insulin_adjustment_workbook_complete.pdf

8/19/2019 insulin_adjustment_workbook_complete.pdf

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Staying on Target TM

Your Insulin Adjustment WorkbookYes, You Can Do It!

S T AY I N

G O

N

T A

R

G E T

™

TARGET THERAPY


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YES, YOU CAN DO IT!Your ‘How-To’ Guide for

Adjusting Basal and Bolus Insulin

This workbook will help you learn new skills so that you can you live a

healthier life with your diabetes. “What is Basal-Bolus?” introduces

flexible insulin therapy, (also called intensive therapy) as a way to correct

your blood glucose levels. “Terms to Learn First” gives you the definitions

that you will need. “Making Bolus Insulin Changes,” outlines how to

make changes to rapid and short acting insulin doses. “Putting it All

Together” gives you a plan to get started. “Adjusting for Basal Insulin,”

explains changing long acting insulin doses. “Trouble-Shooting,” tells

what to do when you are having a hard time. “Problem-Solving and

Exercises” gives you a chance to practice what you learned. Use this guide

as you work with your diabetes health care team to help you avoid the

complications of diabetes.

BD provides this workbook for informational purposes only. It is not intended to be a substitute for professional

medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified healthcare

provider with any questions you may have regarding a medical condition. Never disregard professional medical advice

or delay in seeking it because of something you have read in this workbook


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WHAT IS BASAL-BOLUS? ........................1

Managing Your Blood Glucose....................2

Practicing Flexible / Intensive Therapy..........2

Responsibilities / Rewards of Basal-Bolus ....2

‘Normal’ Insulin Delivery ............................3

TERMS TO LEARN FIRST ..........................4

Blood Glucose Goals ..................................5

Target Glucose............................................5

Algorithm ..................................................5

Basal Insulin................................................6

Bolus Insulin ..............................................6

Insulin Adjustment and

Pattern Management..................................7

Insulin Sensitivity Factor (ISF)

and Correction ..........................................7Peak Action ................................................8

MAKING BOLUS INSULIN CHANGES ......9

Understanding How Insulin Works............10

Blood Glucose Monitoring:

When to Test ............................................12

Making Changes Using

Pattern Management................................13

Correcting for Blood Glucose

That is Out of Range ................................17

Correction Method I............................18

Correction Method II ..........................18

Correction Method III ..........................19

Calculating Your InsulinSensitivity Factor (ISF)................................19

Insulin/Blood Glucose Formula ............19

Rule of 1500 ......................................21

Rule of 1700 ......................................23

Correcting for Known Changes

in Meals or Exercise ..................................25

Correcting for a Change in Meals ......25

Calculating Your Carb:Insulin Ratio ....25

Method I ............................................26

Method II ............................................26

Correcting for a Known

Change in Exercise ..............................29

PUTTING IT ALL TOGETHER ..................30

Getting Started: A Five-Step Plan..............31

Practice Problems......................................31

ADJUSTING THE BASAL DOSE ..............34

Testing the Nighttime Basal ......................35

Testing the Daytime Basal ........................37

Option I ..............................................37

Option II..............................................38

Option III ............................................38

TROUBLESHOOTING ..............................39

PROBLEM SOLVING AND EXERCISES ....44

SEE – YOU REALLY CAN DO IT! ............49

INTERACTIVE TABLE OF CONTENTSTo go directly to the topic of interest, click on the link below.


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WHAT IS BASAL-BOLUS?


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When you have diabetes, it is important

to avoid high and low blood glucose(sugar). This section reviews how out-

of-control blood glucose can lead to

diabetes complications. It also introduces

flexible/intensive therapy with basal-bolus

insulin adjustment1 as a way to help

keep you healthy.

Managing Your Blood

Glucose – Keeping in control meansthat your blood glucose is always in a

range that is not too high or too low.

Controlling blood glucose helps you stop

or delay the risk of developing eye, kidney,

nerve, foot and heart disease caused by

blood glucose that is too high for a long

period of time. It can be hard to stay

in control with one, two, or even three

injections of insulin a day. You can still

have many times when the insulin does

not match your food or exercise, so your

blood glucose gets too high or too low.

Practicing Flexible / Intensive

Therapy – Research shows that flexible

(also called intensive) insulin therapy can

work to control blood glucose levels in

most people. With this therapy you:

1. Take four or more insulin injections a

day, adjusting your insulin doses as

needed to keep your blood glucose

within your goal range OR

2. Use an insulin pump.

The goal is to keep your blood glucose close

to normal by taking insulin to match the

quantity of food you eat and also meet your

body’s needs at other times. The insulin

that works between meals and through the

night is called “basal.” The insulin that

works to match food or lower high blood

glucose is called “bolus.” “Basal-bolus” is

a term used by health care professionalsto describe flexible therapy.

Responsibilities / Rewards

of Basal-Bolus – Before starting

flexible (basal-bolus) therapy, you

should think about its pros and cons.

“Pros” – You will have more freedom

and other benefits, such as:• Ability to eat when and how

much you want

• Freedom to skip a meal

• Better diabetes control

• Feeling of greater well-being

• Reduced risk of complications

“Cons” – You will have more work,

including:• Checking blood glucose four or more

times a day, and sometimes during

the night

• Learning and practicing carbohydrate

(carb) counting

WHAT IS BASAL-BOLUS?

1 All glucose values used in this workbook are plasma values. If you use a blood glucose meter that reads whole

blood values, you should decrease them by about 10%.


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• Deciding on your insulin dose

according to the amount of carbyou expect to eat and the exercise

or activity you plan

Although some people can have frequent

or severe hypoglycemia (low blood

glucose) with this therapy, most people

have less because there is a better match

between their insulin and food. You can

adjust flexible therapy for your lifestyle,eating and sleeping schedules and

physical activity. You will learn to match

your insulin to your food, exercise, and

adjust for high or low blood glucose

when it happens.

‘Normal’ Insulin Delivery –

A diabetes-free pancreas releases a small

amount of insulin throughout the dayand night. This insulin is described as

basal and is steadily discharged from the

pancreas so that there is always some

available. At night and between meals,

basal insulin works with a small amount

of glucose made by the liver that is also

being constantly released. After eating a

meal or snack with carb in it, two things

happen:

1. Blood glucose rises.

2. The pancreas releases an extra burst

of insulin that in turn helps to deliver

blood glucose into the body’s cells,

where it is used for energy.

This insulin is released as a “squirt”

or a “pulse” that is called a bolus. Insomeone without diabetes, a bolus of

insulin keeps blood glucose levels in

range after meals.

Figure 1 shows normal insulin delivery

in a person without diabetes. The top

portion shows the blood glucose curves

during a day in which someone eats

three meals. The bottom portion showsthe blood insulin levels for the same

three meals. In basal-bolus therapy, the

insulin doses and times are designed to

match normal insulin delivery as closely

as possible.

If you have type 1 diabetes, your pancreas

cannot make insulin. To use flexible

therapy with basal-bolus insulin, you will

decide how much insulin to take to keep

blood glucose within your goal range.

Mid-night

Mid-night

3AM

6AM

9AM

Noon 3PM

6PM

9PM

High

Normal

Low

Bolus

Basal

B l o o d G l u c o s

e

B l o o d I n s u l i n

Figure 1Normal Insulin Delivery in People

without Diabetes


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TERMS TO LEARN FIRST


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The goal of flexible therapy is to imitate

the way a normal pancreas works. Insomeone who does not have diabetes,

insulin automatically works at the right

times, matching meals, activity or stress.

When you have diabetes and use flexible

therapy, you have to figure out and

deliver the correct dose of bolus insulin

yourself. Your Diabetes Team will guide

you along the way. Your Diabetes Team

may include your doctor, certified

diabetes educators such as a diabetes

nurse educator and a registered dietitian.

Some teams also include an exercise

physiologist, social worker and

pharmacist. This section teaches

you words you need to know before

you begin.

Blood Glucose Goals – The range

your blood glucose should fall into most

of the time. The American Diabetes

Association (ADA) recommends the

following blood glucose goals of

90-130 mg/dl before meals and less

than 180 about 2 hours after a meal.

Your Diabetes Team will help you set

your goals, for your blood glucose.

Target Glucose – A single number

that falls within your blood glucose

goals. The target glucose is used to

adjust your insulin dose.

Algorithm – A formula that helps

you determine the amount of insulinthat you take before eating based on

your current blood glucose level. Some

people may have a different algorithm

for each meal. Think of it as following

a recipe. A sample algorithm looks like

the chart below. This is only a sample.

You should not use this table for

treatment.

