Carbohydrate Counting Educational Assessment Tool (CC-EAT)


Effective education is important in the management of children with type 1 diabetes (T1D). Assessment is an integral part of any educational programme, ensuring specific learning goals are achieved. Carbohydrate counting is a method used to manage T1D. There are no assessment tools for carbohydrate counting for primary school children, so an age-appropriate carbohydrate counting assessment tool for primary school children with T1D was developed. This would ensure that, by the time the children moved to secondary school, they had good carbohydrate counting knowledge. The assessment tool was piloted and reviewed by leading dietitians in the field of diabetes and trialled by dietitians. The results show that it is effective.

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Effective education is key for children with T1D, to help them successfully manage their condition and become independent. Assessment provides a baseline of knowledge and a method to ensure that specific learning goals are met. It also helps the educators to evaluate their teaching methods and approaches. Carbohydrate counting can lead to improved HbA1c. With the development of medical technology such as CSII and increased knowledge of the effects of dietary macronutrients on post-prandial glucose levels, such counting has become increasingly important. A literature review of 30 peer-reviewed articles revealed one carbohydrate counting assessment tool for children with T1D over the age of 12 (Koonitz 2010) and none for children under the age of 12. Moving to secondary school is a huge transition and ensuring that carbohydrate knowledge is good before leaving primary school helps the process. The tool also needed to be used by any dietitian who gave carbohydrate counting education to primary school children with T1D.


There is no accredited carbohydrate counting education programme so the Goals of Diabetes Education (2016) were used. This has age-appropriate educational goals, including goals for carbohydrate counting. A primary school teacher reviewed every assessment test to ensure its content was age appropriate, that the language was suitable and that there was continuity through the age groups. She was especially helpful regarding the scoring system. The first trial of the tool used local food pictures. The Bath area has a population of 10% non-white British, below the average 20% non-white British in the UK. To ensure that the assessment tool was suitable for all ethnicities and cultures, 50 primary school menus from Birmingham, an ethnically and culturally diverse city, were viewed online. A group of Year 6 children tried out all the assessments and gave valuable feedback. Some of the parents were teachers and their feedback regarding age-appropriate norms was particularly helpful. Children from other year groups also tried the tool and gave good feedback. It was important to get comments from leaders in the field of diabetes dietetics, so the assessment tool was sent to four such dietitians and their comments were incorporated into the final tool developed. Dietitians in the South West Paediatric Diabetes Network (SWPDN) were asked to trial the tool using a protocol developed to see if it was effective. All results were anonymous. The only information given was year group and gender. An online survey was sent out to dietitians for feedback.


Although the numbers who have completed the trial are low, early results show that the tool is effective. The assessment revealed that one participant in Year 6, who has an excellent HbA1c, had poor knowledge of carbohydrate counting, as his parents did it for him. The assessment also showed that his overall knowledge of diabetes was poor. He was given extra education so that he could manage his diabetes independently at secondary school. In the pilot, one participant in Year 2 was having difficulties in the classroom. He scored well in his age-appropriate knowledge of carbohydrate counting and this was shared with the teacher. The child’s confidence increased and there was an improvement in his behaviour at school. Another participant in Year 5 with poor diabetes control showed age-appropriate knowledge of carbohydrate counting. The dietitian could step back, allowing other members of the team to help improve the participant’s control. Feedback from the dietitians showed the assessment tool was effective and it would guide them in their provision of education. The children reported that they enjoyed doing the assessment.

Sustainability and Spread

It is hoped that continuing with the trial of the assessment tool will produce further results to show its effectiveness. Assessment is an integral part of education in the management of T1D. The plan is to send articles to peer-reviewed journals, such as Diabetes Care in Children and Young People, to share this message with a wider audience. The goal is to have the tool with the scoring system on the SWPDN Resource page for all dietitians to download. If the assessment tool is used nationally, when a child with T1D moves to a different service area, a record of the carbohydrate counting assessment will let the receiving service know the child’s carbohydrate knowledge. At present there is no cost, except time, attached to the project. There will be a cost to review and update the tool in the future. It is hoped to develop partnerships with other stakeholders, such as Diabetes UK, where there is a robust reviewing process. The NHS plans to be paperless by 2023 so development has started on an assessment tool app. Currently the project is run by volunteers, but a media business that works on NHS projects has offered help. Using mobile technology gives the children comfort and a familiar experience, which helps to break down barriers.

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QiC Diabetes Commended 2018
Diabetes Education Programmes – Children, Young People and Emerging Adults
Carbohydrate Counting Educational Assessment Tool (CC-EAT)
by Royal United Hospitals Bath NHS Foundation Trust


Anna Carling

Job title:
Senior Dietitian
Place of work:
Royal United Hospitals Bath NHS Foundation Trust


Quality In Care Diabetes

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  • 2021 KEY DATES
  • Open for entry:
    Tuesday 20 April 2021
  • Extended Entry Deadline:
    Monday 12 July 2021
  • Judging day:
    Tuesday 7 September 2021
  • Awards ceremony:
    Thursday 14 October 2021