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TARGET THERAPY
Staying on Target
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Your Insulin Adjustment Workbook
Yes, You Can Do It!
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
INTERACTIVE TABLE OF CONTENTS
To go directly to the topic of interest, click on the link below.
Managing Your Blood Glucose....................2
Calculating Your Insulin
Sensitivity Factor (ISF)................................19
Practicing Flexible / Intensive Therapy..........2
Insulin/Blood Glucose Formula ............19
Responsibilities / Rewards of Basal-Bolus ....2
Rule of 1500 ......................................21
‘Normal’ Insulin Delivery ............................3
Rule of 1700 ......................................23
TERMS TO LEARN FIRST ..........................4
Correcting for Known Changes
in Meals or Exercise ..................................25
Blood Glucose Goals ..................................5
Correcting for a Change in Meals ......25
Target Glucose............................................5
Calculating Your Carb:Insulin Ratio ....25
Algorithm ..................................................5
Method I ............................................26
Basal Insulin................................................6
Method II ............................................26
Bolus Insulin ..............................................6
Correcting for a Known
Change in Exercise ..............................29
WHAT IS BASAL-BOLUS? ........................1
Insulin Adjustment and
Pattern Management..................................7
Insulin Sensitivity Factor (ISF)
and Correction ..........................................7
PUTTING IT ALL TOGETHER ..................30
Getting Started: A Five-Step Plan ..............31
Peak Action ................................................8
Practice Problems......................................31
MAKING BOLUS INSULIN CHANGES ......9
ADJUSTING THE BASAL DOSE ..............34
Understanding How Insulin Works ............10
Testing the Nighttime Basal ......................35
Blood Glucose Monitoring:
When to Test ............................................12
Testing the Daytime Basal ........................37
Making Changes Using
Pattern Management................................13
Option II..............................................38
Correcting for Blood Glucose
That is Out of Range ................................17
Correction Method I............................18
Option I ..............................................37
Option III ............................................38
TROUBLESHOOTING ..............................39
PROBLEM SOLVING AND EXERCISES ....44
Correction Method II ..........................18
Correction Method III ..........................19
SEE – YOU REALLY CAN DO IT! ............49
WHAT IS BASAL-BOLUS?
1
WHAT IS BASAL-BOLUS?
When you have diabetes, it is important
to avoid high and low blood glucose
(sugar). This section reviews how outof-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 means
that 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 professionals
to 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
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%.
2
•
Deciding on your insulin dose
according to the amount of carb
you 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.
This insulin is released as a “squirt”
or a “pulse” that is called a bolus. In
someone 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 shows
the 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.
Figure 1
Normal Insulin Delivery in People
without Diabetes
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.
High
Normal
Low
Blood Insulin
A diabetes-free pancreas releases a small
amount of insulin throughout the day
and 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:
Blood Glucose
‘Normal’ Insulin Delivery –
Bolus
Basal
Midnight
3
AM
6
AM
9
AM
Noon
3
PM
6
PM
9
PM
Midnight
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.
3
TERMS TO LEARN FIRST
4
TERMS TO LEARN FIRST
The goal of flexible therapy is to imitate
the way a normal pancreas works. In
someone 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 insulin
that 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 Short
Acting Insulin
If your Blood
Glucose is:
Your Rapid-Acting
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 if
your blood glucose level were 184 mg/dl,
you would need to take 4 units of rapid or
short acting insulin before breakfast.
5
NOTE: For an algorithm to work you
need to eat the same amount of food
and 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
•
Ultralente™ - occasionally used as
basal insulin, does have some peak
action. (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.
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:
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:
•
•
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.
Bolus Insulin – Taken before you
Insulin Lispro (Humalog®), Insulin
Aspart (Novolog®), Insulin glulisine
(Apidra™) or
• Regular insulin, which is referred to
as a short-acting insulin.
6
Insulin Adjustment and
Pattern Management –
Insulin Sensitivity Factor
(ISF) and Correction –
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
98 mg/dl
129 mg/dl
250 mg/dl 150 mg/dl
89 mg/dl
105 mg/dl
225 mg/dl 111 mg/dl
102 mg/dl 88 mg/dl
Bedtime
240 mg/dl 138 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.
•
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 to
the 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.