SAMPLE ALGORITHM

Pre-Breakfast Algorithm For Rapid Or ShortActing Insulin

If your Blood Your Rapid-ActingGlucose is: Insulin Dose should be:

0-100: 2 units

101-150 3 units

151-200 4 units

201-250 6 units

251-300 8 units

Over 300 12 units

STEPS FOR USING A ALGORITHM

1. Test your blood glucose.2. Find your reading in the blood glucose

column.3. Check the rapid-acting insulin dose

column to see how many units to take.

For example, according to the algorithm ifyour blood glucose level were 184 mg/dl,you would need to take 4 units of rapid orshort acting insulin before breakfast.

TERMS TO LEARN FIRST


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NOTE: For an algorithm to work you

need to eat the same amount of foodand carbohydrate every day. (If you

always have a sandwich with 2 slices of

bread, a piece of fruit, a glass of milk

and a small bag of chips for lunch, this

method will be fine.) If you eat a big

salad one day and a plate of spaghetti

the next, these foods have different

effects on your blood glucose and you

would need different doses of insulin, so

this is not the best way for you to decide

how much insulin to take before meals.

Basal Insulin – Works steadily day

and night to keep your blood glucose

within your goal levels. Taken as an

injection, basal insulin is long acting and

works around the clock. Taken via insulin

pump, a very small amount of basal

insulin is released constantly at fractions

of a unit per minute. The goal is to

match the amount of insulin with the

low level of glucose produced by your

liver. This helps your blood glucose levels

remain stable day and night - even if you

don’t eat anything. Types of basal insulin

include:

• Long-acting insulin such as insulin

glargine (Lantus®) is often used for

basal insulin because they last a long

time and have no peak action.

• Ultralente™ - occasionally used as

basal insulin, does have some peakaction. (See Peak Action.)

• Short or rapid-acting insulin (see

below) given by an insulin pump –

tiny amounts of rapid acting insulin

are delivered throughout the day

and night. This is the best example

of basal insulin and may be closest

to imitating the way the pancreas

normally works. Another advantage

is that basal rates on a pump can

be changed to meet your needs at

different time periods of the day

and night.

Bolus Insulin – Taken before you

eat and to correct for a high blood

glucose, it is released in a squirt or pulse.

This allows the insulin to provide a rapid

burst of action. Bolus insulin acts as the

“extra” insulin that is released by a

normal pancreas to help your body use

the glucose from a meal or snack. The

extra insulin will bring your blood glucose

levels down before they climb too high.

Types of Rapid-acting insulin used for

bolus insulin are:

• Insulin Lispro (Humalog®), Insulin

Aspart (Novolog®), Insulin glulisine

(Apidra™) or

• Regular insulin, which is referred to

as a short-acting insulin.


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Insulin Adjustment and

Pattern Management – Adjusting insulin doses based on a

pattern of blood glucose readings over

three days or more is called “Pattern

Management,” or “Pattern Control.”

If your blood glucose is too high or too

low at certain times of the day or night,

an adjustment to your insulin dose may

be needed. In this case it is helpful to

look for patterns in your blood glucose

readings over three days or more. For

example, take a look at Jean’s blood

glucose readings before dinner for the

past three days:

JEAN’S THREE-DAY BLOOD GLUCOSE RECORD

(Goal 90 mg/dl-130 mg/dl)

Breakfast Lunch Dinner Bedtime

98 mg/dl 129 mg/dl 250 mg/dl 150 mg/dl



You can see that her dinner numbers are all

too high. The problem may be related to

how much carbohydrate (carb) she ate at

lunch, snacking, schedule or basal insulin.However, it is most likely that her food at

lunch did not match her pre-lunch bolus.

She ate too much carb for her insulin bolus

dose. For more information on Pattern

Control or Pattern Management, see the

BD Publication: Pattern Control.

Insulin Sensitivity Factor

(ISF) and Correction –• ISF is the amount that one unit of

rapid- or short-acting insulin will

lower your blood glucose reading.

It is used to calculate your correction

or supplemental dose.

• Correction dose is the amount of

insulin you need to correct a high

blood glucose level and bring it into

the range your blood glucose should

fall into most of the time.

Once you know your ISF, you can give

yourself the right dose of insulin to keep

you within your blood glucose goals. The

ISF is different for different people and

your Diabetes Team will help determine

it for you. For instance, if your blood

glucose at lunch is 200 mg/dl and your

goal is 90-130 mg/dl, you will learn to

take a correction dose, an extra amount

of rapid- or short-acting insulin to bring

your high blood glucose down to the

range your blood glucose should be in

most of the time. Correction is usually

required before a meal, so you will need

to add or subtract this dose of insulin tothe amount of insulin needed for your

carbohydrate intake. The correction dose

is extra insulin if your blood glucose is

too high or a lower insulin dose if your

blood glucose is to low.


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EXAMPLE:

Calculating Laurie’s Correction Dose• Laurie’s ISF is 1 unit of rapid or short

acting insulin for every 50 mg/dl of

blood glucose.

• Her target pre-meal blood glucose is

100 mg/dl, but her pre-dinner blood

glucose reading is 250 mg/dl.

• She is 150 mg/dl over her target level.

Current blood glucose – target blood

glucose = amount of glucose over target[250 mg/dl – 100 mg/dl = 150 mg/dl]

• Using Laurie’s ISF, she would divide

150 mg/dl by 50 to find that she

would need to add an extra 3 units

of rapid or short acting insulin to her

meal-time dose to correct the blood

glucose to 100 mg/dl.

Amount of glucose

= correction dose over targetISF

[150 = 3]50If Laurie’s pre-dinner blood glucose was

75, she would reduce her insulin dose in

the same manner as outlined above.

• Her target pre-meal blood glucose is

100 mg/dl, but her pre-dinner blood

glucose reading is 75 mg/dl.• She is 25 mg/dl below her target level.

Current blood glucose – target bloodglucose = amount of glucose over target

[75 mg/dl – 100 mg/dl = -25 mg/dl]

• Using Laurie’s ISF, she would divide

25 mg/dl by 50 to find that she wouldneed to subtract 0.5 units of rapid or

short acting insulin to her meal-time

dose to correct the blood glucose to

100 mg/dl.

Amount of glucose

= correction dose over targetISF

[-25 = -0.5 units]50

Peak Action – The time when insulin

is working the hardest to bring blood

glucose down. It is essential to know

when your insulin peaks so that you can

prepare for possible low glucose levels at

these peak times. Types of insulin with

peak action times are:

Name of Type of Peak ActionInsulin Insulin

Humalog®, Rapid 30 min. toNovolog®, 1 1/2 hoursApidra®

Lantus® Long No peak action

*Regular Short 2 to 4 hours

*UltraLente® Long 8 to 30 hours

*NPH Intermediate 4 to 12 hours

*Lente® Intermediate 7 to 15 hours

*Not commonly used in Flexible Insulin Therapy


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MAKING BOLUS INSULIN CHANGES


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Your first step in learning how to make

these adjustments should be to consultwith your Diabetes Team. This section

will give you the tools you need to adjust

your bolus insulin effectively using

flexible insulin therapy.

Understanding How

Insulin Works

Different types of insulin work at

different speeds. Their action can be

described as basal (steady and long-

acting), bolus (rapid burst of action) or

somewhere in between. They also act

differently in how fast they start working,

when they are at their peak and the

length of time they last. It is importantto understand these differences in order

to make the best decisions possible when

adjusting your insulin dose. By knowing

which insulin peaks and is active you will

know which insulin to change if you are

having hypoglycemia (low blood sugar)

or hyperglycemia (high blood sugar).

View the chart(s) and graph(s) below tohelp you understand the actions of many

different types of insulin including

Humalog® , Novolog® , Regular, NPH,

Ultralente™ , Lantus® , etc.

MAKING BOLUS INSULIN CHANGES

INSULIN ACTION CURVES

Insulin Commonly Used in FlexibleInsulin Therapy for a bolus dose:

Rapid-acting insulin is the most

common insulin used, but short-

acting insulin is also used for

this purpose.

Insulin Action Type of Insulin Onset of Action Peak Action Duration

RAPID ACTING(Used for bolusinsulin – takenbefore eatingand to correctfor a high bloodsugar)

Insulin lispro(Humalog®),Insulin aspart(Novolog®),Insulin glulisine(Apidra®)

15 minutes 1/2 to 1-1/2hours

3 to 5 hours

SHORT ACTING Regular 1/2 hour 2 to 4 hours 6 to 8 hours

B l o o d

I n s u l i n

L e v e l

6AM 9AM Noon 3PM 6PM 9PM MidN 3AM 6AM 9AM


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The most common insulin used for

basal doses is Lantus® , although

Ultralente™ can also be used.

