that are geared specifically for
this population. One way to manage comorbidities is to target one specific condition
that could be the prerequisite of a variety of other morbities. For example, diabetes
mellitus is a group of endocrine disorders that are associated with hyperglycemia
from either defective insulin production, insulin action, or both (4). Diabetes can
lead to a wide spread of conditions such as neuropathy, kidney failure,
cardiovascular disease, vision loss, and amputations (4, 5). For this reason, this
study was focused on diabetes mellitus management as a way for healthcare
professionals to combat the challenges of treating older adults. Specifically, this
study analyzed the major method of diabetes management, which is carbohydrate

counting, to answer the question of which method is more efficient for the average
older adult to control their diabetes.
The older adult community has one of the highest prevalence of diabetes
with approximately 30% being officially diagnosed (3). Hospitals such as Riddle,
need to reevaluate how they are managing diabetes mellitus in relation to older
adults. Riddle Hospital is an ideal location to do this study since many of its patients
are older adults and many are treated for diabetes-related complications that could
be avoided with the right education tools. An outpatient clinic associated with
Riddle Hospital offers year round diabetes education classes that are all taught by
certified diabetes educators (CDE) which provides a great opportunity to collect
information on how effective the education is. It is predicted that finding older
adults within these outpatient diabetes classes will not be difficult since this
population is the majority of Riddles patients.
Carbohydrate counting is a strategy of managing diabetes that has been
around since the 1920s (6) and has become a standard integral of diabetes
education. The strategy is based on the idea that carbohydrates provide the most
influential impact on postprandial glucose levels. Carbohydrate counting is a mealplan strategy that focuses on consuming a consistent amount of carbohydrates at
each meal which for a patient taking insulin, will have a better estimation of how
much insulin is needed to control postprandial glucose levels and prevent
hypoglycemia and hyperglycemia. For patients not taking insulin but rely on oral
medications, carbohydrate counting also provides an additional assessment tool in
determining how effective the medication is to a standard day of eating for the
patient. This strategy allows more flexibility in food choices and can be
individualized to each patient based on their preferences. By keeping carbohydrate
5

intake balanced with the right amount of diabetes medications and injections,
postprandial glucose levels are more likely to stay within recommended levels
resulting in improved glycated hemoglobin. The value of glycated hemoglobin
(HbA1c) provides an estimation of what a patients serum glucose has been over
the span of three months (4). Because of this, HbA1c is used as a biomarker as to
how well diabetes has been managed in an extended period of time.
Currently, there are two main methods of carbohydrate counting commonly
taught. One method utilizes exact 1-gram increments while the other uses 15-gram
exchanges or servings to stay within a subscripted carbohydrate allowance that is
specific for the needs of individual patients at each meal. Not much research has
been done to support one method over the other. However, in one cross-sectional
study by Smart CE, Ross K, Edge JA et al, research found that when carbohydrate
counting was tested for accuracy amount 102 children and 110 caregivers, 81% of
participants using the 15-gram exchange method were within 15 grams of accrual
carbohydrate content while 63% of those using 1-gram increments were within 10
grams of accrual carbohydrate content (7). While this study was performed on
children and their caregivers, the results could indicate that the exchange method
does show a higher prevalence of accuracy.
In a randomized controlled clinical study by Scavone G, Manto A, Pitocco L et
al, 256 participants were split into two groups to evaluate the effectiveness of
carbohydrate counting on glycemic control (8). Group A was picked to be trained in
a nutritional education program where carbohydrate counting was the main
component of management while group B was simply instructed to continue their
daily routine they were on previously before the study. Both groups were instructed
to keep a log book to track their daily blood glucose levels. At the end of the study,
6

significant reductions were seen in Group As HbA1c with no increased incidents of

