Diabetes & Endocrine ECHO: Carbohydrate Counting and Apps to Help – 11/16/17


So now we’re going to turn it over to Karmella. Yay, alright. Now I get to talk about some good stuff. Alright. (laughter) Alright. So we did carbohydrate counting about a year ago, actually, when I was looking at my old slides. So I thought we could kind of do a review, to kind of briefly introduce carbohydrate counting, help with some points that I suggest when we talk to patients about dietary modification and supporting blood sugars, and then towards the end, some new apps that are available. Ones that some of my patients are using, and then a newer one as well. That might be something for you guys to be able to think about recommending or maybe something that your own patients are using as well. There is so much confusion out there, when it comes to what should we be recommending to our patients? And also for the patient’s themselves being confused with all of the new fads, and types of diets, and products that come out all the time. So my goal is to help kind of, work through some of that confusion and give you some basic suggestions and recommendations on how we can support patients with their diet. So, let me start with, what is a diabetic diet? There isn’t one. Actually, with our new guidelines, we want to refer to patients who have diabetes, a person with diabetes. So when we talk about a diet that’s best for blood sugar control, It’s very similar to what we might recommend for somebody else, even if they do not have diabetes. Specifically, the goal is to support them with eating a healthy eating pattern, that includes all food and beverages that are within a calorie level that’s appropriate for a healthy weight. And the dietary guidelines Kind of speak to more of an emphasis around calorie, nutrient- or calorie levels of the foods that we’re eating for a healthy weight. So it includes vegetables, fruits, grains, especially whole grains. Try and encourage patients to eat low-fat or fat-free dairy products, having a variety of protein foods, not just red meat. And then oil, specifically healthy oils that include more of those mono-unsaturated fats. So that’s what we kind of want to encourage our patients is to eat a variety of foods, an to be able to hit on all or most of these food groups, in order to get all of their nutrition in. But outside of that, a tool that we have when we’re thinking about a meal plan, when we’re thinking about how we want to counsel patients on what they should be eating, is we have carbohydrate counting. And this is an evidence-based way of helping patients understand what role food has on their blood sugars, and specifically carbohydrates. And the total amount of carbohydrates that a patient eats, can directly influence what their blood sugars are going to do. And that’s really important because carbohydrates, although absolutely necessary for a healthy diet, you know, they’re our energy source. They’re what our brain uses for energy, they’re what our muscles prefer to use for energy. But we want to make sure that we have a more moderate amount of carbohydrates, instead of over consuming them, which is what I see happen a lot. And carbohydrate counting, kind of fits well into diet recommendations, thinking about exercise and how consumption of carbohydrates before an exercise session, or afterwards can be helpful. And then carbohydrate counting can also be useful when we talk to patients about you know, if you do experience a hypoglycemic event, you know, how carbohydrates can be supportive and treating that. So carbohydrate counting is the best way in terms of helping patients change their diets in order to support blood sugars. So one of the first things that I start with when I talk to patients about carbohydrate counting, is helping them to understand how food impacts our blood sugars in the sense that different foods, and the amounts of the food that we’re eating at a particular meal or snack, can have dramatic differences in what our blood sugars are going to do. The foods that we eat are composed up of three macronutrients You all know them, carbohydrates, proteins, and fats. And they actually all can have an impact on our blood sugars. But carbohydrates are- is the nutrient that has the most direct or highest impact on what our blood sugars do. Proteins and fats, I’m going to go back for just a second. Proteins and fats, when consumed in a large amount, can also cause blood sugars to go high as well. And that’s a lot of times what we might see with patients who for example, have pizza. And they might have four or five slices of pizza. Yes, there’s a lot of carbohydrates, but there’s also a lot of protein and fat along with that that can all have an impact on how high their blood sugars go, and also how high or how long they stay elevated. So this is a graph, it’s not very technical. It’s very basic. But my point with this type of graph is to understand that when patients, or us, eat carbohydrates at meals, our blood sugars go up. Whether you have diabetes or not, when our body is digesting and breaking down carbohydrates, our blood sugars are going to increase. So we will see a postprandial rise in our blood sugars. But what we want to try to do, is not allow that blood sugar rise to go up too high and then come down in a short time period. One to two hours. So the first blue, blueish line there that you see there is for when people have a large amount of carbohydrates, and there’s not much protein, perhaps there or even perhaps some fat there, that we see that those carbohydrates are quickly turned