NPH insulin may be used as a partial

basal dose in the evening. This is

most commonly used with short-acting (regular) insulin as a bolus dose.


LONG ACTING(Use for basalinsulin – takenin injection orin a pump to actthrough day andnight to keepblood glucoselevels stable)

Ultralente™

Lantus®

Approx.4 to 8 hours

2 to 4 hours

12 to 18 hours

No peak, stable

Approx.24 to 28 hours

24 hours


INTERMEDIATE NPH, Lente 1 to 3 hours 6 to 12 hours 18 to 24 hours

Fill in the chart/graph below to show the action of the types of insulin you are taking now:

My Bolus __________________ insulin:

My Basal__________________ insulin:

Starts to work at: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Peaks (Works hardest from) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Lasts until: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Starts to work at: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Peaks (Works hardest from) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Lasts until: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Graph your insulin curves below:

7AM Noon 6PM 12MN 7AM

B l o o d

I n s u l i n

L e v e l

B l o o d

I n s u

l i n

L e v e l




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Blood Glucose Monitoring:

When to Test

Checking your blood glucose levels is

important. You need the information

to 1) Make insulin changes, and

2) See if you made the correct

adjustments.

Many people using flexible insulin

therapy check their blood glucosebefore each meal and at bedtime.

Your Diabetes Team may also ask you

to check your blood glucose two hours

after a meal. (This reading will show

how well the mealtime insulin dose is

working.) In addition, to make sure

that you are not having hypoglycemia

at night, it is sometimes important

to check blood glucose at 3AM.

The 3 AM blood glucose, although

inconvenient, is important because

it can help guide the decision to

change your nighttime basal insulin.

It is common for blood glucose to

drop before 3 AM and then to rise

by morning. Figure 3 shows the

effects of different types of insulinon your blood glucose at different

times of day.

HINT: If your blood glucose meter can

do mealtime averaging, this can help you

find the times of day that your blood

glucose levels are usually too high or low.

Along with your careful reflections about

your carbohydrate intake, stress and

activity levels, this may also guide

your insulin adjustments.

Insulin Dose Blood Glucose

Breakfast Lispro Breakfast BGM

Lunch Lispro Lunch BGM

Supper Lispro Supper BGM

Bedtime Lantus Bedtime BGM

Figure 3Effects of Previous Insulin Dose onBlood Glucose Readings Tested at

Mealtimes and Bedtime


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Making Changes Using

Pattern ManagementYou can learn to adjust your insulin

dose by looking at your pre-meal blood

glucose levels over three or more days to

see if you notice any special pattern. In

the following example and throughout

the workbook, assume that the blood

glucose goals recommended by the

American Diabetes Association are in use

(pre-meal plasma values of 90-130 mg/dl,

blood glucose 2 hours after meals less

than 180 mg/dl.)2 and a target of

100 mg/dl.

How to Evaluate Your Blood

Glucose Record:• Record your blood glucose levels in

column format (as below) to more

easily identify a pattern. Many of the

data management software programs

will do this for you automatically

when you download the data.

• Look at the readings by group

according to the time of day.

• Select the blood glucose readings

by group that are out of your goal

range.

Day # Breakfast Lunch Dinner Bedtime 3 AM

Pre Post Pre Post Pre Post

Day 1

Day 2

Day 3

Three-day Blood Glucose Record:Pre-meal Goals 90-130 mg/dl Post-meal Goals < 180 mg/dl

2 American Diabetes Association, Standards of Medical Care for Patients With Diabetes Mellitus. American

Diabetes Association: Clinical Practice Recommendations, Diabetes Care. 27:Supl:10, 2005.

Guidelines for Pattern Management

Any time you see a consistent pattern of

either high or low blood glucose levels

over a period of three days, you could

adjust your insulin by:• Increasing the appropriate insulin or

decrease the food eaten if the blood

glucose levels are too high.

• Decreasing the appropriate insulin or

increasing the food eaten if the blood

glucose levels are too low.

Most of the time the appropriate meal

to change or insulin to adjust is the rapid

or short-acting insulin taken the meal

before the “out of goal values” appeared.


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Q&A PRACTICE PROBLEMS

Q – What is the Pattern in Jane’s Three-day Blood Glucose Record?

Pre-meal goals 90-130 mg/dl Post-meal goals < 180 mg/dl



1 – Mon 90 125 110 189

2 – Tues 75 134 116 210

3 – Wed 100 141 131 196

Average 88 133 119 198

Q – Does Jane Need an Insulin

Adjustment?

A – Maybe! But first she should think

about whether she had eaten too muchcarb at dinner. Over the next few days,

she should decrease her portion sizes of

food at dinner she is eating (which will

decrease the amount of carb). If there

is no improvement in her blood glucose

readings, Jane should look for other

possible causes and solutions.

Q – Could Jane’s dinner insulin

(Humalog®) be the reason that her

bedtime glucose is out of range?

A – If Jane suspects her dinner insulinneeds to be adjusted, she could try

increasing it by 0.5-1 unit. Over the

next three to five days she would need

to observe whether her bedtime blood

glucose readings are improved.

NOTE: It is very important to consider

all possible causes for an out-of-goal

blood glucose reading before you adjust

your insulin dose. The nice thing about

pattern management is that you can

make a small change every few days

with great safety!

A – Jane’s pre-breakfast, pre-lunch and pre-supper readings are in goal blood glucose

range, but her bedtime readings are all high and out of range.


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A – In this record, the breakfast, lunch

and dinner values are in the goal range.

However, the bedtime values are not

only too high on average, but also too

variable. Tom needs to look for and

understand what caused the low value

of 73 at bedtime on Tuesday.

Any time you see a consistent pattern of

either high or low blood glucose levels

over a period of three days, you could

adjust your insulin as follows. Either

increase the appropriate insulin if your

blood glucose levels are too high, or

decrease it if your blood glucose levels

are too low.

REMEMBER:Most of the time, the appropriate insulin

to adjust is the rapid or short-acting

insulin taken at the meal before the

“out-of-goal” values.

• The change should be only 1 or 2

units or 10% of the usual dose at

that time of day and can be as small

as 1/2 unit.

• You can make changes every three

days.

• Make a change, evaluate the effect

for a few days and then make a

change again. You do not need tomake big changes. (When blood

glucose values are quite variable,

extra caution is needed because

making even a small change in insulin

under these conditions might be

dangerous).

HINT: Sometimes it is too early for you

to see a real pattern. In this case youshould probably not make any changes

and wait a few more days to see if a

pattern emerges. Or, by waiting a few

days you might find that your blood

glucose levels came back into the goal

Q – What is Different About Tom’s Three-day Blood Glucose Pattern?

Pre-meal goals 90-130 mg/dl Post-meal goals < 180 mg/dl



1 – Mon 90 125 110 239

2 – Tues 75 134 116 73

3 – Wed 100 141 131 266

Average 88 133 119 193


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range without any insulin changes.

Always make insulin dose changes onlyafter a full examination of the blood

glucose levels and do it carefully!

If you are unsure, consult with yourDiabetes Team.

Based on your results, fill out the answers

to the following questions:

1. Do you see a consistent pattern?

________________________________

2. Which insulin is affecting the pattern

of your glucose levels?_____________

3. What kind of change might have

helped bring your blood glucose

levels into goal range?_____________

4. Do you want to wait a few more days

before you make any change to see if

there really is a pattern?____________

5. Have you experienced changes in

your stress and/or activity levels overthe past three days?_______________

6. Have your food choices or amounts

been different than usual for you?

________________________________

7. Are you experiencing hormonal

changes (such as those during

menstruation or perhaps related to

any medication you may be taking)?

________________________________

8. Is your pattern of values before

breakfast out of the goal range?____

(If YES, this indicates that you need

to change your basal insulin. Please

refer to p. 37 for a discussion of this

topic.)

HINT:

Some people find it easier to use a

computer program to identify blood

glucose patterns. If you are interested

in this type of a program, contact your

meter manufacturer for information

on how to obtain one.

Record Your Blood Glucose for the Past 3 Days and Pick Out the Patterns You SeePre-meal blood glucose goals:________ Post-meal blood glucose goals:________



1 – Mon

2 – Tues

3 – Wed

Average


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Correcting for Blood Glucose

That is Out of Range

Know Your Blood Glucose Goals

In this workbook, the American Diabetes

Association (ADA) recommended pre-

meal blood glucose goals of 90 to 130

mg/dl will be used. If you are above 130

mg/dl, you will increase your insulin;

if you are less than 90 mg/dl you will

decrease the insulin. Many people usea target of 100 and make adjustments

if they are above or below this target.