hypoglycemia and weight gain (8). This study showed promising results for
carbohydrate counting since both hypoglycemia and increased weight gain are
commonly seen in those attempting to improve glycemic control (8).
The Scavone, et al study also brought attention a potential barrier in the use
of this strategy the high risk of non-compliance. Over the course of the study, 27%
of participants using the carbohydrate counting method dropped out (8). Scavone,
et al brings up the fact that there are several potential roadblocks for all
carbohydrate counting users. Some obstacles include the time and effort it takes
patients to count carbohydrate content at each meal, the difficulties that patients
face when first learning how the strategy works and even the availability of CDEs
out there to teach carbohydrate counting (6).
In a cross-sectional study done by Watts, Anselmo and Kern (9), a quiz was
given to diabetes patients to assess their knowledge in management, food labels,
and glycemic target ranges for diabetes. The study discovered that the domains
most often misunderstood by patients were identifying carbohydrate foods,
carbohydrate content of foods and interpreting food labels for carbohydrate content
(9). Many participants in this study often mistook high-caloric foods typically seen
as unhealthy such as butter as a source of carbohydrate while misidentifying
healthy foods such as fruit as not having any carbohydrates. Participants in the
study who had received diabetes education within the last three years scored
significantly higher (mean score 24.6) than those without nutritional education
(mean score 21.6) (9).

Another drawback to carbohydrate counting is that patients have been seen

to increase fat consumption since this macronutrient does not count towards a
carbohydrate allowance (10). This observation challenges the theory that
carbohydrate counting does not promote weight gain (8). Further study on the
affectedness of carbohydrate counting on weight gain is obviously needed.
A unique obstacle that older adults must face in attempting to use the
carbohydrate counting method is their high risk of low numeracy. Numeracy is the
ability to utilize and understand numbers in everyday life (11). Carbohydrate
counting requires users to have a moderate to advanced amount of knowledge in
numeracy and be able to manipulate numbers in a way to stay within their
recommended carbohydrate daily allowance. Populations most at risk of lower
numeracy are older adults, minorities, women, those with less than a high school
education, those with an annual income less than $20,000, and those with less than
a ninth-grade health literacy level (11). Low numeracy has been associated with
inaccurate portion size estimations, misinterpretation of food labels, and poor
glycemic control (11). Based on which counting method a patient is taught and how
good the patient is at math, calculating how much carbohydrates at each meal can
be extremely challenging for older adults.
While there are multiple factors other than knowledge that influences
behavior, knowledge enables informed actions. For this reason, patients must be
provided the proper tools to assist in the management of diabetes that have the
highest potential of effectiveness for them. Despite there being an extensive
amount of research on the impact of carbohydrate counting on glycemic control,
little is known on the efficiency between the different methods. In particular, even
less is known on the impact of these methods on a major population that uses
8

carbohydrate counting - the geriatric community. This study aims to validate which
method of carbohydrate counting is most efficient for the older adult population. By
analyzing data, this study hopes to discover new and alternative way to improve
diabetes management through carbohydrate counting and give insight into
additional complications that is exclusively associated to this population.
METHODOLOGY
Subject Recruitment
A minimum of 12 subjects who met the criteria were recruited for this study.
Since this study is focused on the older generation, data from subjects 50 years old
and older were analyzed. All genders were studied. Participation criteria also
includes an individuals with diabetes who had been taught carbohydrate counting at
any point prior to the study. Only subjects diagnosed with diabetes or prediabetes
were able to participate. Vulnerable subjects such as minors, prisoners, mentally
handicapped or disabled persons, pregnant women and neonates were excluded
from the study. Minors were excluded from the study due to vulnerability to coercion
and undue influence. No inducements or advertisements were used for recruitment.
Subjects were recruited from patients who were attending the outpatient diabetes
classes at Riddle Hospital in their outpatient Health Center 4 building. The
researcher attended a total of three classes where at the end of the class that
reviewed carbohydrate counting, the researcher orally introduced the study to the
class to recruit participants.
Study Design
A cross-sectional design was utilized for this study since the focus of this
study was to assess the association with accurate carbohydrate estimation and type
of carbohydrate counting strategy. In a 7-week study, the researcher attended three
9