7
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
over target
= correction dose
ISF
[
]
150 = 3
50
If 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 blood
glucose = amount of glucose over target
•
Using Laurie’s ISF, she would divide
25 mg/dl by 50 to find that she would
need 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
over target
= correction dose
ISF
= -0.5 units
[-25
]
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
Insulin
Type of
Insulin
Peak Action
Humalog®,
Novolog®,
Apidra®
Rapid
30 min. to
1 1/2 hours
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
[75 mg/dl – 100 mg/dl = -25 mg/dl]
8
MAKING BOLUS INSULIN CHANGES
9
MAKING BOLUS INSULIN CHANGES
Your first step in learning how to make
these adjustments should be to consult
with 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 longacting), 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 important
to 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 to
help you understand the actions of many
different types of insulin including
Humalog®, Novolog®, Regular, NPH,
Ultralente™, Lantus®, etc.
INSULIN ACTION CURVES
Type of Insulin
Onset of Action
Peak Action
Duration
RAPID ACTING
(Used for bolus
insulin – taken
before eating
and to correct
for a high blood
sugar)
Insulin lispro
(Humalog®),
Insulin aspart
(Novolog®),
Insulin glulisine
(Apidra®)
15 minutes
1/2 to 1-1/2
hours
3 to 5 hours
SHORT ACTING
Regular
1/2 hour
2 to 4 hours
6 to 8 hours
Blood Insulin Level
Insulin Action
6AM
9AM
Noon
3PM
6PM
9PM
MidN
3AM
6AM
9AM
Insulin Commonly Used in Flexible
Insulin Therapy for a bolus dose:
Rapid-acting insulin is the most
common insulin used, but shortacting insulin is also used for
this purpose.
10
Insulin Action
Type of Insulin
Onset of Action
Peak Action
Duration
LONG ACTING
(Use for basal
insulin – taken
in injection or
in a pump to act
through day and
night to keep
blood glucose
levels stable)
Ultralente™
Approx.
4 to 8 hours
12 to 18 hours
Approx.
24 to 28 hours
Lantus®
2 to 4 hours
No peak, stable
24 hours
Blood Insulin Level
The most common insulin used for
basal doses is Lantus®, although
Ultralente™ can also be used.
6AM
9AM
Noon
3PM
6PM
9PM
MidN
3AM
6AM
9AM
Insulin Action
Type of Insulin
Onset of Action
Peak Action
Duration
INTERMEDIATE
NPH, Lente
1 to 3 hours
6 to 12 hours
18 to 24 hours
Blood Insulin Level
NPH insulin may be used as a partial
basal dose in the evening. This is
most commonly used with shortacting (regular) insulin as a bolus dose.
6AM
9AM
Noon
3PM
6PM
9PM
MidN
3AM
6AM
9AM
Fill in the chart/graph below to show the action of the types of insulin you are taking now:
My Bolus __________________ insulin:
Starts to work at: ____________________________
Peaks (Works hardest from) __________________
Lasts until: ____________________________________
My Basal__________________ insulin:
Starts to work at: ____________________________
Peaks (Works hardest from) __________________
Lasts until: ___________________________________
Graph your insulin curves below:
7AM
Noon
6PM
12MN
7AM
11
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 glucose
before 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 insulin
on your blood glucose at different
times of day.
Figure 3
Effects of Previous Insulin Dose on
Blood Glucose Readings Tested at
Mealtimes and Bedtime
Insulin Dose
Blood Glucose
Breakfast Lispro
Breakfast BGM
Lunch Lispro
Lunch BGM
Supper Lispro
Supper BGM
Bedtime Lantus
Bedtime BGM
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.
12
Making Changes Using
Pattern Management
You 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.
Three-day Blood Glucose Record:
Pre-meal Goals 90-130 mg/dl
Post-meal Goals < 180 mg/dl
Day #
Breakfast
Pre
Lunch
Post
Pre
Dinner
Post
Pre
Bedtime
3 AM
Post
Day 1
Day 2
Day 3
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.
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.
13
Q&A PRACTICE PROBLEMS
Q – What is the Pattern in Jane’s Three-day Blood Glucose Record?
Pre-meal goals 90-130 mg/dl
Day #
Breakfast
Pre
Post-meal goals < 180 mg/dl
Lunch
Post
Pre
Dinner
Post
Pre
Bedtime
Post
1 – Mon
90
125
110
189
2 – Tues
75
134
116
210
3 – Wed
100
141
131
196
133
119
198
Average 88
3 AM
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.
Q – Does Jane Need an Insulin
Adjustment?
A – Maybe! But first she should think
about whether she had eaten too much
carb 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 insulin
needs 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!
14
Q – What is Different About Tom’s Three-day Blood Glucose Pattern?