into sugar in the body. Our blood sugars go high, and then we can actually see that the blood sugars drop pretty quickly as well, after eating. And this is what people might say when they experience, I feel really tired I need to take a nap after eating, or they might actually feel like they’re having a low blood sugar you know, a couple hours afterwards. So this is something that we want to kind of keep from happening. I see this happen a lot when patients either forget to take their insulin, or sometimes when people are eating 90 or 140 grams of carbohydrates in a single sitting, and that is not uncommon. I see that happened a lot, especially when we see patients consuming beverages that have sugar in them, and then also carbohydrates in the food that they’re eating. So there is kind of like double dipping in a way, because we have a high consumption of carbohydrates in a single sitting. A lot the body kind of has to work through. The mixed meal, that red line is what our goal is. Yes, we’re going to see some increase in blood sugars with eating, but then we would hope that that doesn’t increase too high. So one to two hours after eating, keeping that below 180, maybe below 150 for some people, and then seeing that that line kind of stays with us longer. So this helps us to feel energized with food. Feeling like we can get through our day, feel like we don’t need to take a nap, or feel tired, and we feel like energized. And the energy, or the nutrition from those carbohydrates are sustaining us. Okay, so as I mentioned carbohydrates are the foods that have the most dramatic effect on our blood sugars in terms of increasing them. And anytime I start this conversation with patients, I see how the patient can immediately hear, for some reason, and I’m very careful about addressing this, is that they hear, “Okay, well blood sugar- or carbohydrates increase my blood sugars, and my goal is for that not to happen, I want my blood sugars to stay down, my doctor keeps telling me to keep my blood sugars down, I’m just going to avoid that.” And that’s not necessarily what we wanted to see happen either. As I mentioned earlier, carbohydrates are our main fuel source, so they’re what we need for energy and being able to do the things that we need throughout the day. So I’m really intentional about telling patients It’s not that we want to avoid carbohydrates, but that we need to understand that a moderate amount of carbohydrates is the goal. So having some at breakfast, some at lunch, some at dinner, and how many, we’ll talk about that in a second, really depends upon a few things. And sometimes it’s starting out with a certain amount, seeing how they respond, and then making adjustments as necessary. These are the foods that contain carbohydrates, and that’s a big list, right? There’s a lot of foods that have carbohydrates in it, and so most of the things that people are eating at meals, there’s going to be carbohydrates. So, quick review. Breads, crackers, cereals, pasta, rice, and grains. Only the starchy vegetables to really concern ourselves with. Other things like broccoli, cauliflower, carrots, you know, they are gonna have some carbohydrates in them but such a small amount that we don’t consider them in the carbohydrate group. Beans and legumes. Milk and milk products. Fruit and juices. And then all of those sweets we love and enjoy. Cakes, cookies, that sort of thing. Proteins and fats have little to none carbohydrates. So just so we’re all on the same page, proteins would be meat, fish, chicken. And fats would be things like butter, cheese, oils. Peanut butter would fall into that as well. And as I mentioned, these can also increase blood sugars, but it’s more if they’re eaten in a large quantity, and in a high amount. So we prioritize first with patients, looking at the total amount of carbohydrates that they’re eating at a single meal, and their total for the day. And then usually follow-up appointments from my perspective, going to talking about fats and protein, other suggestions, but we first prioritize carbohydrates. The more carbohydrates that you eat in a single time, tends to find higher blood sugars after meals. So there’s a threshold, in a way, of how much the body can take, and for- to keep blood sugars under control. Some common challenges that I see, is that we don’t fully know how many or how much we’re eating at a single meal. The typical american underestimates what they eat by at least 30 percent. And that’s rather significant. So a lot of people think they’re eating less than they might actually be eating. The amount of carbohydrates found in food, some patients can get confused on what foods have carbohydrates, and how much? Hidden sources of carbohydrates. Another common challenge I see, is that because we talk so much about blood sugar control, keeping blood sugars low, is that that word “blood sugar”. So sugar, is that patients instinctively look on a food label only at the sugar grams, and they forget to look at total carbohydrates. And so that sometimes is something to kind of address with them. Another challenge is that patients are not looking at the serving size listed on a food label. Which can be really different from their own personal portion size, whatever it is that they may be eating. Easily forgotten sources of carbohydrates that can actually add up rather quickly. Milk substitutes, yogurts, baked beans, tomato sauce, salad dressings, barbecue sauce, I forgot to add on here ketchup, that’s another one. Orange chicken with the syrup, and the sweet sauce that’s on there. Sugar free foods, protein