outpatient diabetes classes at Riddle Hospital. At these classes, diabetes

management were reviewed and discussed over a span of 3 classes. The class is
taught either method of carbohydrate counting based on the instructors
preference. At the end of the class that reviewed carbohydrate counting, the
researcher orally introduced the study. When all participants were identified, the
researcher distributed identical questionnaires to test the subjects ability to
estimate carbohydrate content. The questionnaire consisted of a total of 11
questions. Participants were asked to identify their age and which type of
carbohydrate counting method they would be using to complete the questionnaire.
The quiz asked participates to estimate the carbohydrate content of every day food
items such as sandwiches, side dishes, fruits, pastas and breads. Participates were
instructed to use whichever carbohydrate counting method the subject felt
comfortable using to answer the questions. The last question asked if the
participant experienced any challenges in carbohydrate counting and provided
multiple choices to pick from. The questionnaire can be found in the appendix of
this study. Subjects were given unlimited time and were able to use calculators if
necessary. No follow-ups were necessary for this study.
Once data was fully collected, the primary investigator scored the
questionnaires on accuracy. Quizzes completed by participates below the age of 50
were discarded. The remaining quizzes were then split by which method the
participant used. The primary investigator scored the averages of both groups and
compared the results. Based on which method scores the highest on the quiz, the
primary investigator was able to determine which method was associated with
higher incidences of accuracy in estimating carbohydrate content for the older
population.
10

Resources
No pre-existing carbohydrate counting questionnaire was found prior to the
study so the researcher developed a questionnaire from scratch with the guidance
from the hospitals in-patient dietitians. The questionnaire was expected to take
approximately 10 minutes to complete. Calculators used during the questionnaires
were both from the subjects themselves or the researchers personal calculator. This
study received no funding.
Statistical Analysis
Questionnaires were scored using the averages of how many meals subjects
were able to accurately estimate carbohydrate content. Data was submitted to an
Excel (Microsoft 2013 version) spreadsheet to calculate the averages of both
groups. The averages were then compared to each group to assess which method
was associated with higher accuracy amongst the older participants. How close
subjects were at estimating open-ended questions were also looked at. This would
be done by adding up the differences from what the subjects estimated to what the
actual carbohydrate amount was. This told researchers a range of how close
subjects were estimating the right carbohydrate amount.
RESULTS
A total of fourteen questionnaires were completed during the seven-week
long data collection. Of these fourteen, twelve met the studys criteria data from
those who did not meet criteria were discarded.
The samples averages from the questionnaire are categorized by
carbohydrate counting method and can be found in the Appendix. The questionnaire
results indicated that majority of participants utilize the one-gram increment
method (66.6%) compared to that of the exchange system (33.3%). Analysis of the
11

raw data indicated that the exchange system was associated with higher accuracy
(57.5%) at estimating carbohydrate content compared to the one-gram increment
method (35%) within the older group. Within the open-ended portion of the
questionnaire, participants using the exchange system were on average 18.75
grams within the actual carbohydrate content of the listed foods. Participants using
the exact 1-gram increment method in comparison were within 31.25 grams of the
actual carbohydrate amount.
DISCUSSION
The focus of this study was to examine and compare the different strategies
that are being taught to patients to see which were most efficient in helping to
manage diabetes mellitus. How efficient a strategy is was determined by which
method resulted in higher accuracy carbohydrate content estimations from the
questionnaire. The results of the study indicated that two-thirds of older adults
utilize the exact 1-gram method of carbohydrate counting. Although the 1-gram
increment was the more popular method, the averages of the questionnaire showed
it was the exchange system that was associated with higher accuracy of estimating
carbohydrate content. Participants using the exchange system scored on average a
57.7% compared to the 1-gram method with a 35% average.
The raw data from the questionnaire also indicated that participants using the
exchange system were within a closer proximity of the actual carbohydrate amounts
than that of the exact 1-gram increment method. This association reflects that of
the results of the Smart CE, Ross K, Edge JA, et al study that showed in a similar
study design with children and their caregivers, the exchanges system subjects
were within a closer range of actual carbohydrate content. This study distinguishes

