Diabetes and Carb Counting in Japan

So I wrote this post a while back and I feel that it’s not nearly the catastrophe that I was initially shocked by. True, some things are a bit off par to what I have learned, but time has allowed me to see that the things I have learned in US help me survive as a diabetic.

Now, I’m more concerned about spreading what I have learned in the US with other Japanese type ones. I think that through this avenue, I can hopefully reach out and help other type one that might be stuck in an monolithic view of T1D treatment.

Anyway, on to the main post from last month…

So I asked a bunch of people last month about carb counting here (Carb Counting Insight) and I got a lot of responses. I did this mostly to prep myself for an upcoming meeting with Endo in Japan. I did a bunch of digging before hand and learned how diabetes treatment in Japan is so very different from the US. I get a bit unnerved when I heard that this country is behind the 8 ball, and I can only wonder what people with diabetes in Japan deal with on a day to day basis.

This was the first time to be seen by a doctor in Japan for diabetes, and I really wanted some sort of informal consensus on what carb counting was to those of us in West.

I found it really strange coming out of the nutritionists’ office, getting an explanation of what carb counting was contrary to what I learned in the US. I was basically told that carb counting is ‘diabetic exchanges’ in disguise (and they told me the only difference between the US and Japan is that the exchange in Japan is 10g carbs = 1 carb exchange whereas 15g carbs = 1 carb exchange in the US).

Some surprising highlights from the carb counting class was that all vegetables, sans squash and a few others are ‘free’. That pasta raises blood sugar slowly, and that a serving of beer is always one carb (10g carbs…). The ‘classroom’ included a table filled with wax fruit and vegetables… portion sizes of the vegetables were surprisingly small… I knew the answer I was about to get when I asked about broccoli- that I typically eat 100-150g of broccoli. I was told that it is still ‘free’ (and not count it…)

When I asked about dietary fiber, I had this feeling that I was going to be told to subtract thing like fiber when carb counting… Never once have I heard not to subtract fiber from a carb count. never… until last month. It’s not like Japan uses ‘net carbs’- they just don’t subtract fiber completely. What doesn’t help is that most food labels do not include dietary fiber in Japan. This includes foods high in fiber, such as peanut butter, beans, etc…

So, as for myself, I’m sticking to what I learned in the US (and on this forum), but I’m wondering if anyone has experienced anything quite like this. Are there any other -developed- countries that seem to be faltering T1D care?

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No other-country experience to report; however, I do have a couple comments.

The carb-counting is just a pseudonym for exchanges is weird, but sorta meaningless, IMO, assuming they’re still telling you to dose your insulin based on how many “exchanges” you’re eating. Does it matter if you count by 1’s or 10’s? When I decided to switch from the Sliding Scale that my endo had me on to carb-counting, my ex-endo told me that carb-counting is just another type of sliding scale, only one that requires a LOT more work. (Nevermind, that the SS involves constantly chasing your tail, instead of trying to prevent problems!)

As for vegetables as “free” … sounds like they’re oversimplifying, most likely for people who won’t correctly deal with complexity. From what I’ve seen/heard, the response to vegetables varies from person to person as much as anything else about diabetes. I can’t ever quite get sweet potatoes right, but pumpkin is as pie (pun intended), and Brussels sprouts are like eating green potatoes to me! Others, not so much. Blackberries send me to the moon, but I can eat watermelon like, well, water. Again, others find just the opposite. Like you, I don’t count broccoli (or cauliflower) and eat it like a poor-substitution for candy, when it’s available. Fiber, well… I count it – whether it actually counts or not, I have not determined, but counting it works out better for me, than not.

I know there’s a lot of talk about the poor care for T1D in the UK (and let’s not even get started on their approach to T2D - GAH!!) – maybe not in these areas, but in terms of availability of various options. I don’t know how true that is in practice - only what I’ve heard (so please don’t flame me, dear friends in England!). I’m guessing there are challenges to overcome in every country - some in terms of knowledge/approach, as you’re finding in Japan, some in terms of cost like in the US, and others in availability of tools, such as CGMs and pumps to the general population. By the same token, I imagine there are also benefits in each place over the others. Wouldn’t it be nice to have the best of all in one place?? Or better yet - everywhere??