bars. So these are some things that some patients can actually be eating, and they’re not really considering impacting their blood sugars. A few other challenges that I think are just important to be aware of when we’re trying to address supporting patients with diet changes, is that patients sometimes will prioritize looking in the grocery store for sugar-free products, and thinking that they don’t have to worry so much about how much they’re eating, or thinking if it’s sugar free It’s not gonna really impact my blood sugars. But I always say sugar-free doesn’t mean carb free. And so sugar is a type of a carbohydrate. And helping patients understand that their total carbohydrates are what are impacting their blood sugars can be helpful, so that they’re not feeling like or assuming sugar free candies is not going to impact their blood sugars. Some people responds differently to different foods. And as years and years go on, I find this more and more often happening. Because it does happen. Some people, you know, have a different response to certain foods compared to other people. So some people don’t really see too much of an increase in blood sugars with oatmeal. And then I have a few people that that is, their postprandial blood sugars increase rather significantly. Even with the total amount of carbohydrates. So I think there is something to be said with that. Some patients, when they’re eating new foods expect it to have the same impact on thier blood sugars as other foods they’ve eaten. An example is quinoa. So some people who start to eat quinoa might think it has same type of impact on their blood sugars as rice does, and it might actually be different because of the protein content in quinoa being much higher than rice. Okay. So in terms of how to carbohydrate count, we have this little bit of like a conversion factor, if you want to call it that. Where a serving of a carbohydrate food contains 15 grams of carbohydrates. Now, the reason why this is such a helpful thing to understand, is because some foods have a lot more volume. Like you can eat more cups for example, of that food before it contains a total of 15 grams of carbohydrates, and other foods not so much. So the example I give, three cups of popped popcorn has 15 grams of carbohydrates in it. Two tablespoons of raisins has the same carbohydrates, 15 grams. So reading labels is really helpful to look at grams of carbohydrates. And that’s often how I kind of counsel patients is learn carbohydrate grams versus servings, but when you can give something like that as a comparison, it kind of helps people to understand “oh, so you know, I can’t equate different foods being the same volume amount, and having the same amount of carbohydrates.” Another example, a 1 ounce slice of bread is 15 grams of carbohydrates versus a quarter of a large baked potato is 15 grams of carbohydrates. So again, volume wise, that’s a lot different. That can be different. One medium piece of fruit is 15 grams of carbohydrates. So a medium piece of fruit, you kind of want to imagine like the size of a tennis ball is 15 grams of carbohydrates. Juice, it’s 4 ounces of juice is 15 grams of carbohydrates. I compare a lot of times milk and juice. So 8 ounces of milk is about 15 grams of carbohydrates, 4 ounces of juice. And this is where patients can kind of have some flexibility in terms of their own personal preferences. You know, some may say “I really want my juice in the morning time so I know that if I’m gonna have juice, I’m gonna have to be really diligent about measuring out 4 ounces, or if I want 8 ounces, I have to count that as 30 grams of carbohydrates, and then I might not have much more left over for my toast, and my oatmeal, and cereal and anything else that I may want.” But they can make that choice if that’s what they want. But to understand volume differences can be really helpful for guiding choices. This is a picture of the new label. Last year we were told that this was going to be mandated by manufacturers starting in July 2018. And now there’s some discussion about perhaps that being delayed. But I’m already actually seeing it on some of our products, is this new food label. There are a lot of changes that are being made. And I think there’s some good changes on here, but specifically for us when we talk about carbohydrates, is that you can see the total carbohydrate row here. And then listed below is dietary fiber, which we’ve always had. Total sugars, which we’ve had. And then there’s going to be this new one, which is added sugar. I mean I think to be honest, It’s a good thing. The reason I like that is that it’s going to give some accountability to manufacturers. Because how much they put- how much sugar that they add to their breads, or to their cereals, is that they’re gonna have to actually disclose that. So added sugars is what the manufacturers specifically added to their product. And so patients can use this to help kind of decide maybe brand to brand what’s maybe a better choice for them. But this does not remove the overall intention of looking at a food label, which is, it’s the total carbohydrates that impact our blood sugars. And so that’s what they need to look at when they look at a food label. And again, a lot of times they’re only looking at sugars or sometimes what they may do, is they may think that fiber and sugars is not included in that total carbohydrate row, and so some people will add that. And so I do make sure it’s clear for patients to understand that those numbers below the total carbohydrate row are already included. So really, the