Counting Carbohydrates and Dosing Insulin for School Nurses Presented by: Megan Porter, RD, LD,CDE Randall Children's Diabetes and Endocrine Center

Carbohydrate Counting: How does it help? Fewer high blood sugars Fewer low blood sugars More accurate dosing of insulin whether your using syringes, pens or the pump! Lower blood sugar values overall No “off limits” foods Flexibility in meal and snacks Randall Children's Hospital

First, let’s review what foods are counted as carbohydrates: Randall Children's Hospital

Approximate Carbohydrate Amounts by Age Approximate Carbohydrates by Age Boys < 5 years old 30 to 45 grams of carb at each meal 5–12 years old 45 to 60 grams of carb at each meal Teens 60 to 75+ grams of carb at each meal Girls 45 to 75 grams of carb at each meal Snacks, if needed, are usually 15 to 30 grams of carb. For active children, more carbohydrates at each meal/snack are usually needed. Randall Children's Hospital

Types of Insulin Plans There are 2 methods of insulin dosing using carbohydrate counting: Set Dose: A child follows a consistent carb meal plan with a consistent amount of insulin. Usually the child will not take any insulin during lunch, possibly, only if blood sugars reach a designated level, s/he may get a correction shot of insulin. Basal/Bolus: uses a changing carb intake with an adjustable amount of insulin. Child will be receiving an insulin injection, or insulin through a pump for all carbohydrates that are eaten at lunch and possibly for snack times. With this plan, their insulin dose is determined by: The amount of carbohydrates that they will consume Their blood sugar prior to the meal Randall Children's Hospital

So How do you figure out or teach another person to find out how many carbohydrates are in their lunch? Randall Children's Hospital

Where to find information: Look on the internet to see if there is any carbohydrate information for their school: http://www.mesd.k12.or.us/shs/hss/Nutrition/nutritionlinks.shtml Or http://www.pps.k12.or.us/departments/nutrition/8142.htm To view the major allergens or carbohydrate counts for menu items, place your cursor over the (*) asterisk next to the menu item. After each menu, there is a printable list of the allergens and carbohydrate counts for that month. Menus may not have all allergens and are subject to change.     Breakfast 2013-14 (all grades) Lunch Menus K-5, K-8 and Middle School High School September 2013 October 2013 November 2013 December 2013    December 2013   January 2014    January 2014   February 2014    February 2014   March 2014   April 2014 May 2014 June 2014 Author: PPS Nutrition Services Subject: Bean and Cheese Burrito Date: 10/1/2013 9:36:36 AM Allergens Beans and Cheese - Gluten, Milk, Soy and Wheat Tortilla - Gluten, Soy and Wheat Carbohydrates Total - 44g Beans and Cheese - 18g Tortilla - 26g Randall Children's Hospital

When visiting this website: You will find that the average Carbohydrate amount in a school lunch is about 95-100g CHO. With a minimum of 60g CHO to a maximum of 125g CHO. Average lunch entrée contains: two starches = about 30g CHO High carb. Entrees = 45-50g CHO White milk carton = 11g CHO Chocolate milk carton = 22g CHO 1 fruit serving = 15g CHO 1 vegetable serving = 5g CHO 1oz bread = 15g CHO (rolls are 2oz and = 30g CHO) Randall Children's Hospital

If available, the Nutrition Facts Label is a great resource Labels are the best resource for carbohydrate counting Pay attention to: Serving Size Total Carbohydrate Randall Children's Hospital

How to get more information? PPS nutritional services usually maintains accessibility to carbohydrate amounts for individual entrees and keeps a record of the food labels used. For more information you can contact: Ben Dandeneau, RD @ bdandene@pps.net Randall Children's Hospital

Carbohydrate Counting Using Books Use when eating foods without a Nutrition Facts Label: Fresh fruits Fresh Vegetables When eating casseroles, mixed food items Randall Children's Hospital

Carbohydrate Counting Using the Internet There are many great websites that offer carb counting calculators, but make sure that the website is credible: American Nutrient Database www.ars.usda.gov/main/site_main.htm?modecode=12-35-45-00 Calorie King www.calorieking.com GoMeals www.gomeals.com Many great smart phone applications are out there to assist you in carb counting: CalorieKing Carb Counting with Lenny Randall Children's Hospital

Portion Estimation Method This method is best used when unable to measure out or if the serving size is not know. It involves estimating the portion of the food using your hands as a guide. Can be used when a child reports how much eaten. Can be used to tell the child to only self serve this amount of fruit. Randall Children's Hospital

*Based on an adult hand Randall Children's Hospital

If a child packs a lunch to school You can ask that the parents/guardians put notes on each food item with the grams of carb. This will help the child, teacher, school nurse or cafeteria aid to figure out how many carbs the child is eating or ate during school lunch.

