1 Carb Counting and Insulin Administration Module Georgia Hospital Association Diabetes Special Interest Group

2 Program Objectives  Define basal bolus insulin therapy  Define carbohydrate (CHO)  Identify the carb content of various food groups

3 Program Objectives (cont.)  Calculate carb content by reading a food label  Calculate the carb load in a sample meal  Calculate meal insulin dosage using carb/insulin ratio  Calculate initial Total Daily Insulin (TDI)

4 BASAL BOLUS INSULIN THERAPY  Calculate initial Total Daily Insulin (TDI): Adjust Pre-Admission TDI considering for change in diet, stress, meds, etc. OR Calculate Weight (kg) x 0.5 units = TDI for Type 2 (consider using 0.3 for renal impaired or 0.4 for Type 1)

5 Next  Give 50% as Glargine or Detemir (This is the BASAL insulin.)  Give 50% divided in thirds or 17% per meal as rapid-acting insulin analog (This is the MEAL BOLUS insulin to cover the carbs consumed at the meals.)  Give in proportion to CHO consumed at meal if patient is carb counting or give divided equally in thirds for consistent carb meals.

6 Another way to calculate the meal bolus insulin is to estimate the carb to insulin ratio.

7 Calculating the Carb to Insulin Ratio  If previously on insulin, divide the total daily dose of insulin into 600. This will estimate the CHO ratio or how many grams of CHO 1 unit of rapid acting insulin will cover. Example: 600/60 = 10 Therefore, 1 unit will cover about 10 grams of CHO

8 Calculate the Correction Factor “CF”  If BG >140 mg/dL: (BG-100) / CF = units of rapid acting insulin (This is the Correction Bolus.)  If the Total Daily Insulin is known, then CF = 1700 / Total Daily Insulin OR  If the Total Daily Insulin is not known then CF = 3000 / Wt (kg) Do Not Use Correction (Sliding Scale) Insulin as the Only Diabetes Management Tool

9 Insulin Administration Guidelines  Test capillary blood glucose before meals, bedtime and when appropriate at 3 AM.  If BG is in target range at meal time give the meal bolus within 15 minutes of the start of the meal  If the BG is above target range at meal time give the meal bolus plus the correction bolus

10 Guidelines continued  The basal insulin is administered whether the patient is eating or not.  Corrections are given whether the patient is eating or not.  The meal bolus is held if the patient is not eating or is adjusted based on the amount of carb consumed at the meal.

11 Carbohydrate Counting  Counting just the carbohydrate in the food eaten is one method for meal planning that works well for many people with diabetes  Carbohydrate counting focuses the attention on food choices that most affect blood glucose levels

12 Fixed or Flexible Meal Plans  The carbohydrate at each meal or snack may be consistent from day to day or flexible, depending on the type of carbohydrate counting meal plan used.  Carbohydrate affects blood glucose more than any other nutrient.

13 Carbohydrate Facts  One of three major energy sources in foods  Most common carbs are sugars and starches (chains of sugar)  Carbs are primarily found in milk, fruit, starch and starchy vegetables  Carbs are also in honey, molasses, syrup and sugar

14 Nutrients in Food CHO has the greatest effect on post meal blood glucose

15 Nutrients in Food Groups

16 “Diabetes Food Lists” CHO Starchy Vegetables & Food Groups

17 Approximately 15 grams of CHO per serving Reference: Life with Diabetes Third Edition, American Diabetes Association Starch Group

18 Approximately 15 grams of CHO per serving Reference: Life with Diabetes Third Edition, American Diabetes Association Fruit Group

19 Approximately 12 grams of CHO per serving Reference: Life with Diabetes Third Edition, American Diabetes Association Milk Group

20 Approximately 15 grams of CHO per serving Reference: Life with Diabetes Third Edition, American Diabetes Association Other Carbohydrate Group

21 Approximately 5 grams of CHO per serving Reference: Life with Diabetes Third Edition, American Diabetes Association Vegetable Group

22 Sample Meal Plan 1800 Calories Breakfast (60 grams CHO)  4 CHO x 15 g = 60 g 2 Starches 1 Fruit 1 Milk Protein (1 ounce)  1 Fat  Free Foods or Beverages totaling less than 20 calories Lunch (60 g of CHO)  4 CHO x 15g = 60 g 3 Starches 1 Fruit  2 servings of Vegetables Protein (3 ounces)  1 Fat  Free foods or beverages totaling less than 20 calories Dinner (60 g of CHO)  4 CHO x 15 g =45 g 2 Starches 1 Fruit 3 Vegetables x 5 grams per serving = 15 g  Protein (3 ounces)  1 Fat  Free food or beverage totaling less than 20 calories Bedtime Snack (15 g of CHO) 1 CHO = 15 g 1 Starch, fruit or milk  Protein (1 ounce)  Free food or beverage totaling less than 20 calories

23 “Carbohydrate Counting” 1. Look at the “Serving size” 2. Look at the “Total Carbohydrate” in grams 3. Subtract half the fiber (if greater than 5 grams) and half the sugar alcohol (if any listed) from the “Total Carbohydrate” 4. This is the amount you will Cover with insulin

24 Count the CHO in This Sample Meal Plan  2/3 cup pasta  1 oz. slice garlic bread  Meat tomato sauce  1 small salad  ½ cup cooked broccoli, cauliflower  1 cup unsweetened tea  1 packet of low cal dressing (3 grams of CHO)  1 packet of sweetener (1 gram of CHO)  ½ cup lite fruit

25 Answer This meal is approximately 60 grams of CHO: 2/3 cup pasta = 30 grams of CHO 1 oz. slice of bread = 15 grams of CHO ½ cup lite fruit = 15 grams of CHO  We count the CHO in the fruit, milk and starch groups.  We do not count the vegetables unless there are at least three servings.

26 Practice Carb/Insulin Ratio  If patient weighs less than 150 lbs: Total CHO in grams divided by 15 = number of units of insulin for meal bolus Example: 60 grams = 4 units of insulin 15  If patient weighs 150 lbs or more divide total CHO in grams by 10 to find the units of insulin for meal bolus Example: 60 grams = 6 units of insulin 10

27 Estimating Meal Insulin Dose  If patient is on 1800 calorie diet he/she usually receives about 60 grams (4 carbs) at each meal at a hospital. If the patient plans to eat all of the meal, give the meal bolus as ordered by physician. If the patient eats half the meal or more exactly half the carb, give half the meal bolus If the patient skips the meal, do not give the meal bolus, but do give the correction bolus if BG is above target and you have orders for correction insulin.

28 Nursing Judgment  The nurse may give the meal bolus within 15 minutes of the start of the meal if the patient is not a reliable eater.  If the patient is a reliable eater the nurse should give the meal bolus with the meal.  If the meal bolus has been given and the patient failed to eat adequate CHO load consider substituting liquid CHO for the solid CHO that was not consumed. Example: 1/2 cup apple juice = 15 grams of CHO This should be done as soon as possible to prevent hypoglycemia.

29 Summary  Up to 100% of the carbohydrate can be changed into BG in your body  You can estimate the carb load for your patient’s meal by adding the grams of carb found in fruit, milk, and starch on the tray  You can also use the food label to find out how much carb is in a serving size by reading the total carb and subtracting half the fiber and half the sugar alcohol.

30 Summary (continued) There are three components to subcutaneous insulin therapy: Basal insulin to control blood glucose between meals Meal or prandial insulin to cover the CHO load at the meal Correction insulin to bring a high blood glucose into target range.