only thing they need to look at outside of the serving size, is the total carbohydrate grams listed on a food label. And again, the only time I might find is compare Oroweat Bread to Dave’s Killer Bread, how much added sugar do each of them have and then that can maybe help guide choices. But other than that, it;s the total carbohydrates. Okay. How much should people be eating? How much should we have carbohydrates at each meal and snack? Technically, it depends on a lot of things. It depends upon a patient’s weight, and what their goals are, what their activity levels look like, you know, how active are they at work? Are they sitting for most of the day? What medications that they’re on, and how far away are we at goal, in terms of their blood sugar control, that can sometimes help to kind of decide. But for our sake here today, a really good starting point for many people is to have them start with around 45 to 60 grams of carbohydrates at each meal. So if some some people want to start there and then we have them occasionally check postprandial blood sugars one to two hours after eating, and we can see where they are, we can make some adjustments where we can say okay, well you can technically have a little bit more if you’re really hungry, and you’re finding that a lot less and you typically eat, or remind you that your blood sugars are still quite not where we want them to be after meals, so let’s reduce that a little bit. I generally don’t recommend below 30 grams of carbohydrates at a meal. I think that’s too low if we go below that, and again, carbohydrates give us a lot of nutrition, energy, and fuel for for ourselves. So, I would not recommend below 30. So somewhere between 45 to 60 grams of carbohydrates per meal per meal. Not per day. Sometimes patients get confused with that. They hear “per day”, but I think it’s good to be clear, 45 to 60 per meal. And if you want to think about snacks, I suggest perhaps 15 to 30 grams of carbohydrates per snack. If the patient likes snacks, they find that’s helpful for them to have something between meals, so they don’t overeat carbohydrates or meals. That is, as I mentioned earlier, It’s not uncommon for me to see three times this amount of carbohydrates in a single sitting. Especially when eating out, especially when eating out. For some patients, this could be a significantly less than what they’re doing now. And if that’s the case, I suggest just slowly decreasing per meal until they feel a little bit comfortable with this. Okay lastly before we get into the apps, for some people carb counting is overwhelming. They don’t like it. They’re not gonna do it. So instead, this is a great suggestion for visual people. When they’re sitting down and have a plate in front of them is that half of their plate is those non starchy vegetables. So carrots, broccoli, cauliflower, or lettuce mushrooms, onions, any of those things. And then the other half of the plate is divided into quarters, one being the meats or alternative soy products perhaps, and then the other quarter is where those carbohydrates are. So that’s going to be the potatoes, or the rice, or the yogurt, or fruit for example. So that can be just a way of helping the when you first call it “anchor your plate” with those non-starchy vegetables, is that they’re just not gonna have that much more room left on that plate for those carbohydrates. So if they’re not willing to carb count, and you want to help them to reduce their total carbohydrates if they’re eating any (inaudible), this is something that you could potentially help them to kind of visually see. Myplate.gov has posters that helped this, it’s a little bit more colorful, that could be also useful for patients as well. One thing I didn’t mention earlier, is that anytime we start to carb count for patients I mean they’re kind of grasping it, and they’re counting them, and they’re trying to stay within their goal, is that some of them may experience some hypoglycemia. Especially if we haven’t adjusted their insulin. And we don’t ever want a patient to have to cover their insulin. So eat more carbohydrates so they don’t go low. Instead, we would want to work with them on reducing their insulin with the healthy carbohydrate level and helping them to not have a low blood sugar. So, that can sometimes happen. And then unfortunately if you’re not aware of that or giving the patient a heads-up, that as we slowly decrease their carbohydrates, we may see that some of them may say “Forget this. I’m just gonna eat more because I’m going to low.” So that’s something else to think about. Okay, so apps. So we’ve talked about MyFitnessPal before and Calorie King, and I just wanted to mention them again because I really do like these apps. And then the three new ones I have today are called One Drop, My Sugr, and then Glucose Buddy. So MyFitnessPal, there is an online and an app version. The free version is what most of my patients use. And then the premium version, I’ve got like three people that use it. Which you just get a little bit more reporting functions and information. But I certainly don’t think it’s necessary. It’s rated really pretty well. There’s a lot in the database that they already have within this. A program which is really great for many patients. It’s not really meant or set up for tracking blood sugars or medications, though. There is one note section where technically I have had patients indicate what the blood sugars are, and what they’re taking for medications, but there’s no reporting function from that aspect, and more useful for counting