12

itself by using the older adult population as its sample group which, as previously
stated, is seeing a high incidence of diabetes diagnoses.
Over the course of the seven-week study, three different certified diabetes
educators (CDE) taught the Riddle hospital outpatient diabetes classes. The first two
of these educators utilized the exact 1-gram method to review carbohydrate
counting while one used the exchange system. It was this last educator, the one
who utilized the exchange system, which taught the class what she referred to as
the servings method of carbohydrate counting. After the review, it was apparent
that this servings method was just an alternative name for the exchange system.
When asked about this servings method, the educator informed the primary
researcher that CDEs no longer use the term exchange system but instead now the
servings method. This alternative name did cause confusion within the sample
subjects from this class since participants were unfamiliar with the exchange
system name. This become important since the questionnaire asked subjects to
indicate which carbohydrate counting method they would be using to answer
questions the exact 1-gram increment or the exchange system. After review of this
class questionnaires, there were evident confusion on what method to indicate
since the servings method was not an option to choose from. After review of the
open-ended portion of the questionnaire, the studys researchers were able to
estimate what method subjects were using. For example, one question listed
oatmeal and asked participants to estimate how many carbohydrates were within
the specified serving size. Some subjects answered such as 2 servings or as 32
grams where the researcher took the servings as the exchange system and the 32
grams as the exact 1-gram method.

13

While both methods scores were not relatively high, it should be noted that
the participants of this study were recently introduced to carbohydrate counting one
to two weeks prior of the questionnaire at most. Some participants remarked that
the class the questionnaire was given was the first time they had even been
formally educated on how to count carbohydrates. Another limitation that should be
noted was the size of the studys sample. This study was only able to collect the
minimal amount of data from a total of twelve subjects who met the criteria for this
study. The small amount of subjects was due to low class attendance. To try to
combat this, the primary researcher attended multiple diabetes classes but still was
only able to gather the twelve. This relatively small sample cannot speak for
another population let another one as big as the geriatric.
No preexisting quiz could be found to assess subjects carbohydrate counting
knowledge so one had to be created for this study. An advantage the researchers
had was access to Riddle Hospitals CDEs who were able to guide the researching
team on what items would be most beneficial to quiz participants on.
As predicted, conducting this study at Riddle hospital served as an optimal
location since twelve of the fourteen members that attended the outpatient
diabetes classes with fifty years old or older. All three CDEs were well
knowledgeable on how to teach diabetes management for the older population
since as they reported, its the mass majority of their clientele.
The last portion of the questionnaire asked participants what challenges they
face with carbohydrate counting. This enabled study subjects to express openly
what opinions and concerns they have related to utilizing carbohydrate counting.
Within both methods, various participants remarked counting carbohydrates takes

14

too much time and effort. A couple remarked they were still learning what qualifies
as a carbohydrate and many mentioned a deficit in knowing the appropriate portion
size. Knowing the associated portion size was the most common concern many
subjects reported struggling with. These responses supports that from the Scavone,
et al study that discussed the challenges patients face when utilizing carbohydrate
counting such as the time and effort commitment. Long-term compliance was
unable to be examined in this study since all participates were new to diabetes
management. Unlike the Watts, Anselmo and Kern study, majority of participants in
the study did not struggle in identifying what foods fell into the carbohydrate food
group.
CONCLUSION
Diabetes mellitus is a major health risk many older Americans face. Learning
what management techniques benefit these individuals the most can prevent future
complications and help reduce financial costs. One of the most used of these
techniques, carbohydrate counting, causes its own set of challenges such as
learning portion sizes and the time it takes to use the tool on a daily basis as
demonstrated from this study. The older population alone faces additional
challenges since this group is at a higher risk of low numeracy. Healthcare workers
need to tailor their service in a way that is most beneficial for older adults to learn
and use.
Despite the popularity of the exact 1-gram increment method, results
supported that the exchange or servings method is associated with closer
carbohydrate estimations. While averages from the studys questionnaire were not
relatively high for either method, subjects using the exchange system were with a