‘Correcting’ – The term used for an

immediate change in your insulin dose

based on one event, such as a:

• Single out-of-target blood glucose

level.• Change in a single meal (you are

invited out to a French restaurant

for dinner).

• Change in your exercise routine

(you are going for a bike ride).

Correcting means you make a minor

change in your insulin dose based on the

event now, but go back to your usualinsulin dose tomorrow.

EXAMPLE:

If you wake up and your blood glucose

reading is 200 mg/dl but you want it to

be 100 mg/dl, you would make an

immediate insulin “correction.” To dothis you would take a certain dose of

short or rapid-acting insulin to bring that

blood glucose value down to 100 mg/dl.

NOTE:

Correction doses of insulin are calculated

for each person and may change

throughout the day. People usually

need a bigger correction dose atbreakfast than at lunch and dinner.

Methods of Correction – There are

many ways to correct for an abnormal

blood glucose value. The three most

common methods will be discussed here.

Check with your health care professional

to see which method is best for you.

Correction Method I – Fixed Insulin

Dose Based on Blood Glucose Value.

Uses an algorithm (formula) to tell you the

amount of insulin to take based on your

blood glucose levels before meals and at

bedtime. The carb you eat at each meal

should be the same from day to day.

EXAMPLE:Ken’s Diabetes Team gives him an

algorithm of blood glucose values and

insulin doses. Ken will give the insulin

dose that corresponds to his current

blood glucose.


21/53

Ken’s Algorithm for Correction Method 1

Blood Glucose Values Insulin Dose (Rapid or Short -Acting)Breakfast Lunch Supper Bed


22/53

Joe’s Algorithm for Correction Method II

Correction Method III – Change in

Insulin Dose Based on Your Insulin

Sensitivity Factor

As you learned earlier, your “Insulin

Sensitivity Factor” (ISF) tells you how many

points lower your blood glucose will go for

every 1 unit of short or rapid acting insulin

you take. Method III uses your ISF to figure

out how much to raise or lower your

insulin dose to bring your blood glucose

back to goal range. If you use Correction

Method III before a meal you will need to

add the correction amount of insulin to the

amount of units needed to “cover” the

number of carbohydrates you will eat. (Seep. 28 for a discussion of carbohydrates.)

REMEMBER:

The ADA recommended pre-meal values

of 90-130 mg/dl as a goal range are used

in this workbook. Your Diabetes Team

may set a different pre-meal goal for you.

Calculating Your Insulin

Sensitivity Factor (ISF) –Your Diabetes Team may use any of the

following methods to help find your ISF:

1. Insulin/Blood Glucose Formula

(One unit of rapid or short-acting

insulin for every 50 mg/dl increase or

decrease in your blood glucose level).

2. Rule of 1500 - if you are using short-

acting insulin (Regular).3. Rule of 1700 - if you are using rapid-

acting insulin (Humalog®, Novalog®,

Apidra®).

ISF Method I – Insulin/Blood

Glucose Formula

With ISF Method I, you take one unit

of rapid or short-acting insulin for every

50 mg/dl increase or decrease in your

blood glucose level.

EXAMPLE:

Blood glucose target is 100 mg/dl.

John’s pre-lunch blood glucose is 180

mg/dl and his Insulin Sensitivity is 50.

His reading shows that he is above

his target by 80 mg/dl.

[180 mg/dl – 100 mg/dl = 80 mg/dl]

He should take 1 (1.5 if you measure

1/2 units) extra units at lunch.

If his usual dose of rapid or short-acting

insulin at lunch were 12 units, he

would increase it by one and take

13 or 13.5 units.

Blood Glucose Values Pre-meal rapid orshort acting insulin

Less than 60 Subtract 3 units

60-90 Subtract 1 unit

90-130 Take usual dose

130-200 Add 1 unit

200-250 Add 2 units

250-300 Add 3 units

300-350 Add 4 units

350-400 Add 6 unitsOver 400 Add 8 units


23/53

PRACTICE PROBLEMS:

Blood glucose target: 100 mg/dl Susan’s pre-lunch blood glucose

is 205 mg/dl.

Her reading shows that she is above

her target by 105 mg/dl

[205 mg/dl – 100 mg/dl = 105 mg/dl]

Q – How many extra units should

Susan take?

105 mg/dl = 2 units50

A – She should take 2 extra units. In this

case she should take a total of 14 units.

Bob’s pre-lunch blood glucose

is 60 mg/dl.

His reading shows that he is below his

lower target by 40 mg/dl

[100 mg/dl – 60 mg/dl = 40 mg/dl]

Using ISF Method I he would:

40 mg/dl = .8 units50

• Round .8 units to 1 unit

• Decrease his insulin dose by 1 unit.

• Take a total of 11 units.

Find Your Correction Dose for the

Highest Pre-Meal Blood Glucose you

had yesterday:

ISF = 50 mg/dl Target = _____ mg/dl

Record yesterday’s pre-meal blood

glucose readings.

Take your highest pre-meal blood

glucose and subtract your target goal:

[_______ – ________ mg/dl = _________.]Target Goal

Divide your answer by 50 and add the

number to your usual insulin dose:

[__________ divided by 50 = _________.]

Add to your usual pre-meal dose.

If You Had a Low Blood Glucose

Yesterday, Figure out the Insulin

Dose You Need:

Record yesterday’s pre-meal blood

glucose readings.

Take your lowest pre-meal blood glucosereading and subtract your target goal:

[_______ – ________ mg/dl = _________.]Target Goal

This will be a negative number.

Divide your answer by 50 and subtract

the number from your usual insulin dose.

[__________ divided by 50 = _________.]

Subtract from your usual pre-meal dose.

The corrections above using ISF Method I

should bring your blood glucose back to

normal at the next meal if you make noPre-Breakfast Pre-Lunch Pre-Dinner


24/53

other changes. Although any single meal

may not correct properly, if after a few days they do not, you may have the

wrong ISF or the wrong carb-to-insulin

ratio for you. Work with your Diabetes

Team would have to adjust the ISF and

carb-to-insulin ratio.

ISF Method II – Using the ‘Rule of

1500’ – To get a good first guess at your

insulin sensitivity, divide the sum of all ofyour daily insulin doses into 1500.3

EXAMPLE:

Calculate Rita’s ISF Using the Rule of1500.

If Rita took 10 units of Regular insulin at

breakfast, 12 at lunch, 13 at supper, and

15 units of Lantus® at bedtime, her total

would = 50 units a day.

Dividing 50 units into 1500 would = 30.

So as a first guess, each unit of insulin

would lower Rita’s blood glucose by

30 mg/dl. (See Rule of 1500 box below)

Rule of 1500

1) Add all insulin doses

10 units Insulin Regular12 units Insulin Regular13 units Insulin Regular

+ 15 units Insulin Lantus®50 units

2) Divide sum of insulindoses into 1500

1500 = 30 mg/dl50 units of insulin

3) Answer = ISF

Insulin Sensitivity Factor =1 unit of short or rapid -acting insulin will lowerblood glucose 30 mg/dl

PRACTICE PROBLEMS:

1. Calculate your ISF using the Rule

of 1500.

Fill in all the insulin doses you take in oneday and add them up:

Divide 1500 by your total units of

insulin/day

1500 =

(your total units of insulin/day)

The answer is your ISF (the number of

points one unit of insulin will lower your

blood glucose).

# of units Type of insulin

Total units/day

3 Klingensmith, GJ. American Diabetes Association, Intensive Diabetes Management, Third Edition, 2003.

p. 107. 2003.


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Fill in your pre-meal blood glucose

values from yesterday and calculateyour adjusted insulin dose using the

steps below:

Circle your high pre-meal blood glucose.

Subtract your target goal from your high

pre-meal blood glucose.

[_______ – ________ mg/dl = _________.]Target Goal

Divide this number by your insulin

sensitivity factor (ISF)

= ________

(ISF)

Add the answer to your usual insulin dose.

If you had a low blood glucose

yesterday find the insulin dose that

should be given:

Take your low pre-meal blood glucose –

your target = ____________.

This will be a negative number. You will

need to subtract insulin for correction.

[_______ – ________ mg/dl = _________.]Target Goal

Divide the number by your ISF and subtract

answer from your usual insulin dose.

[__________ divided by _____ = ______.]

Subtract from your usual pre-meal dose.

