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

2. 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
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3. First, let’s review what foods are counted as carbohydrates:
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4. 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.
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5. 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
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6. So How do you figure out or teach another person to find out how many carbohydrates are in their lunch?
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7. Where to find information:
Look on the internet to see if there is any carbohydrate information for their school: Or
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 (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
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8. When visiting this website:
You will find that the average Carbohydrate amount in a school lunch is about g 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)
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9. 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
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10. 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,
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11. Carbohydrate Counting Using Books
Use when eating foods without a Nutrition Facts Label:
Fresh fruits
Fresh Vegetables
When eating casseroles, mixed food items
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12. 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
Calorie King
GoMeals
Many great smart phone applications are out there to assist you in carb counting:
CalorieKing
Carb Counting with Lenny
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13. 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.
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14. *Based on an adult hand
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15. 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.

16. 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
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17. 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
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18. 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
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19. 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
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20. 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
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21. 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) 1 2 3 4 5 6   7
500 8
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22. 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
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23. 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:
= 1 unit
= 2 units
Determined in Step 1 using
I:C ratio:
60g CHO divided by 15 = 4 units
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24. 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
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25. 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:
Contact:
Contact their endocrinologist/diabetes educator
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26. Thanks for your time I’m happy to answer any questions you may have