calories, carbohydrates, proteins, fats. Okay. Calorie King, we’ve mentioned this before. There’s that book that I absolutely love, many of my patients love it. It’s super small, in a sense that it can fit in purses or in the car. And there’s so much information, in terms of fast food places, restaurants, just general food items, where calorie, fat grams, and carbohydrate grams are included in this book. So it’s a great reference book. And there is also an online version as well. And an app available that it does allow for tracking blood sugars as well as carbohydrate intake. So that’s something that might be good to consider for some people. Okay. There we go. So now we have a newer app Which is called One Drop. It is available for free for Apple and Android devices. It has a rating of 4.5 stars, but it’s only been out for a short time here, so I wouldn’t be surprised if we see this go up. Because, not to bias everybody, but I really like this one. This one was really fun. And I’ll show you some screenshots here in a second, But what they actually did- They did a clinical trial, and they did two types of things. So the first one is that they just kind of monitored those who use the app, in terms of blood sugar control. And they found that those who were getting into it throughout the week, whether that was just once a day or actually a few times a day, found that their hemoglobin A1C went from 8.2 to 7.2 in two months time. So a 1% drop, I think is rather significant in a two month time period. But anytime patients have something that they get information from, reinforces what they should be doing, I think that motivates patients. And apps, I think are like the future. I think we’re gonna see more and more of these things available for for patients. They then also had what they called their “Experts Program”, and it’s available at cost. And I think it’s $20. I have a slide here in just a second, but patients can actually get coaching support from a certified diabetes educator. And in four weeks they found that average blood sugars went from 185 to 158. So it’s using the app, and then getting some support within that app, with suggestions and just accountability to carb counting, and exercise, and taking medications, and monitoring blood sugars. So, it is a feature within this, which is interesting. Within the app, so you can see on that first screenshot you see that drop so they can check blood sugars, they can enter in that blue one, is their medications. Basal-bolus and oral medications. They can then measure or add in what they’re eating, and then the last one, that orange one is for exercise. So this app allows you to do all four things. The middle screenshot you can see here, is that they just tap that middle circle which is this one, is the pink one or somewhat red, that allows them ti put their blood sugars in, and then you can actually get some feedback that when their blood sugars are entered, this white dot shows them if it’s somewhat elevated or low. So if it were a 300 blood sugar it’s going to come around a little bit more. So visually speaking, it helps people to kind of see perhaps how high their blood sugars are in a different way, outside of like an absolute number. I know it’s kind of hard to see, but down a little bit lower it allows people to kind of rate themselves on how stressed out they are, how their energy levels are, happiness and confidence, or you know, their care of their blood sugars. So, there’s added features within that. And then this is a screen shot I know it’s a little bit overwhelming, but I played around with it and what I did is I entered in like for a day, a random blood sugar number, insulin, I entered in Lantus and Novolog, they actually have a list of medications entered, so people just have to search for that. So I start typing Lantus, find it, and so they can actually account for what types of medications they have in there. And then at the top there, is that it will average out for the day what their blood sugars are. That 100% is how much of their blood sugars is above goal. So this is 100% of blood sugars being above goal, and that 0% is below goal. And you can actually modify that, specifically within the app what your goals are, high and low with the range. And then keeps track of the total units of insulin that has been entered into the app. So you can see here, at 74% bolus and then 26% basal. And then you see it tracks carbohydrates. You just- you can either enter in directly a certain amount of carbohydrates, or you can search for the individual foods being consumed. So I searched pizza, and English muffins, and bananas and it had a lot of that already in there, so then it will also track calories which I think is really great as well. And then also for steps, and then activity time. Great color coordination, in my opinion. Really easy to see that. Some additional features within this app is there’s a- they call them “food moments”, so there are recipe suggestions and with carbohydrate count information. This okay- so it’s $19.95, is what it would cost to get that experts program, access to the CDE. They have their own glucometer, where when you’re testing blood sugars is that, that information is automatically uploaded within the app. So this program have a lot of features. The last feature of this that I wanted to show you guys, is that it has a reporting function within the free version, which I think is kind of nice. And so it just does it in a different way, that you can actually send these reports to- the patient you can send it to you. So they can email it to you, or whoever that