15

much closer range to the actual carbohydrate amount (within 18.75 grams) than
that of the exam 1-gram method (within 31.25 grams).
Many comments from the study indicated that knowing the appropriate
portion sizes continues to be an ongoing challenge older adults face when
estimating carbohydrate amount of a meal. In addition, it should be noted that
subjects within this study were new to carbohydrate counting. Future studies should
examine how accurate each method is on patients who have been carbohydrate
counting long-term. Within these future studies, it may be beneficial to compare the
different types of carbohydrate counting method to subjects glycated hemoglobin
or as better known as their A1c.

16

REFERENCES
1. Werner CA. The Older Population: 2010. United States Census Bureau. 2011.
http://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf . Accessed December
05, 2014.
2. Food Environment Atlas. United States Department of Agriculture. March 14,
2014. http://www.ers.usda.gov/data-products/food-environment-atlas/go-to-theatlas.aspx. . Accessed December 5, 2014.
3. Mushi MN, Maguchi M, Segal AR. Treatment of Type 2 Diabetes in the Elderly. Curr
Diab Rep. 2012; (12): 239-245. dio: 10.1007/s11892-012-0269-4
4. Nelms M, Sucher K, Lacey K, Roth S. Disease of the Endocrine System. Nutrition
Therapy and Pathophysiology. 2nd ed. Belmont, Ca: Brooks/Cole Cengage Learning:
2011: 472-487.
5. Scalone L, Cesana G, Furneri G, Ciampichini R, Beck-Peccoz P, et al. Burden of
Diabetes Mellitus Estimated with a Longitudinal Population-Based Study Using
Administrative Databases. PLoS ONE. 9(12): e113741.
doi:10.1371/journal.pone.0113741
6. Davis N, Wylie-Rosett J. Death to carbohydrate counting? Diabetes Care. July
2008; 31 (7): 1467-1468. dio: 10.2337/dc08-0807
7. Smart CE, Ross K, Edge JA et al. Can children with Type 1 diabetes and their
caregivers estimate the carbohydrate content of meals and snacks?
DiabeticMedicine. 2009; (27): 348-353. dio: 10.111/j. 1464-5491.2010.02945.x
8. Scavone G, Manto A, Pitocco D et al. Effect of carbohydrate counting and medical
nutritional therapy on glycaemic control in Type 1 diabetic subjects: a pilot study.
PubMed. 2009; (27): 477-479. dio: 10.1111/j. 1464-5491.2010.02963.x
9. Watts SA, Anselmo JM, Kern E. Validating the AdultCarbQuiz: A Test of
Carbohydrate-Counting Knowledge for Adults with Diabetes. Diabetes Spectrum.
November 3, 2013; 24 (3): 154-160. dio: 10.2337/diaspect.24.3.154
10. Rodacki M, Rosado E, Souto DL, Zajdenvergy L. Impact of advanced and basic
carbohydrate counting methods on metabolic control in patients with type 1
diabetes. Nutrition. 2014; 30 (3); 286-290. dio: 10.1016/j.nut.2013.08.010
11. Bowen ME, Cavanaugh KL, Wolff K, Davis D, Gregory B, Rothman RL. Numeracy
and Dietary Intake in Patients with Type 2 Diabetes. PubMed. 2013; (31): 240-247.
dio: 10.1177/0145721713475841

17

APPENDIX 1. Carbohydrate Counting Questionnaire

Carbohydrate Counting Quiz: Test Your

Knowledge!
Age: ______
This study has been explained to me, I understand it, and I agree to take
part: yes or no (Circle one)
Which method of carbohydrate counting will you be using for this
questionnaire? (Circle one)
Exchange System or One-gram increment
Below you will find 11 questions listing foods you may come across in your
everyday life! Using which ever method you feel comfortable with,
estimate the amount of carbohydrates of the listed foods. Some questions
are open ended while others are provide multiple choices.