Let’s do this together: 2 Cookies = 20g CHO White milk = 11g CHO Small fruit = 15g CHO Total Carb.s = 95g CHO Tater Tots = 25g CHO Chicken nugget = 15g CHO BBQ Sauce = 9g CHO Randall Children's Hospital

Once we determine the amount of carbohydrate the child will eat, or has eaten, we need to determine the insulin dose: All students who take insulin at school should have written school insulin orders signed by their MD Follow insulin directions given by MD It is up to the parent/guardian to keep you posted on any changes made to their child’s insulin directions & to keep supplies stocked Randall Children's Hospital

How to determine their insulin dose Factor How the insulin directions are written: Insulin-to-Carb Ratio = 1 unit of rapid- or short-acting insulin for each ____grams of carb High Sugar Correction Factor = 1 unit of rapid- or short-acting insulin for every____ points (mg/dL) blood sugar level is over the target of ____ mg/dL *These two independent calculations determine the total insulin dose the child will take You fi Randall Children's Hospital

You figure the dose in a 3-step process: 1st Step: Child takes blood sugar, and counts carbohydrates to be eaten. Insulin-to-Carb Ratio: Determine how much rapid- or short-acting insulin is needed for the amount of carbs the child is going to eat. For example, using a 1:20 insulin to carb ratio: Determined carbs= _95__ grams divided by _20_ grams = _4.75_ units Round up to the nearest 0.5 unit for 5 units Randall Children's Hospital

Insulin to Carb Ratios (1:X) Or we have provided you with an insulin dosing spread sheet: Second: Find their insulin to carb. Ratio then scroll down and across to determine the dose. I:C ratio = 1:20 Insulin to Carb Ratios (1:X)   5 6 7 7.5 8 10 12 15 18 20 25 30 35 40 Grams of Carbs 1 0.5 2 1.5 3 2.5 4 3.5 4.5 6.5 5.5 45 9 50 8.5 55 11 60 65 13 9.5 70 14 11.5 75 12.5 10.5 80 16 13.5 85 17 90 95 19 100 16.5 14.5 105 21 17.5 110 22 18.5 15.5 115 23 120 24 General Instructions: Round insulin dose to the nearest half unit. Example: 30 gram/ (1:8) = 3.75 units --> Round to 4 units First: Find the amount of carb.s the child will eat or has eaten. For our example: 95g CHO Randall Children's Hospital

2nd Step: Blood Glucose Correction Factor or High Sugar Correction (HSB) High Sugar Correction is usually written as: 1 unit of rapid- or short-acting insulin for every____ points (mg/dL) blood sugar level is over the target of ____ mg/dL Example: 1:50>150 What this means: 1 unit of rapid- or short-acting insulin for every 50 mg/dL above 150 mg/dL Remember: It is important that a pre-meal blood sugar is used to determine the HSB Example: Premeal Blood sugar = 273 mg/dL Blood Sugar (mg/dL) Insulin Dose (units) 150-200 1 201-250 2 251-300 3 301-350 4 351-400 5 401-450 6 451-500  7 500 8 Randall Children's Hospital

3rd Step: Total Dose Add the number of units from the 1st and 2nd steps together to get the total dose: Total Dose = __5__ + __3__ = __8__ units (amount of rapid- or short-acting insulin needed for carbs+high blood glucose) Determined in Step 1 using the I:C ratio or dosing chart Determined in Step 2 using the HSB or correction chart Randall Children's Hospital

Jimmy’s Insulin to Carb ratio is 1:15 and his Let’s Review Jimmy’s Insulin to Carb ratio is 1:15 and his HSB is 1:50>150 He comes before Breakfast and his BG = 215 mg/dL and he’s going to eat 60g carbohydrate Answer: 4 units to cover carbs PLUS 2 units for the high blood sugar = 6 units insulin Determined in Step 2 using HSB chart: 151-200 = 1 unit 201-250 = 2 units Determined in Step 1 using I:C ratio: 60g CHO divided by 15 = 4 units Randall Children's Hospital

For this to happen accurately the child must have available at all times during school: Test strips Blood sugar meter Syringes/pen needles Insulin delivery device Glucagon Up-to-date school insulin orders Other items: Ketone strips Low blood sugar treatments 15g CHO snacks + Protein Randall Children's Hospital

Talk with the child’s caregivers/family Diabetes management is time consuming and can be overwhelming for some. If your school needs further assistance you can: Talk with the child’s caregivers/family Contact the American Diabetes Association, Safe at School Program Website: http://www.diabetes.org Email: oregonswwashington@diabetes.org Contact: 503-736-2770 Contact their endocrinologist/diabetes educator Randall Children's Hospital

Thanks for your time I’m happy to answer any questions you may have