they want to. This is a different one that they have available. And then, I’m not sure that you would consider this a good thing or a bad thing, but when I emailed this to myself, and then when I opened up my email and clicked on the link, that brought this to view within my Google pages, is that it then alerted me on my phone that somebody was looking at it. So it lets them know that whenever anybody is looking at the reports that they send, they’re looking at it. But this is, I think a really easy graph. Good color coordination, again. It gives a lot of good information with how many times are they monitoring their blood sugars, how much in, below, or above range are they, what their insulin is, and how many units have they taken, and then their carbohydrates. So that’s One Drop. The other the other one is My Sugr. So it’s almost like this little sugar monster that you either make happy or you make sad, depending upon what your blood sugars are, or how many carbohydrates that you’re eating. This was started back in 2007 in Austria, so it’s been around quite a long time and it’s the rating of 4.7 stars. For additional cost, you can get PDF reports as well as access to a CDE as well. So that has the same feature in here. Here are some screen shots. You can kind of see on the left-hand side, entering a few things I’ve got ten points so far. Positive points, because average blood sugars, deviation from that, and whatever carbohydrates that you’ve entered. But there’s some good color coordination. And when you’re entering in your carbohydrates you can select breakfast, lunch, dinner. You can select how you feel, you can select if you’re having a low blood sugar, and it keeps track of that information. I have one patient that uses this and she really likes it. This could perhaps be used for somebody who might be wanting some fun with the type of an app because again you’re, you’re trying to make that little sugar monster happy. But these screenshots are just kind of features that you can add in. Again, your ranges, you can put in reminders for when you need to take your Lantus, or when you need to take your your Novolog. And you can even specifically enter in what your carb to insulin ratios are within that app. So it’s kind of already in there for you. So a lot of like, individualization that can happen within this type of an app that allow people to kind of, set it up for them. This is a whole day entered in, so a little bit different type of a screenshot here. But essentially similar information in terms of average blood sugars, how many highs and low blood sugars do they have entered, and then what’s the carbohydrates. I couldn’t report- or I couldn’t print, or show you guys the PDF reports because that only comes within the paid version. And I didn’t pay for it. So I was only using the free version. But that’s what apparently it looks like, so I pulled from their website. Okay, the last one, since we have a few more minutes, Glucose Buddy. So this is actually an app that’s been rated number one for the last nine years, in terms of diabetes management apps out there. I also really like this app. So apparently, I could only find that it was used for iOS devices, so I could be wrong about that, but when trying to search and see, I have an iPhone, so I was able to use it But I don’t, I can’t, couldn’t tell if it could be used for Android devices. One thing that’s a little bit different about this app, that I thought could be a positive for some patients who don’t always remember what medications that they’re on, is that they can- you can see that little like, grayed out area “name your medication”. So they can just write in there, or type in there I should say, what medications that they’re on. So it’s not them trying to find the right one It’s them being able to just put it in themselves. So that could be a good or a bad thing. But, you can add in what medications again, you’re taking, you can add in carbohydrate goals, you can enter in your blood sugars, you can enter in just carbohydrate value of a label that you’ve eaten, or you can add in individual foods that you’re eating, as well. On the left-hand side though, that screenshot there, is that you can add in your blood sugars, I know it’s not really great here, you can add in your A1C, your medications, I can’t tell what that- blood pressure, you can add in your carbohydrates or calories, you can add in your weight, and activity. So it seems to be a little bit more inclusive in terms of what you can get. That middle screen shot is not that great. So let’s go to that far right one, there we go. So this is where I was entering in blood sugars, insulin, and then carbohydrates. And so it does something similar to One Drop, which is great in my opinion, is it gets that top panel banner there which kind of shows for you what your average blood sugars are, how much insulin have you taken, what your carbohydrates look like, you can see I’m already at 500 grams of carbohydrates this day. And then what the activity is, as well. Great color coordination, I think easy to see. And navigation, I think within all of these apps, are pretty easy to kind of use, just to play around with. It does give some, they call it “insights” in terms of like, reports that you can get for averages, and insulins, and carbohydrates. And it can then on the far right side, also do for the week. So you can kind of see not just day to day, but then in a week’s time on the last seven days, some of the information that’s there. So those are the three that I played around with, and I think all of them were