[Usual dose – __________ = __________.]

Fill in the table below with your

calculations using your owninformation:

REMEMBER:Guidelines for Taking Correction

Doses for Out-Of-Goal Blood Glucose:

1. Check your blood glucose about 2

hours later. Use your post-meal blood

glucose goal. In this booklet, the

ADA recommendation of less than

180 mg/dl is used.

2. If your blood glucose is still not withinyour range of blood glucose goals,

lower your ISF number (try changing

by 5).

3. If you have hypoglycemia (low blood

sugar), increase your insulin sensitivity

number.

ISF Method III – Using the Rule of

1700 – Another way to get a good

first guess at your insulin sensitivity is

to divide the sum of all of your insulin

doses into 1700.4

Usual InsulinDose

AdjustedInsulin Dose

Pre-Breakfast

Pre-lunch

Pre-dinner

Pre-Breakfast Pre-Lunch Pre-Dinner

4 American Diabetes Association, Intensive Diabetes Management, third Edition, p. 107. 2003.


26/53

EXAMPLE:

If you take 10 units of Humalog® atbreakfast, 12 at lunch and 13 at dinner,

and you take 15 units of Lantus® at

bedtime, your total would = 50 units a

day. Dividing this into 1700 would give

you 34 (this number can be rounded upto 35). So as a first guess, each unit of

insulin would lower your blood glucose

by 35 mg/dl.

Now you try it using the 1700 rule.

PRACTICE: Calculate Your ISF Using

the Rule of 1700.

Using the chart below, fill in all the

insulin doses you take in one day and

add them up:

Divide 1700 by your total units of insulin/day.

1700 = ________

(your total units/day)

The answer is your ISF (the number of

points one unit of insulin will lower your

blood glucose).

Figure out your adjusted insulin dose

based on your pre-meal blood

glucose readings:

Target Goal = ______________

Fill in your pre-meal blood glucose values

from yesterday in the chart above.

Circle your high pre-meal blood glucose.

Subtract your target goal from your high

blood glucose reading.

_______ – ________ mg/dl = _________Target Goal

Divide this number by your ISF.

= ________

(ISF)

Add the answer to your usual pre-meal

dose.

# of units Type of insulin

Total unitsper day =

Rule of 1700

1) Add all insulin doses

10 units Insulin Humalog®12 units Insulin Humalog®13 units Insulin Humalog®

+ 15 units Insulin Lantus®50 units of insulin/day

2) Divide sum of all insulindoses into 1700

1700 = 34 mg/dl50 units of insulin

3) Answer = ISF

Insulin Sensitivity Factor =1 unit of short or actinginsulin will lower blood

glucose 34 mg/dl

Pre-Breakfast Pre-Lunch Pre-Dinner


27/53

If you had a “low blood glucose”

yesterday, figure out your correctioninsulin dose.

Subtract your target goal from your low

pre-meal blood glucose.

_______ – ________ mg/dl = _________Target Goal

This will be a negative number. You will

need to subtract insulin to make the

correction.

Divide your answer by your ISF and

subtract answer from your usual insulin

dose.

= ________

(ISF)

Subtract the answer from your usual

pre-meal dose.________ – _________ = _____________

Fill in the table below with your

calculations using your own

information:

Every time you take a correction dose for

an out of goal blood glucose you shouldnote the effect on your blood glucose. If

your glucose correction doses never bring

you back to your goal range, you should

lower your sensitivity number. If you

are under-correcting you are not giving

enough insulin. You will know this

because your high blood glucose

readings will remain high and the low

blood glucose readings will stay low.

This means you need a larger correction

dose, so reduce your ISF by 5.

If you are over-correcting you are taking

to much insulin. You will know this

because your high blood glucose values

will become low and your lows may

become high. This means you need

to decrease your correction dose,

raise the ISF by 5.

Usual InsulinDose

AdjustedInsulin Dose

Pre-Breakfast

Pre-lunch

Pre-dinner


28/53

Correcting for Known

Changes in Meals or Exercise

You have learned to adjust insulin to stay

within your blood glucose goals. Insulin

doses are also commonly adjusted for

changes in diet or exercise. Changing

your insulin dose based on what you will

eat and the activity you plan to do is

often called “insulin dosing.”

Correcting for a Change in Meals

Since most people do NOT eat the same

thing every day, you need to learn how

to calculate your short or rapid acting

(bolus) insulin for different meals and

different amounts of carbohydrates.

If you are not sure about which foods

are carbohydrates, discuss this with

your diabetes educator. As with insulin

correction for out-of-goal blood glucose,

different methods are available for insulin

dosing for a change in the food that is

usually eaten at meals. One method

involves adding or subtracting insulin for

more or less food. Another way is to

take a certain amount of insulin for a

specific amount of carbohydrate. Checkwith your Diabetes Team to see which

method they recommend for you.

Both methods require that you learn how

to count carbohydrates. In addition, youalso need to learn how sensitive your

insulin dose is to the carb you eat. This

is called your Carb:Insulin Ratio. For

information about carb counting, see the

BD Publication “Carbohydrate Counting:

Eat to Win” and talk to your diabetes

educator.

Calculating Your Carb:Insulin Ratio –A carb:insulin ratio is the amount of

rapid or short acting insulin you need

to match or “cover” the amount of

carbohydrate you eat. Your ratio

depends on how sensitive your blood

glucose is to insulin. The more you

weigh, the less sensitive your body is

to insulin. The more sensitive you are

to insulin, the more carbohydrate that

will be covered by one unit of insulin.

Knowing your ratio and how to

calculate your mealtime insulin to

match the carbohydrate in your meal

gives you the greatest flexibility with

improved glucose control. You will

be much freer to eat what you want,

when you want, with fewer concernsabout high or low blood glucose.


29/53

Method I: A Quick and Easy Way

to StartBefore you begin, keep the following

guidelines in mind. Use 1 unit of insulin

for every 15 grams of carbohydrate

(1:15). Some people will need more

insulin (1 unit for every 10 grams of

carbohydrate). Others will need less

insulin and use 1 unit for every 20 grams

of carbohydrate. Most people with type

1 diabetes have ratios between 6 and

10, but you may want to start with

a very sensitive level of 15 grams of

carbohydrate per unit of insulin and

see if this works for you.

Method II: The Rule of 500:5

Add up all the insulin given for 24 hours

and divide it into 500. The answer is

your carb:insulin ratio.

EXAMPLE:

Your total insulin dose is 50 units.

500 divided by 50 = 10

Your carb: insulin ratio is 10:1

Again, this is a starting point, you

need to start with this ratio and adjust

it based on your blood glucose records.

Your Diabetes Team can guide you in

this process.

Keep Detailed Records for About

One WeekThe best way to find your carb:insulin

ratio is to use the following Food and

Carbohydrate Counting Record below

and write down:

1. Everything you eat and how much

you eat - you will need to weigh and

measure! (If you know how to count

carbs, include them. Otherwise, usetables or a calculator to figure out the

carbs in all of the food you eat and

record each amount.)

2. Your insulin dose for each meal.

3. Your blood glucose levels before

the meal.

4. Your blood glucose records after

the meal. (Your blood glucose level

should increase about 50 mg/dl

2 hours after you eat. If it is much

higher or lower than that, your

Insulin:Carb ratio will need to

be adjusted.)

NOTE:

If you have never used a carb:insulin

ratio, discuss this with your Diabetes

Team and let them guide you through

this process. Also, like the ISF, you may

have a different carb: insulin for each

meal. Typically, this ratio is lower at

breakfast.

5 Warshaw, H.S. and Kulkarni, K., Complete Guide to Carb Counting. P. 146. American Diabetes Association 2001.


30/53

Food and Carbohydrate Counting Record

Food Eaten Amount Grams Carb

__________________________________________________ ____________________________ _______________________________________

__________________________________________________ ____________________________ _______________________________________

__________________________________________________ ____________________________ _______________________________________

__________________________________________________ ____________________________ _______________________________________

Total: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Snack Time: Food Eaten Amount Grams Carb

_______________ __________________________________ ____________________________ ______________________________________

_______________ __________________________________ ____________________________ ______________________________________

Total: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _


__________________________________________________ ____________________________ _______________________________________

__________________________________________________ ____________________________ _______________________________________

__________________________________________________ ____________________________ _______________________________________

__________________________________________________ ____________________________ _______________________________________

Total: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Snack Time: Food Eaten Amount Grams Carb _______________ __________________________________ ____________________________ ______________________________________

_______________ __________________________________ ____________________________ ______________________________________

Total: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _


__________________________________________________ ____________________________ _______________________________________

__________________________________________________ ____________________________ _________________________________________________________________________________________ ____________________________ _______________________________________

__________________________________________________ ____________________________ _______________________________________

Total: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Snack BG before snack_________

Time: Food Eaten Amount Grams Carb

_______________ __________________________________ ____________________________ ______________________________________

_______________ __________________________________ ____________________________ ______________________________________

Total: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Brkfst AMtime: PM

Carbgoal:gms

BG beforemeal

BG 2 hoursafter meal

Insulin Comments:

Lunch AMtime: PM

Carbgoal:gms

BG beforemeal

BG 90 minafter meal

Insulin Comments:

Supper AMtime: PM

Carbgoal:gms

BG beforemeal

BG 90 minafter meal

Insulin Comments:


31/53

Method I – Insulin Dosing Based on

Carb Intake – A set dose of insulin isgiven for a meal and a specific amount

of carbohydrate is eaten at the meal. If

you eat the usual amount of carbs, you

take the usual amount of insulin. Your

health provider will prescribe a specific

amount of carbohydrate for each meal.