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The exchange system is what I learned when I was first Dx’ed in 1984 and I think that most dietitians and PWD would consider that to be pretty old school. I’m not sure when they changed to carb counting and MDI here, as I went quite some time without seeing a doctor at all however when I came back, maybe late 90s early 00s, I had sort of come up with my own MDI scheme using R/NPH but didn’t conceive of “counting” as much as “guessing” which caused considerable weight gain. Part of the exchange plan was that the AM NPH was recognized to be “peaky” so the theory was that your AM NPH “peak” would hit at lunchtime to cover lunch. The plan would also be to eat the same amounts of food at the same time every day.

I didn’t really start carb counting until I got my pump so it was like a lightbulb going on and started working much better, pretty much right out of the box. I probably blame the pump but I suppose that carb counting certainly helped!

I haven’t ever bothered counting fiber. Whenever I eat whole grainy types of stuff, they seem loaded with hard carbs so I count without discounting the fiber at all.


That matches my experience (DX’d in 1983) and yes, I think the whole exchange system reflected the fact that the predominant treatment, R/NPH, didn’t really allow for anything else. Which is why what @Peter16 was told in Japan seems so out of kilter–like insulin has advanced so why stick with this musty old way of doing things. Seems analogous to the “You’re doing fine let’s not change anything” schtick a lot of us have run into over here, though. I was stuck on R/NPH for far too long because of non-specialist PCPs with that attitude. You do expect specialists to be more current, but I think in the profession as a whole there’s a reluctance to do things differently from what has come to be anointed as Standard Treatment. Maybe more of a reluctance in some cultures than others–I don’t like to generalize but I do have the impression that Japan is very conservative in a lot of ways (“The nail that sticks up gets the hammer!”), but it’s not like outmoded treatment regimes aren’t inflicted on people here too. Plenty of stories here on TuD illustrating that.


My understanding is that the US practice of “counting” a carb as 15g was a remnant of the transition from the exchange system. Unfortunately most of the world (including the US) teaches the philosophy that you should be able to “medicate” to adjust for “normal” eating. In the UK they actually call their carb counting approach Dose Adjustment for Normal Eating (DAFNE). And “normal” eating is following the guidelines associated with the SAD (Standard American Diet) which for an adult male consists of 300-500g of carbs a day. So it is easy to see how someone on a high carb diet can ignore low carb parts of their diet as well as just ignoring fiber.

And a common pattern is that the US often sets the “lead” for practices such as diabetes care (and carb counting) and the rest of the world follows. But by following the rest of the world may lag the US by 10-20 years. Even in a developed country like Japan or UK you see this pattern.

Personally I don’t believe that those of us with diabetes should eat a high carb low fat diet like the SAD. We should at some level control and restrict the carbohydrates in our diet and then medicate only as necessary. It just seems foolish to eat with abandon and then hope we can medicate to cover that mistake.


I agree @DrBB and @Brian_BSC, though, what Peter didn’t say is how they’re using those “carb exchanges.” In the old “Diabetic Diet,” the plan was to eat a certain amount of macro-nutrients every day, which they identified by portions or “exchanges.” I think they idea was just to simplify the process on the assumption that most people aren’t detailed enough to identify how much of what is in their food. A secondary issue with that plan was that they recommended a fairly high-carb, low fat approach, though it wasn’t the essence of the “exchange” system. My mother followed such a diet as recommended by Mayo Clinic somewhat successfully for many years – she didn’t lose and weight on it, but didn’t suffer and diabetes complications – of course, that doesn’t mean it works well for anyone else! I’ll admit that my “bad days” have a lot higher carbs, but 300-500g a day, every day, and I wouldn’t fit through my front door!! :dizzy_face:

I’m curious to know the rest of the details of the Japanese plan as laid out to @Peter16. How does dosing work?