Pre-meal goals 90-130 mg/dl
Day #
Breakfast
Pre
Post-meal goals < 180 mg/dl
Lunch
Post
Pre
Dinner
Post
Pre
Bedtime
Post
1 – Mon
90
125
110
239
2 – Tues
75
134
116
73
3 – Wed
100
141
131
266
133
119
193
Average 88
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.
•
•
•
3 AM
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 to
make 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 you
should 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
15
range without any insulin changes.
Always make insulin dose changes only
after a full examination of the blood
glucose levels and do it carefully!
If you are unsure, consult with your
Diabetes Team.
Record Your Blood Glucose for the Past 3 Days and Pick Out the Patterns You See
Pre-meal blood glucose goals:________
Post-meal blood glucose goals:________
Day #
Breakfast
Pre
Lunch
Post
Pre
Dinner
Post
Pre
Bedtime
3 AM
Post
1 – Mon
2 – Tues
3 – Wed
Average
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 over
the 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.
16
Correcting for Blood Glucose
That is Out of Range
Know Your Blood Glucose Goals
In this workbook, the American Diabetes
Association (ADA) recommended premeal 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 use
a 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 usual
insulin 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 do
this 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 at
breakfast 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.
17
Ken’s Algorithm for Correction Method 1
Blood Glucose Values
Insulin Dose (Rapid or Short -Acting)
Breakfast
Lunch
Supper
Bed
<50
6
8
9
0
50-69
8
10
11
0
70-89
9
11
12
0
90-130
10
12
13
0
131-160
11
13
14
1
161-190
12
14
15
2
191-220
13
15
16
3
221-250
14
16
17
4
251-280
15
17
18
5
281-310
16
18
19
6
Over 310
18
20
20
8
Correction Method I – How to Use
an Algorithm
1. Use the algorithm for a week or two.
2. Monitor your blood glucose often.
3. Record every reading in your logbook.
4. Share your results by fax, phone or
in person with your health team member.
5. Your health team member will work
with you to make any needed
adjustments to your algorithm.
6. After a little practice, you will be able
to use the algorithm with confidence
on your own.
HINT:
Remember, for this method to work well
you need to eat the same amount of
carbs at breakfast, lunch and dinner
from day to day!
Correction Method II – Change
in Insulin Dose Based on Blood
Glucose Value
Your Diabetes Team prescribes a fixed
amount of pre-meal insulin to use for
every high, out-of-goal blood glucose
reading. Uses an algorithm that tells
you how much insulin to add or subtract
from your usual dose, depending on
your current blood glucose value.
EXAMPLE:
Joe’s fixed dose of rapid or short acting
insulin before breakfast and lunch is 6
units, and his pre-dinner dose is 8 units.
His doctor gives him an algorithm of
blood glucose values and pre-meal
rapid- or short-acting insulin.
18
Joe’s Algorithm for Correction Method II
Blood Glucose Values Pre-meal rapid or
short 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 units
Over 400
Add 8 units
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. (See
p. 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 shortacting insulin (Regular).
3. Rule of 1700 - if you are using rapidacting 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.
19
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 units
50
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 units
50
• 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
Pre-Breakfast
Pre-Lunch
Pre-Dinner
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 glucose
reading 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 no
20
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.
EXAMPLE:
Calculate Rita’s ISF Using the Rule of
1500.
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.
ISF Method II – Using the ‘Rule of
Dividing 50 units into 1500 would = 30.
1500’ – To get a good first guess at your
insulin sensitivity, divide the sum of all of
your daily insulin doses into 1500.3
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 Regular
12 units Insulin Regular
13 units Insulin Regular
+ 15 units Insulin Lantus®
50 units
2) Divide sum of insulin
doses into 1500
1500
= 30 mg/dl
50 units of insulin
PRACTICE PROBLEMS:
1. Calculate your ISF using the Rule
of 1500.
Fill in all the insulin doses you take in one
day and add them up:
# of units
Type of insulin
3) Answer = ISF
Insulin Sensitivity Factor =
1 unit of short or rapid acting insulin will lower
blood glucose 30 mg/dl
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).
Total units/day
3 Klingensmith, GJ. American Diabetes Association, Intensive Diabetes Management, Third Edition, 2003.
p. 107. 2003.
21
Fill in your pre-meal blood glucose
values from yesterday and calculate
your adjusted insulin dose using the
steps below:
Pre-Breakfast Pre-Lunch
Fill in the table below with your
calculations using your own
information:
Usual Insulin
Dose
Pre-Dinner
Adjusted
Insulin Dose
Pre-Breakfast
Pre-lunch
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 _____ = ______.]