If you eat more carbs, you take more

insulin, as determined by your prescribed

carb:insulin ratio. If you eat less carbs,

you reduce your insulin, again using

the ratio.

EXAMPLES:

George’s Health Team prescribed

carbohydrates for his meals as

follows:

• 60 grams of carbohydrate forbreakfast and lunch.

• 70 grams of carbohydrates for

supper.

If George expects to eat more carbs, he

will take more insulin, as determined by

his prescribed carb:insulin ratio. If he

plans on eating less carbs, he will reduce

his insulin, again using the ratio.

What should George do if he is going

to change the amount of food he isgoing to eat? (George usually eats

70 grams of carb for dinner, and he

takes 7 units.)

• If George is very hungry today and

plans to eat 90 grams of carb for

dinner, he would eat an extra 20

grams of carb.

• If his carb:insulin ratio is 10:1, forevery 10 extra grams of Carb, he

needs 1 extra unit, so for an extra

20 grams, he needs 2 extra units

of insulin.

• In this case, for a 90-gram dinner,

he would take 9 units of insulin

(see the chart below).

Usual Grams of Usual Dose ofCarbohydrate InsulinCarb:Insulin Ratio: 10:1

70 Grams Carb 7 Units Humalog®

90 Grams Carb 9 Units Humalog®


32/53

Method II – Insulin Dosing Based on

Carb:Insulin RatioUnlike Method I, you do not have a

usual amount of food that you take or

a usual insulin dose. You simply use

the Carb:Insulin Ratio to determine

your dose.

EXAMPLE:

Mary’s Carb:Insulin Ratio is 10:1

Mary is meeting an old friend at afavorite restaurant and she is planning

to eat a 90-gram lunch. To figure out

her insulin dose, knowing that her ratio

is 10:1, all she has to do is to divide

the number of carb by her ratio as

follows:

90 grams of carbohydrate divided

by 10 units of insulin = 9 units ofHumalog®

[ 90 = 9 units of Humalog®]10

Correcting for a Known Change

in ExerciseExercise lowers your blood glucose levels.

If you have started an exercise program

and your blood glucose levels are too low

and you are using an insulin pump, you

will need to adjust your basal insulin.

(See “Adjusting the Basal Dose” p. 37).

This is the hardest of the adjustments

because everyone responds to exercise

differently. If you are giving bolus

injections of insulin, you should lower

your bolus dose before exercise. An

example of how to do this can be found

on p. 37.

Try to measure your exercise by intensity

(how hard you work) and how much

time it takes. Think of your exercise

as mild, moderate or intense.

• Mild exercise – you will not sweat at

room temperature, no matter how

long you do it.

• Moderate exercise – you will sweat

after 15-30 minutes.

• Intense exercise – you will start to

sweat almost right away.

The more intense your exercise and the

longer it lasts, the more you will need to

decrease you insulin.


33/53

PUTTING IT ALL TOGETHER


34/53

You have learned a lot of information

about making changes to your bolusinsulin doses. Now it is time to put

these facts to work for you. This

section will help you practice using

your new knowledge in your

everyday routine.

Getting Started:

A Five-Step Plan

1. Define your target blood glucose

level.

2. Calculate your insulin sensitivity

factor (ISF).

3. Try starting a carb:insulin ratio of 10

or 15 grams of carb:1 unit of insulin.

4. Count the number of carbohydrates

you will be eating.

5. Reduce, if necessary for exercise.

PRACTICE PROBLEMS:

Tom’s Night OutLet’s look at how Tom uses the 5-step plan

above to calculate his insulin adjustment.

Tom has a fun evening planned. He is

going out to an Italian restaurant for dinner

with some friends after a game of singles

tennis. When he tests his blood glucose

before dinner, he finds it is 190 mg/dl.

Here is his information for the five steps.

• Blood Glucose Goals: 90-130 mg/dl

• Target blood glucose level is 100 mg/dl

• The initial ISF is 1 unit for every

30 mg/dl of blood glucose. Tom’s

total insulin dose is 50 units/day.

Using the rule of 1500, 1500/50 = 30

• The initial carb:insulin ratio is 10:1,

1 unit of Regular insulin for every

10 grams of carb. Using the ruleof 500, 500/50 = 10

• Tom is planning on eating about

90 grams of carbohydrates

• See below for step 5

PUTTING IT ALL TOGETHER

Tom’s Calculations:

Insulin needed for carbohydrates 9 units (90 divided by 10)

Insulin needed to correct for high blood glucose (190-100=90) divided by 30 (ISF)=3

Total insulin for food and carb 9 + 3 = 12 units

Reduction for high intensity exercise (Step 5) 3 units

TOTAL amount of pre-dinner insulin 9 units


35/53

Your Night Out –

Using the Five Steps, calculate the answers in the chart below:

Your Morning Breakfast and Run

Let’s say you are going to eat 2 slices

of toast (30 grams), a fried egg, hash

browns (15 grams) and a 1/2 glass of

juice (15 grams). This is a total of (60

grams of carb), but you are going to run

2 miles before lunch. Using the five

steps, use the space below to figure out

your insulin adjustment based on your

plans for breakfast and exercise:

Now check the following chart and

see how well you did!

Your Morning Breakfast and Run

Planned Food (Carbs) 60 Carbs

Divided by Carb/Insulin Ratio 8 Carbs/U of Insulin60/8 = 7.5 U of Insulin

Current Blood Glucose 180 mg/dl

Current Blood Glucose – Target Blood Glucose 180 – 100 = 80

Insulin Sensitivity 30

Current BG – Target BG 80_______________________ = __ = + 2.5 U of insulinInsulin Sensitivity 30

Reduction for Exercise (Should be Negative) -3 U of Insulin

Add Units of Insulin (7.5 U + 2.5 U -3 U) = 7 U TOTAL DOSE

Planned Food (Carbs) ________ Carbs

Divided by Carb/Insulin Ratio ________ Carbs/U of Insulin =________ Units of Insulin

Current Blood Glucose ________ mg/dl

Your Target Blood Glucose ________ mg/dl

Current Blood Glucose – Target Blood Glucose ________ mg/dl

Your Insulin Sensitivity Factor? ________

Divide your Blood Glucose Calculation by Insulin Sensitivity ________ U of insulin

Subtract for Exercise if Necessary ________ U of insulin

________ Total Dose


36/53

After correcting for food, elevated blood

glucose and expected exercise, youwould take 7 units of short-acting

insulin.

IMPORTANT REMINDERS:

• After adjusting your insulin dose for

exercise you must check to see if the

insulin given was too much or too

little. (Checking your blood glucose

level before, during and after exercisewill provide the information you need

to change future doses.)

• Talk to your Diabetes Team about

how your doses are working for you.

• Be sure to test for urine ketones

if blood glucose levels are over250 mg/dl.6 Do not exercise when

you have ketones in your urine.

• Eat a carb food if blood glucose levels

are


37/53

ADJUSTING THE BASAL INSULIN DOSE


38/53

Adjusting the basal dose is more

challenging than changing the bolusdose. Basal insulin is designed to always

be working in the background to keep

your blood glucose steady when you are

not eating. The basal insulin has the

major job of keeping your blood glucose

normal during the night, if you do not

eat or if you delay a meal. Insulin used

to provide a basal dose include Lantus®

and Ultralente™ insulin and the basal

setting on an insulin pump. This section

will help explain how to make changes

to your basal insulin.