FWIW, my memory of the old exchange thing was that you had a sort of budget for the day, and there were all these tradeoffs that also included things like fats–e.g., cheese–as being worth x portions of an apple and the like. I don’t remember there being any specifics about grams of carb, though it may have been in there somewhere. Mostly I remember that it was such a p.i.t.a., and such a depressing medicalization of my life at a granular level, that I mostly blew it off and just played it by ear on general principles.

OT, but thinking about those days reminds me of the little booklets and whatnot they gave out about this stuff when you were newly dx’d, and how they were invariably festooned with depictoins of Healthy Old Folks riding their bikes and whatnot. Now there seems to be more diversity in how they depict PWDs, but back then, as a newly dx’d guy in his 20s, that stuff really added to my frustration and resistance to the whole business. I knew it was silly but on some level it really did p*ss me off. I used to joke about having been diagnosed with Old Fart’s Disease (not that I’d say that now–I think I qualify for the term myself, for one thing).

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My first reaction to your Japanese experience, @Peter16, is the whole feeling I get with such a health policy. It makes me revolt at the patronizing paternalistic system. To be fair, this is a policy aimed at a population with a broad range of literacy, numeracy, and level of motivation. They’re just trying to help the most people and harm the fewest. That’s actually noble on the face of it.

For someone like me, however, I feel like they’re dumbing down diabetes and losing their chance to treat it better. They’re assuming I have little facility with numbers and trying to make it simple so I can succeed. As someone who is comfortable with using math in everyday real life experiences, I resent that. I resent that the policy has mediocrity as its goal and doesn’t even address the more capable audience with an upgraded option policy that permits them to do better.

Now I know that I don’t represent the average diabetic but I feel much better that my diabetes regime is finely tailored to my abilities and preferences. It is after all, my health!

Thank you for writing about this.


Hey, I was definitely diagnosed with OFD! Worse, the T2D diagnosis came on my 50th birthday! I told my parents that they should have opted for the “Extended Warranty” when I was born!

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Well said Terry. As I say to my Doctor “You are not walking with my feet.” He is concerned about the number of hypos I have. My hypo awareness although low at 2.8 - 3.0mmol/L (45mg/dL) has not changed since the day I was diagnosed as T1. Listening to what your body is telling you gives the best results.

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You know–perhaps I was fortunate in one way—I stormed out of my doc’s office so fast, and in such a state of rage, that all I got was the truly surreal, sh***y HappyHappy brochures just like @DrBB described. Nobody had a chance to describe anything else to me. In retrospect, I am glad.

So I only encountered the concept of exchanges through devouring every used book on the subject of diabetes from Powell’s (just google Powell’s in Portland and you will see that means a Lot of books, many still quite current). It immediately presented as much too cumbersome.

My strength as an artist–as a choreographer–was my ability to “boil down” a very large subject to its essences in search of the universal. As applied to this new challenge, it rapidly became apparent that the “essence” of my body’s difficulty was carbs. Just count the damn carbs. So that is what I do.

I also know a bit about the gorgeous, ancient cultural traditions of Japan. But really, aren’t all our various healthcare systems or non-systems, juggling the wellbeing of their diabetic populations with the economies of entrenched food systems. Our ADA needs money from Macdonald’s or their ilk. In Japan, maybe it is that their very healthy ancient ways of eating are being invaded by MacDonald’s or their ilk—Hehe…

Goodness—Call me Carried Away. Sorry. Blame it on my friend, @DrBB who set off a stream of nasty memories…Blessings all…One of the very best things about TuD is its global membership, so I’m sure we have some international members who can put me in my place!..Onward–that’s my family Mantra at the moment…

I learned carb counting at the Joslin Clinic in Boston and their counting method treats green vegetables as “free”. I’ve been counting that way for years with no problems.

I don’t eat pasta (other than Annie’s frozen lasagna) but I did learn how to eat pasta for a visit to Italy in 2011. I had to reduce my insulin dose by 20% and then test every hour. I usually started going high at around 4 hours out.


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I guess to start with, I should clarify that I’m seeing a doctor that studied in the United States and understands carb counting to a fair extent- the hospital however has a different understanding of carb counting.