1)

2 scrambled eggs or egg

substitute
3 strips bacon
1 slice whole wheat toast

Estimate the carbohydrate content of this

meal:
A. 1 exchange/ 15 grams
B. 2 exchanges/ 30 grams
C. 4 exchanges/ 60 grams

1 tablespoon butter
1 cup black coffee with
artificial sweetener

2) Which contains more carbohydrate?

A. 2 slices of whole wheat bread
B. One cup of white rice
C. They contain the same amount of carbohydrates
3) How many
this meal?
A. 5
B. 3
C. 8

2 cup Chicken Noodle soup

6 Saltine crackers
1 large banana

18

carbohydrates are in
exchanges/75 grams
exchanges/ 45 grams
exchanges/ 120 grams

4) How many
this meal?
A. 2
B. 3
C. 4

carbohydrates are in
3 oz turkey
2 slice of Swiss cheese
Lettuce and 2 slices of tomato

exchanges/ 30 grams
exchanges/ 45 grams
exchanges/ 60 grams

1 Tablespoon Mayonnaise
2 slices of bread
5) How many carbohydrates are in this meal?
A. 4 exchanges/ 60 grams
2 cups pasta
B. 5 exchanges/ 75 grams
C. 6 exchanges/ 90 grams
cup tomato sauce
D. 7 exchange/ 105 grams
3 medium sized meatballs
cup of broccoli
16 fl. Oz Diet Soda
6) How many carbohydrates are in this meal?
A.
B.
C.
D.

3 oz chicken breast
1 cup mashed potatoes

2
1
5
4

exchanges/ 30 grams
exchange/ 15 grams
exchanges/ 75 grams
exchanges/ 60 grams

cup carrots
1 cup apple juice
7) Estimate how many carbohydrates
are in this meal.
1 cup oatmeal
2 cups skim milk
cup orange juice
Answer: _________________________
8) Estimate how many carbohydrates are in this meal.
3 oz hamburger
1 hamburger bun
1 slice of American cheese
Lettuce and 2 slices of tomato
Answer: _________________________________
9) Estimate how many carbohydrates are in this meal.
19

1/2 cup black beans

1 cup brown rice
4 oz ground beef
1/4 cup onions
Answer: _________________________________
10)
Which contains more carbohydrates?
A. cup canned peaches
B. cup oatmeal
C. 1 large banana
D. They contain the same amount of carbohydrates
11)
What are some challenges (if any) do you have with
carbohydrate counting? (circle all that apply).
A. I dont understand how to count carbohydrates
B. It takes too much effort
C. It takes up too much time
D. I have never been taught how to count carbohydrate
E. I have trouble understanding what counts as a carbohydrate
F. I do not see any benefits with carbohydrate counting
G. I do not know the portion sizes
H. I have no challenges with it
I. I rather not answer

APPENDIX 2. Raw Data from Questionnaire

Age

Score

Carbohydrate
Counting Method

20

Grams within
Accurate
Carbohydrate

66
51
51
65
70
53
61
50+
57
56
68
55

80%
50%
40%
60%
30%
10%
40%
60%
30%
20%
50%
40%

Exchange system
Exchange system
Exchange system
Exchange system
One-gram increment
One-gram increment
One-gram increment
One-gram increment
One-gram increment
One-gram increment
One-gram increment
One-gram increment

21

Content
15
15
30
15
45
30
45
30
30
35
20
15