Testing the Nighttime Basal

Adjusting the basal insulin is done

much less often than the bolus insulincorrections. The best way to check your

basal insulin is to look at your nighttime

and morning glucose readings first. It

is easier and more important to be sure

that the basal is correct at night, since

you may be hypoglycemic (have a low

blood sugar) at night but not know it!

Many people become less sensitive to

insulin between 3 AM and 7 AM. As

a result, you could have a high blood

glucose value when you wake up in the

morning or you could have a low blood

glucose level in the middle of the night.

How to Test and adjust The Basal

Insulin To Normalize Your MorningBlood Glucose

1. Check your blood glucose at bedtime,

at 3 AM and in the morning before

you eat.

2. Pick a day when your bedtime

glucose is close to your goal range.

3. Set your alarm for 3 AM and write down

your blood glucose value after you test

(it is too easy to go back to sleep and

forget the reading you got at 3 AM).

4. In the morning check your pre-

breakfast reading.

5. Using the graph below (Figure 4),put a dot that matches each of your

blood glucose readings - at bedtime,

3 AM and fasting (pre-breakfast).

6. Connect the dots.

ADJUSTING THE BASAL INSULIN DOSE

Bedtime 3:00 AM Pre-Breakfast

400

300

200

100

0Bed 3 AM

Time

B l o o d G l u c o s e

Fasting

Figure 4Graph for Adjusting Basal Insulin


39/53

Pattern What to do... Expected Pattern

A Normal – leave alone Pattern A

B Increase 10 PM - 3 AM Pattern A

C Increase 10 PM - 3 AM Pattern A

D Decrease 10 PM - 3 AM Pattern A or E

E Increase 3 AM - 7 AM Pattern A

F Decrease 3 AM - 7 AM Pattern B or C

7. Your graph should look like one of the 6 patterns shown in the next graph

(Figure 5) and labeled A-F.

8. Select the example that looks the closest to the pattern of your Basal Insulin in

Figure 4.

9. Look up the change in Table 1 below. The table below will indicate the change to

your basal dose that is needed.

Pattern What to do... Expected Pattern

A Normal – leave alone Pattern A

B Increase Lantus®

or Ultralente™ Pattern AC Reduce bedtime snack, keep insulin dose the same Pattern A

D Decrease Lantus® or Ultralente™ Pattern A or E

E Increase or add bedtime Lantus® or Ultralente™ Pattern A

F Decrease bedtime Lantus® or Ultralente™or reduce bedtime snack

Pattern A

Table 1: Changes to Basal Insulin

Changes to Basal for an Insulin Pump

Changes to Basal for Lantus® or Ultralente™

400

300

200

100

0Bed 3 AM

Time


Fasting Bed 3 AMTime





Fasting

A B C D E F

Figure 5Patterns of Overnight Blood Glucose Values


40/53

For many people, the suggestion under

the column, What to Do will correct theproblem and give an expected normal

pattern A. In some cases, the pattern

may require more than one change.

The result of the first, usually safer

change is shown under the column,

Expected Pattern. You may want to

make a second change based upon the

new problem. Talk to your Diabetes

Team about how that change should be

made. Changing more than one dose of

insulin at a time can be complicated and

should be left to your Diabetes Team.

How much to change the insulin is

very individual, please check with your

Diabetes Team for advice. It is safest to

make small changes often rather than

big changes infrequently.

Testing the Daytime Basal

Your health care provider may ask you

to check your daytime basal dose. Here

are a few methods to use. Follow your

provider’s best recommendation for your

individual case.

Option I: Skip a meal

(the simplest method).

• Day 1 - skip breakfast, then checkyour blood glucose every 2 hours,

until lunch)

• Day 2 – skip lunch and check your

blood glucose every 2 hours, until

dinner

• Day 3 – skip dinner, again checking

your blood glucose every 2 hours,

until bedtime

• In all cases, if your blood glucose

is rising, your basal is too low; if

it is falling, your basal is too high.

Blood Glucose Results to Test Daytime Basal Rate

Time of Day

Meal

Breakfast - Day 1

Lunch - Day 2

Lunch - Day 3


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Option II: See if your basal rises after

your last bolus has finished working.(This only works with rapid or short-

acting insulin.)

• Measure your blood glucose four

hours after you take your rapid orshort-acting insulin.

• Continue to measure your blood glucose

every hour until you are sure that your

blood glucose is not rising or falling.

Blood Glucose Results to Test Daytime Basal Rate

Option III: Delay a meal and measure

the effect on your blood glucose.

Whichever method you choose, decide

if you need a change in your basal dose

and do it very carefully. Your Diabetes

Team may recommend that you collect

data over two time periods before

making a change. It is also advised that

this process be used on nights or days

when your activity level is similar to your

usual pattern. Small dose changes can

have a BIG effect on your blood glucose

levels!

After you make your adjustments, keep

checking your blood glucose closely for

the next few days. You need at least 4

days to 1 week to see if your adjustment

resulted in better blood glucose control.

An adjustment on the basal rate for

an insulin pump may take less time to

evaluate. Use a chart like the following

to write down your blood glucose results.

Day Breakfast Lunch Bedtime 3 AM

Time of Day

Meal

Breakfast - Day 1

Lunch - Day 2

Lunch - Day 3


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TROUBLESHOOTING


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Sometimes you may find your blood

glucose levels go up and down wildly,without any pattern that you can figure

out. This might make you feel like giving

up at times. Getting caught up in the

frustration and anger just makes you feel

more upset and hopeless. This section

can help you cope with these feelings

and put you on the right track to finding

the answers you need.

“I am doing everything right and my

blood sugars still aren’t in my goal…

I just don’t understand it anymore!”

If this sounds like you it’s time to:

• Take a deep breath.

• Take a step back.

• Put on your detective hat.• Figure out what is going on!

Here are some guidelines to help you

in your search for the answer. (There is

an answer - really!) Although you may

groan at the suggestion, the best way

to figure out your problem is to keep

written records.

Go back to the drawing

board with a record log thatincludes:

• Pre-meal, 2 hours post-meal and

bedtime blood glucose levels.

• Time you eat.

• Amount of carb you eat.

• Amount and type of insulin you take.

The Food and Carbohydrate CountingRecord on p. 30 may be helpful.

Now it is time to begin your

detective work

Round up the usual suspects and

concentrate. Then ask yourself a few

easy questions. Any time your answer

is YES, place a checkmark in theappropriate box:

1. Insulin:

❑ Is there something wrong with

your insulin? Was it allowed to

get to warm or freeze?

❑ Is it expired?

❑ Are you giving it at the same time

of day? Are you missing doses orgiving it after a meal because you

forgot to give it before?

TROUBLESHOOTING


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2. Absorption of Insulin

❑ Are your injection sites lumpyor scarred?

❑ Do you have any redness around

your injection sites? Are you

having trouble with your insulin

pump infusion site or are you

injecting in a scarred area? (This

could affect how your body is

absorbing the insulin and can

lead to problems with control.)❑ Have you changed how you

give insulin?

❑ Have you changed the brand of

syringe or size of insulin needle?

❑ If you are using an insulin pump,

is the tubing clogged?

3. Stress

❑ Are you experiencing unusual

stress?

❑ Did you know both physical and

emotional stress could affect your

blood glucose levels?

4. Infection

❑ Do you have an infection?

❑ Did you know infections are

a stress to the body and can

increase blood glucose levels?

5. Illness

❑ Are you ill? Do you have a fever,

a cold, or a virus?

❑ Did you know illness could

increase blood glucose levels?

6. Physical Activity

❑ Have you changed your physicalactivity a lot?

❑ Are you more or less active than

usual? (If so, this can increase or

decrease your blood glucose levels)

7. Food

❑ Are you eating more carb and not

taking enough insulin?

❑ Is it possible you are not counting

your carbohydrates accurately?❑ Are you eating at the same time

of day or does it vary?

❑ Are you eating less and taking too

much insulin?

8. Self-Monitoring of Blood Glucose

and Test Strips

❑ Are your test strips outdated or

have the strips been outside the

vial? (This will make your glucose

readings inaccurate.)

❑ Are you checking at the right

time of day to understand the

effect of your insulin, food and

physical activity?

❑ Did you clean your hands before

checking your blood glucose?

Even small amounts of food

residue can affect results.

If you answered YES to any of the above

questions, correct the problem, give

yourself a few days and see if your

blood glucose levels out.

If you answered NO to all of the above

questions, your next step is to sort

through your insulin doses.


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8 AM 12 noon 6 PM 10 PM

BG Ins BG Ins BG Ins BG Ins

Day 1 94 10 L 104 8 L 205 13 L 150 1 LP19 G

Day 2 108 10 L 103 8 L 197 13 L 155 1 LP19 G

Day 3 97 10 L 112 8 L 215 14 L 125 19 G

Now, read the questions below and circle

the letter that you think is the correct

answer to each question.