An additional point would be that this hospital, being a university hospital, is a bit more advanced than other hospitals and clinics in Japan. I asked many hospitals if they did carb counting, and most used fix dosages or sliding scales. This explains how I got where I am. If I just went to the first hopsital I went to, I may have been stuck with a fixed dose of insulin every day (without corrections!)

So first of all, Thas asked about exchanges and such-
I think that the way you describe exchanges is exactly as they hash it out in Japan, with a few added twists (almost like a Nationalistic twist). I would say that Japan seems to follow this plan for a few reasons. One, that I notice, is that it’s designed around that the average restaurant serves. If Japan is behind on diabetes science, then they are also behind on providing nutritional information (forget about ‘accurate’ nutritional information). The other reason is that many men don’t cook and end up eating out after work.

While the nutrition class gave me an idea about how Japanese people are educated about exchanges, they do not seem to be educated in good eating habits (more veggies, less rice).
They recommend we eat 60% carbs, and the rest (I can’t remember) protein and fat in our diets every day. That said, the average restaurant serves between 150g to 200g rice and very few vegetables. Most ‘lunch boxes’ sold at convenience stores have about 90g carbs- double what I eat in a meal.

As far as some more information-
Another thing that I forgot to mention was about testing blood glucose. It’s my opinion that post meal readings are critical in achieving good A1Cs, Hospitals rent out meters to patients with 120 test strips a month- appx 4x a day. Additional strips are purchased by the patient without coverage from insurance. The question that I haven’t answered is- would a Japanese person with diabetes feel that testing four or fewer times a day be ideal?

I’d have to agree with Terry4, they are really dumbing it down. I got scoffed at more than once by the nutritional nurse for asking questions… the tone was be quiet and listen and walk out learning something. I learned that the system I learned in the US was keeping my A1C below 6.0.

And with that, my A1C of 6.1 was highly applauded. I’ve mentioned that A1Cs of 7 are seen as normal. I told my doctor that I expect to push myself between an A1C of 5.5 to 6, regardless of the lows I seem to get.

That brings me last to newbeach’s comment. I think that since I’ve been in Japan, I’ve noticed what my real ‘operating’ low blood sugar is. Even 70 works fine for me. I think I was stuck in a rut for the past ten years. That said, the concept of listening to your body seems to defy the logic behind diabetes care in Japan. This is partly to blame for how endocrinologists communicate with the healthcare system in Japan. While I’m on a insulin: carb ratio, the insurance company only sees the average number of units I inject- not my actual I:CHO ratio that varies day by day (again, as I mentioned, there’s a large population of T1Ds in Japan who are on fixed doses).

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There is actually a dietary recommendation from the Japan Diabetes Society. It is actually quite interesting given that the US dietary guidelines (DGA) were just revised. Here are some interesting points:

  1. They say that food exhanges are commonly used, but they don’t “recommend” them and note they are difficult (and I see not even a mention of carb counting)
  2. They recommend 50-60% of calories from carbs with the argument that this is what “people” eat and nobody can agree on an alternative
  3. They recognize that sugars (carbs) raise triglycerides (the US DGA doesn’t)
  4. They recommend minimizing fruit because of high sugar content (the opposite of the US GDA).
  5. They lump saturated and polyunsaturated fats together and recommend keeping them to less than 7 and 10% respectively
  6. They note that too much salt may be bad and then suggest you limit yourself to 6000 mg/day. The US DGA kindly “raised” the limit to 2300 mg/day.

ps. The same practice guidelines also has a section which says that self monitoring blood glucose is important but makes no recommendation on frequency or actionable strategy.

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how interesting

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I’m curious about that–would this mean those people are on R/NPH? I was on a fixed dose when I was on that regime in the bad old days, but it’s hard for me to imagine what that would mean with lantus/novolog MDI.

Sounds like basically what they’re saying is that there is absolutely no way they’re going to get people not to have cupfuls of rice at every meal. The US is actually pretty exceptional in that we don’t have a national staple, which is a near-universal thing in the non-Western world. When we were in Zimbabwe years ago we visited an elementary school and the first question they asked was “What is your staple meal?” For them it was sadza, a kind of paste-porridge of mashed white maize. We were stumped for an answer, and they were equally stumped that we didn’t have one. For them, it was a key marker of who they are as a people. If you told a Shona person they couldn’t eat sadza they’d be really at a loss. Japan of course is “First World,” but I think throughout Asia rice is so fundamental that telling people they can’t have it is almost like telling 'em they can’t eat.