pretty good. Some that were- had other features that others didn’t, but I think all of them were pretty good in terms of ease to use and color and things that you could enter in. But I was curious if anybody had any other apps that they used, or have patients that use, that they’ve liked. Maybe you guys could share with us? Yeah! I’ve got- you mentioned My Fitness Pal, I think it’s called. I’ve got a number of people who use that. Awesome. Very good. (silence) Anybody else? Quick question not regarding the apps, but can you comment a little bit, what do you recommend your diabetic patients, as well as like overweight children regarding new like sodas, you know, with low calories, or a Coke Zero, and Crystal Light, and all these like new things out on the market? Sure, okay. So yeah, I mean some of the items in our food system where more calories and sugar are coming from, in our diet, are sugar-sweetened beverages. So it’s a good area to address for a lot of patients, including those that are younger. So we kind of work on some of those long term healthy eating habits, and get ahead of it, or address it sooner. So I encourage patients to first switch to non calorie beverages. So as you mentioned Crystal Lights, those ice drinks that are available, that are calorie free, that are carbonated. But I also really encourage patients to try water. And to really understand that water is really important for us, and that it takes time to get used to it. People who are used to drinking a lot of sugar-sweetened beverages, water, it’s gonna taste terrible to them and they’re not going to like it and they’re just non going to drink it. So one way of helping them, is that I’ll encourage that they either dilute whatever it is that they’re drinking, that has calories in it. And slowly kind of reduce that, especially when it comes to juice. Diluting it. Or, a lot of times I’m seeing more and more people being open and liking fruit infused water. So whether they are throwing in frozen strawberries or frozen pineapple into their water, or you can actually get some of those more formal water bottles that have like, that insert. But that would be what I would suggest to help patients. But the other thing is can patients, can children have you know, some of these non-nutritive sweeteners using Coke Zero using Crystal Light, some of those those sweeteners that we have available? And as long as they’re not consuming, I mean the high recommendation for safety, for like aspartame, Splenda, Sweet and Low, it amounts to a high enough level that as long as we’re not encouraging all beverages being diet sodas or Crystal Light, I think they can have one a day. So the high level is a six-pack of diet soda a day before we start to reach levels that are probably unsafe for those non-nutritive sweeteners. So again, I think one a day would be fine, but I think we should talk to them about drinking water. And we’ve got to get used to it somehow, and it’s something that’s going to help them long-term. And that it’s okay if it’s something that they don’t particularly like in the beginning, but it takes time, so. Does that help? Yes. Thank you. Yeah, of course. I have a question over here. Yeah! So, my question is in regards to hypoglycemia treatment. So like, if a patient experiences a hypoglycemic event, you know, and they follow the rule of fifteen and try to correct it, do you recommend, you know, patients eating like, a high-fat meal after they treat they hypo to kind of help prevent, to drop- you know, prevent whatever it is that dropped off their sugars? Or do you just recommend they just eat something? What do you- What are your thoughts on- What do you guys do? Great question, great question. So a lot of times, what we use for many patients is our fifteen-fifteen rule. Is if they have a blood sugar and that’s technically low, or they’re not feeling the greatest, is to have 15 grams of carbohydrates after they’ve measured what their blood sugar is. What you know, making sure that it’s it’s below a certain number, below 70, or 80 or 70. Eat 15 grams of carbohydrates, wait 15 minutes, and check it again. Make sure that it’s coming back up. As long as it’s come back up, I am okay with telling patients to have a little bit of lean protein. So maybe a string cheese, maybe a couple slices of some meat, and, but it’s a small amount or they should go have their meal if it’s time to eat a meal. So I don’t necessarily recommend a high-fat specific item. I usually recommend that, if they have in the past struggled with after they’ve gotten it back up, and it doesn’t stay up, is to then add in a lean protein to go along with it. But generally speaking, in my experience many patients struggle with this. And they over consume carbohydrates because they feel so terrible. And so, it’s talking through some strategies on how to help them really stick to those 15 grams of carbohydrates so they’re not over consuming, because now we’re just, we’re on that roller coaster all day long, of highs and lows. And a soda, for example, is often one that I see a lot of patients will use. They’ll get a 20 ounce regular soda, they’ll drink from it until they feel better, and then they go high. So I counselled them a lot on, what does 15 grams look like? Wait 15 minutes, check again, see where they’re at, and then they could eat a lean protein if they needed to. But I don’t always recommend it, if they can overdo it. Okay, any other questions before we finish up for today? Alright, thank you so much everyone. Thanks, see you next month.

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