1. What is the problem?

A. Blood glucose too low at

breakfast?

B. Blood glucose too high at lunch?

C. Blood glucose too high at supper?

D. Blood glucose too low at

bedtime?

2. Which of the following types of

problems does Sam have?

A. A basal problem?

B. A bolus problem?C. An eating problem?

3. What should Sam do?

A. Change the basal insulin glargine?

B. Change the breakfast bolus?

C. Change the lunch bolus?

D. Change the supper bolus?

Which Insulin is the

Problem?

1. Basal Insulin

❑ Am I taking enough or too much

basal insulin?

❑ Are my blood glucose levels

always too high or too low?

2. Bolus Insulin

❑

Is my bolus insulin dose correct?❑ Are my blood glucose levels

too high or too low 2 hours

after eating?

Read the following problem and see if

it can help you figure out your basal-bolus questions. Sam takes 19 units of

insulin glargine (Lantus®) at bedtime and

insulin boluses of insulin lispro (Humalog)

in the following amounts: 10 units for

breakfast; 8 units for lunch, and 12 units for

dinner. His mealtime carb amounts are 75

at breakfast; 60 at lunch; and 100 grams

at dinner. His insulin/carb ratio is 8:1 and

his correction dose is 1 unit for every 50

mg/dl and his target glucose is 100 mg/dl.

On days 1-3 he always eats his normal

amount of carb. He does not eat an

afternoon snack. Look at his blood glucose

values and insulin doses in the chart below.


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4. How much of an adjustment is

needed?A. Decrease 1-2 Units

B. Increase 1-2 Units

C. Increase 3-4 Units

D. Increase 5-6 Units

ANSWERS:

1. C – Sam has detected that he is

always too high at supper.

2. B – This is a bolus pattern thatrequires adjustment.

3. B – He should change his lunch bolus

4. B – He should increase his lunch bolus

(insulin lispro Humalog®) by 1 Unit.

He should check back in 3 days to

see if this was enough.

Notice that while his dinner glucose

values were too high, Sam was takinga correction dose of 1 unit of insulin

for day 1 and 2. Since his blood glucose

values were too high by about 75 mg/dl

this was not enough and on day 3 he

increased the correction to 2 units of

insulin lispro (Humalog®).

If you have remaining basal-bolus

questions, check back with yourDiabetes Team.


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PROBLEM SOLVING AND EXERCISES


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Use the problems and exercises in

this section to help you reinforce andstrengthen what you have learned

about insulin adjustment. The more

experienced you become at spotting

problems and figuring out the answers,

the more rewards you will enjoy from

practicing basal-bolus insulin therapy!

Sally’s on Goal at Bedtime but Gets

High Readings in the MorningSally has been using an insulin pump for

3 months. Her basal rate is set at 0.7

units per hour from 10 PM to 3 AM and

her daytime basal rate is 0.5 units per

hour. She has been going to bed with

normal blood glucose values but always

wakes up with blood glucose levels over

165 mg/dl. She increased her basal rate

from 10 PM to 3 AM from 0.6 to the

current rate of 0.7 units per hour but

is still having a problem.

Q – What should Sally do to try to

bring her morning blood glucose level

to her goal range of 90-130 mg/dl?

A. Increase the basal rate from

10 PM to 3 AM?

B. Increase the daytime basal rate

by 0.2 units per hour?C. Set her alarm and check her

blood glucose level at 3 AM?

D. Give a bolus at 10 PM?

A – Choice C is the correct answer - the

only way to find out what is happening

to Sally’s blood glucose level during the

night is to test it at 3 AM. Choice A -

Increasing the basal rate overnight mightcause hypoglycemia in the middle of the

night. Choice B - Increasing her daytime

basal rate would do nothing to help the

overnight blood glucose levels. Choice D -

Giving a bolus at 10 PM could cause a

problem with hypoglycemia at midnight.

Q – What should Sally do if she

checks her blood glucose at 3 AMand discovers that it was 60 mg/dl?

A. Lower the 10 PM to 3 AM basal rate?

B. Eat a big snack at 10 PM?

C. Decrease the snack bolus?

D. Increase the 10 PM to 3 AM basal rate?

A – Choice A is the correct answer.

Sally has pattern D.

PROBLEM SOLVING AND EXERCISES

400

300

200

100

0Bed 3 AM

Time







Fasting

A B C D E F

Figure 5Patterns of Overnight Blood Glucose Values


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By lowering the 10 PM to 3 AM

basal rate, Sally can avoid becominghypoglycemic at 3 AM. By doing this,

she may find that her fasting blood

glucose level normalizes because she will

not get a rebound high blood glucose in

the morning. The other choices will not

result in preventing hypoglycemia at 3

AM. If her morning glucose rises higher,

she can increase her 3 AM to 7 AM bolus

dose.

Jack Needs Help Figuring Out His

Bolus Dose for Certain Meals

Jack takes a bedtime basal dose of insulin

glargine (Lantus®) of 20 units and bolus

meal doses based on a carb:insulin ratio

of 12 grams of carbohydrate/unit and an

insulin sensitivity factor (ISF) of 1 unit for

every 40 mg/dl. His goal blood glucose

range is 90-130 mg/dl, with a target of

100. He exercises regularly and seems

to do well on his current basal dose of

insulin glargine.

Q – What should Jack’s bolus dose be

for the following breakfast meal?

• His pre-meal blood glucose is 112

mg/dl.

• He will have 2 slices of toast,

1 orange, 1 slice of cheese,

1 cup of milk and coffee.

A – Jack needs 5 units of rapid- or short-

acting insulin for his meal of 60 gramsof carb with a blood glucose within his

blood glucose goals.

Q – Can you find Jack’s bolus dose

for the following dinner?

• Jack’s pre-dinner meal blood glucose

is 212 mg/dl.

• He is planning to eat 2 pieces of

bread, a salad with croutons anddressing, steak; large baked potato,

side order of peas and broccoli. For

dessert he will have 1/2 cup of vanilla

ice cream with a small cookie.

• Use this space to figure out Jack’s

bolus dose before peeking at the

following answer!

Planned Food (Carbs) _____Carbs

Divided by Carb/Insulin Ratio _____Carbs/U ofInsulin = ___units of insulin

Current blood glucose _____mg/dl

What is Jack’s target blood glucose? _____mg/dl

Current blood glucose - target blood glucose_____ mg/dl

What is Jack's Insulin sensitivity factor? _____

Divide Jack's blood glucose calculation byInsulin sensitivity

_____ U of insulin

_____ Total Dose


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A – Jack needs 13 units of insulin.Here’s why!

• His carbs total 120 grams (bread =

30 grams, croutons = 15 grams,

large baked potato = 30 grams,

peas = 15 grams, ice cream and

cookie = 30 grams

• His carb:insulin ratio is 12:1

• 120 divided by 12 grams of carb per

unit of insulin = 10 units.

[ 120 grams of carb =10 units]12 grams of carbper unit of insulin

• His blood glucose is 82 mg/dl over his

target [212 – 100 = 112]

• 112 divided by Jack’s ISF of 40 = 2.8

units, round to 3 units.

• 3 units + 10 = 13 units (Jack’s total

bolus insulin dose for dinner)

(correction dose + dose to cover meal

based on carb:insulin ratio = total bolus)

Jack Wants to Exercise More

to Lose Weight – Should His

Insulin Dosing Change?

Jack thinks he could look better and

decides to increase the intensity of his

exercise program to lose weight. He has

increased his walking from 20 minutes to

45 minutes of brisk daily walks. Jack’s

blood glucose levels for the past 5 days:

Pre-breakfast Pre-lunch Pre-dinner Bedtime

100 70 89 72

85 100 88 65

68 87 92 60

90 68 66 80

83 77 62 79

Q – What should he do now?

1. Change his insulin:carb ratio?

2. Increase the amount of food he eats?

3. Lower his basal insulin glargine?

4. Change the insulin sensitivity factor

to 1 unit for every 25 mg/dl?

A – Looking at the pattern of blood

glucose levels, it is clear that all the

values are lower than the desired target

of 100 mg/dl. The best response is

Choice 3 – to lower the basal insulin

glargine by 1-2 units, which will help

bring the blood glucose levels higher

overall. Choice 1 – any change to the

bolus dose from changing his carb:insulin

ratio will have little effect for the entire

day. Choice 2 – increasing the amount

of food, will onl

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