Pre-dinner
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 within
your 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
Subtract from your usual pre-meal dose.
[Usual dose – __________ = __________.]
4 American Diabetes Association, Intensive Diabetes Management, third Edition, p. 107. 2003.
22
EXAMPLE:
If you take 10 units of Humalog® at
breakfast, 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 up
to 35). So as a first guess, each unit of
insulin would lower your blood glucose
by 35 mg/dl.
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 insulin
doses into 1700
1700
= 34 mg/dl
50 units of insulin
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:
# of units
3) Answer = ISF
Insulin Sensitivity Factor =
1 unit of short or acting
insulin will lower blood
glucose 34 mg/dl
Figure out your adjusted insulin dose
based on your pre-meal blood
glucose readings:
Target Goal = ______________
Pre-Breakfast Pre-Lunch
Pre-Dinner
Type of insulin
Fill in your pre-meal blood glucose values
from yesterday in the chart above.
Circle your high pre-meal blood glucose.
Total units
per day =
Divide 1700 by your total units of insulin/day.
1700
= ________
Subtract your target goal from your high
blood glucose reading.
_______ – ________ mg/dl = _________
Target Goal
Divide this number by your ISF.
= ________
(your total units/day)
The answer is your ISF (the number of
points one unit of insulin will lower your
blood glucose).
(ISF)
Add the answer to your usual pre-meal
dose.
23
If you had a “low blood glucose”
yesterday, figure out your correction
insulin 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.
________ – _________ = _____________
Every time you take a correction dose for
an out of goal blood glucose you should
note 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.
Fill in the table below with your
calculations using your own
information:
Usual Insulin
Dose
Adjusted
Insulin Dose
Pre-Breakfast
Pre-lunch
Pre-dinner
24
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. Check
with your Diabetes Team to see which
method they recommend for you.
Both methods require that you learn how
to count carbohydrates. In addition, you
also 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 concerns
about high or low blood glucose.
25
Method I: A Quick and Easy Way
to Start
Before 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 Week
The 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, use
tables 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.
26
Food and Carbohydrate Counting Record
Brkfst
time:
AM Carb
PM goal:
gms
BG before
meal
Food Eaten
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
BG 2 hours
after meal
Insulin
Comments:
Amount
Grams Carb
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
Total: _____________________________
Snack Time: Food Eaten
Amount
Grams Carb
_______________ __________________________________ ____________________________ ______________________________________
_______________ __________________________________ ____________________________ ______________________________________
Total: ____________________________
Lunch
time:
AM Carb
PM goal:
gms
BG before
meal
Food Eaten
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
BG 90 min
after meal
Insulin
Comments:
Amount
Grams Carb
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
Total: _____________________________
Snack Time: Food Eaten
Amount
Grams Carb
_______________ __________________________________ ____________________________ ______________________________________
_______________ __________________________________ ____________________________ ______________________________________
Total: ____________________________
Supper
time:
AM Carb
PM goal:
gms
BG before
meal
Food Eaten
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
BG 90 min
after meal
Insulin
Comments:
Amount
Grams Carb
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
Total: _____________________________
Snack
BG before snack_________
Time:
Food Eaten
Amount
Grams Carb
_______________ __________________________________ ____________________________ ______________________________________
_______________ __________________________________ ____________________________ ______________________________________
Total: ____________________________
27
Method I – Insulin Dosing Based on
Carb Intake – A set dose of insulin is
given 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 for
breakfast 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 is
going 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, for
every 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
Carbohydrate
Carb:Insulin Ratio: 10:1
Usual Dose of
Insulin
70 Grams Carb
7 Units Humalog®
90 Grams Carb
9 Units Humalog®
28
Method II – Insulin Dosing Based on
Carb:Insulin Ratio
Unlike 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 a
favorite 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 of
Humalog®
90
[ 10
]
= 9 units of Humalog®
Correcting for a Known Change
in Exercise
Exercise 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.
29
PUTTING IT ALL TOGETHER
30
PUTTING IT ALL TOGETHER
You have learned a lot of information
about making changes to your bolus
insulin 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 Out
Let’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 rule
of 500, 500/50 = 10
• Tom is planning on eating about
90 grams of carbohydrates
• See below for step 5
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
31
Your Night Out –
Using the Five Steps, calculate the answers in the chart below:
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
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
60/8
=
8 Carbs/U of Insulin
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
_______________________
Insulin Sensitivity
=
80
__
30
=
+ 2.5 U of insulin
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
32
After correcting for food, elevated blood
glucose and expected exercise, you
would 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 exercise
will 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 over
250 mg/dl.6 Do not exercise when
you have ketones in your urine.
