11

Carb Counting and Insulin Carb Counting and Insulin Administration ModuleAdministration Module

Georgia Hospital Association

Diabetes Special Interest Group

22

Program ObjectivesProgram Objectives

Define basal bolus insulin therapy

Define carbohydrate (CHO)

Identify the carb content of various food groups

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Program Objectives (cont.)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)

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BASAL BOLUS INSULIN THERAPYBASAL 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)

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NextNext 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.

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Another way to calculate the Another way to calculate the meal bolus insulin is to estimate meal bolus insulin is to estimate

the carb to insulin ratio. the carb to insulin ratio.

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Calculating the Carb to Insulin RatioCalculating 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 = 10Therefore, 1 unit will cover about 10 grams of CHO

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Calculate the Correction Factor “CF”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

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Insulin Administration GuidelinesInsulin 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

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Guidelines continuedGuidelines 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.

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Carbohydrate CountingCarbohydrate 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

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Fixed or Flexible Meal PlansFixed 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.

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Carbohydrate FactsCarbohydrate 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

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Nutrients in FoodNutrients in FoodFood and Blood Glucose VISUAL #2

Nutrients in Food

Nutrient Contains Calories

Carbohydrate

Protein

Fat

Vitamins

Minerals

Water

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© 2004 American Diabetes Association

CHO has the greatest effecton post meal blood glucose

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Nutrients in Food Groups

V I S U A L # 3 D i a b e t e s E x c h a n g e L i s t s

N u t r i e n t s i n F o o d E x c h a n g e G r o u p s

C a r b o h y d r a t e P r o t e i n F a t G r o u p ( g m ) ( g m ) ( g m ) C a l o r i e s

C a r b o h y d r a t e

S t a r c h 1 5 3 1 o r l e s s 8 0

F r u i t 1 5 — — 6 0

M i l k

F a t - f r e e ( s k i m ) 1 2 8 0 – 3 9 0

L o w - f a t ( 1 % ) 1 2 8 5 1 2 0

W h o l e 1 2 8 8 1 5 0

N o n s t a r c h y V e g e t a b l e s 5 2 — 2 5

O t h e r C a r b o h y d r a t e s V a r i e s V a r i e s V a r i e s V a r i e s

M e a t / M e a t S u b s t i t u t e

V e r y l e a n — 7 0 – 1 3 5

L e a n — 7 3 5 5

M e d i u m f a t — 7 5 7 5

H i g h f a t — 7 8 1 0 0

F a t — — 5 4 5

M o n o u n s a t u r a t e d — — 5 4 5

P o l y u n s a t u r a t e d — — 5 4 5

S a t u r a t e d — — 5 4 5

H y d r o g e n a t e d — — 5 4 5

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““Diabetes Food Lists”Diabetes Food Lists”

CHO

CHO

CHO

Starchy Vegetables&

Food GroupsFood Groups

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Approximately 15 grams of CHO per serving

Reference: Life with Diabetes Third Edition, American Diabetes Association

Starch GroupStarch Group

1818

Approximately 15 grams of CHO per serving

Reference: Life with Diabetes Third Edition, American Diabetes Association

Fruit GroupFruit Group

1919

Approximately 12 grams of CHO per serving

Reference: Life with Diabetes Third Edition, American Diabetes Association

Milk GroupMilk Group

2020

Approximately 15 grams of CHO per serving

Reference: Life with Diabetes Third Edition, American Diabetes Association

Other Carbohydrate GroupOther Carbohydrate Group

2121

Approximately 5 grams of CHO

per serving

Reference: Life with Diabetes Third Edition, American Diabetes Association

Vegetable GroupVegetable Group

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Sample Meal Plan 1800 CaloriesSample Meal Plan 1800 CaloriesBreakfast (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

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““Carbohydrate Counting”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

Shredded WheatNutrition FactsServing Size 2 biscuit (1.6 oz.)Servings per container: 10Total Calories: 155 Calories from fat: 9

FatSaturatedTrans Fat

CholesterolSodiumTotal Carbohydrate

Dietary FiberSugars

Protein

1 g0.2 g0g0mg3mg36.2g

5.5g0.4g5.2g

Vitamin A 0% Vitamin C 0% Calcium 2% Iron 6%

Shredded WheatNutrition FactsServing Size 2 biscuit (1.6 oz.)Servings per container: 10Total Calories: 155 Calories from fat: 9

FatSaturatedTrans Fat

CholesterolSodiumTotal Carbohydrate

Dietary FiberSugars

Protein

1 g0.2 g0g0mg3mg36.2g

5.5g0.4g5.2g

Vitamin A 0% Vitamin C 0% Calcium 2% Iron 6%

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Count the CHO in ThisCount the CHO in ThisSample Meal PlanSample 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

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AnswerAnswer

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.

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Practice Carb/Insulin RatioPractice 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

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Estimating Meal Insulin DoseEstimating 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.

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Nursing JudgmentNursing 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.

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SummarySummary

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.

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Summary (continued)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.