I’m a long ago immigrant to France. I say take what you like of each culture. How fortunate we are!!! Of course communication with doctors and hospital is more difficult but from what people write here, it’s difficult in the State’s too. Depends on your Doctor. you seem to know how to take care of your diabetes: continue! And maybe get your message over to your doctors or to others. i know my Doctor is very interested in sharing.

People are teaching what they learned. From what I hear there are less diabetics in Japan than in other industrialized countries. Is that true Peter? Tell me how you like it there other than your care?

I wish you my best and I wish you the least amount of frustration possible! :relaxed: It is really interesting to see how different cultures cope with diabetes. Thank you for sharing!

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The experience of “Being T1 Abroad” really gives you a unique angle on foreign cultures. What you describe about Japan, however retro it might be in some aspects, is miles and miles advanced over what I experienced in rural China. Where we were among the Jingpo people of Yunnan Province there was basically no knowledge of the disease at all, which made things difficult because the Jingpo have a strong hospitality culture–it can be an insult to turn anything down–and an exceedingly high-carb diet. We were there for my brother’s wedding to a Jingpo woman, and the big celebration aspect exacerbated the problem. Hm, how much should I bolus for this leaf-wrapped ball of rice the size of a baseball and dripping in honey? Not to mention explaining why I was injecting myself, in a region overrun with Golden-Triangle heroin smugglers. Fortunately my brother’s BIL-to-be, Tulum, was/is a surgeon, spoke English pretty well, and was acting as our guide and translator, so he was able to more or less explain things. But people clearly didn’t fully understand what he was talking about. He told me this was because there was little enough access to standard medical treatment in the area let alone specialized pharmaceuticals like insulin, so basically if you have T1 you’re just gonna DKA out and die. They’d just think of it as some kind of wasting sickness. He told me he knew of a case like that in the village a few years earlier.

In any case it was interesting managing T1 just for the five days we were up there. “Interesting” in the sense of being a little scary in some ways. We’d left the bulk of our luggage down in the city because it was a 3-4 hour hike up to the village at 7000 feet. I thought I’d brought enough stuff along to be safe (I was on Lantus-Novolog MDI then), but I ended up having to use so many test-strips that by the end of the week I was down to a single one that I was holding on to for an emergency.

I expect it’s different in the cities, though I didn’t have any direct experience of that while we were traveling around after the wedding. But I do know the medical system incorporates traditional concepts like qi and herbal treatments etc. I’m sympathetic to up to a point–whatever the little street clinic gave my wife for the nasty diarrhea she got from that restaurant in Guilin worked extremely well—but I’m not sure what I would have faced if I’d had to go that route. Fortunately I’d brought along more than enough of my own supplies and didn’t run into any problems. I do know that China is in the midst of a huge D epidemic, as it has been described, so presumably they’re going to have to up their game at least where T2 is concerned.

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Hello @Mari5…So nice to meet up with you again. I always enjoy your posts and your overseas perspective…Hope all is well with you and wishing you and yours a great New Year!..Judith in Portland

Greetings to you Judith. Thank you for your kind words.
I hope I have not been off the subject. There are few people here who count carbs, it seems to me. But I live in rural France. The ones that do count carbs are type 1s with pumps who are followed up in university hospitals. When I got my pump in 2006, I had no information on counting carbs. But a year later doctors started talking about it and I had my training in 2010. It is called" insulinothérapie fonctionnelle". ( which means basically carb counting and adjusting your basal , bolus ration, etc.) Sounds pretty fancy huh? :slightly_smiling:The others use as indicated in your different mails: more or less fixed meal plan with equivalents.

I can imagine how worrisome it can be but I’m sure in a crisis, the medical teams in Japan (or in France) will be able to cope. Sounds much more difficult in China as DrBB says. Good luck, Peter.

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