Eat a carb food if blood glucose levels
are <100 mg/dl.
This is a lot to take in at first, but most
people get very good at doing these
calculations and quickly learn to keep
their blood glucose levels very close to
normal. It is helpful to have a small
calculator when you begin.
6 American Diabetes Association, Position Statement: Physical Activity/Exercise and Diabetes. American Diabetes
Association: Clinical Practice Recommendations, Diabetes Care. 27:Sup1:1, S58-S62. January 2004.
33
ADJUSTING THE BASAL INSULIN DOSE
34
ADJUSTING THE BASAL INSULIN DOSE
Adjusting the basal dose is more
challenging than changing the bolus
dose. 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.
How to Test and adjust The Basal
Insulin To Normalize Your Morning
Blood 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).
Bedtime
3:00 AM
Pre-Breakfast
Testing the Nighttime Basal
Figure 4
Graph for Adjusting Basal Insulin
400
300
Blood Glucose
Adjusting the basal insulin is done
much less often than the bolus insulin
corrections. 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.
4. In the morning check your prebreakfast 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.
200
100
0
Bed
3 AM
Time
Fasting
35
7. Your graph should look like one of the 6 patterns shown in the next graph
(Figure 5) and labeled A-F.
Figure 5
Patterns of Overnight Blood Glucose Values
Blood Glucose
400
A
300
B
C
D
E
F
200
100
0
Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting
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.
Table 1: Changes to Basal Insulin
Changes to Basal for an Insulin Pump
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
Changes to Basal for Lantus® or Ultralente™
Pattern What to do...
Expected Pattern
A
Normal – leave alone
Pattern A
B
Increase Lantus® or Ultralente™
Pattern A
C
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
36
For many people, the suggestion under
the column, What to Do will correct the
problem 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 check
your 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
37
Option II: See if your basal rises after
your last bolus has finished working.
(This only works with rapid or shortacting insulin.)
•
•
Measure your blood glucose four
hours after you take your rapid or
short-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
Time of Day
Meal
Breakfast - Day 1
Lunch - Day 2
Lunch - Day 3
Option III: Delay a meal and measure
the effect on your blood glucose.
have a BIG effect on your blood glucose
levels!
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
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
38
TROUBLESHOOTING
39
TROUBLESHOOTING
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!”
Go back to the drawing
board with a record log that
includes:
•
•
•
•
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 Counting
Record on p. 30 may be helpful.
Now it is time to begin your
detective work
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.
Round up the usual suspects and
concentrate. Then ask yourself a few
easy questions. Any time your answer
is YES, place a checkmark in the
appropriate 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 or
giving it after a meal because you
forgot to give it before?
40
2. Absorption of Insulin
❑ Are your injection sites lumpy
or 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 physical
activity 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.
41
Which Insulin is the
Problem?
Read the following problem and see if
it can help you figure out your basalbolus 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.
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?
8 AM
12 noon
6 PM
10 PM
BG
Ins
BG
Ins
BG
Ins
BG
Ins
Day 1
94
10 L
104
8L
205
13 L
150
1 LP
19 G
Day 2
108
10 L
103
8L
197
13 L
155
1 LP
19 G
Day 3
97
10 L
112
8L
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?
42
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 that
requires adjustment.
3. B – He should change his lunch bolus
4. B – He should increase his lunch bolus
(insulin lispro Humalog®) by 1 Unit.
Notice that while his dinner glucose
values were too high, Sam was taking
a 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 your
Diabetes Team.
He should check back in 3 days to
see if this was enough.
43
PROBLEM SOLVING AND EXERCISES
44
PROBLEM SOLVING AND EXERCISES
Use the problems and exercises in
this section to help you reinforce and
strengthen 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!
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
Sally’s on Goal at Bedtime but Gets
High Readings in the Morning
Sally 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.
night is to test it at 3 AM. Choice A Increasing the basal rate overnight might
cause 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 AM
and 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?
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?
A – Choice A is the correct answer.
Sally has pattern D.
Figure 5
Patterns of Overnight Blood Glucose Values
Blood Glucose
400
A
300
B
C
D
E
F
200
100
0
Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting Bed
3 AM
Time
Fasting
45
By lowering the 10 PM to 3 AM
basal rate, Sally can avoid becoming
hypoglycemic 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 shortacting insulin for his meal of 60 grams
of 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 and
dressing, 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 of
Insulin = ___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 by
Insulin sensitivity
_____ U of insulin
_____ Total Dose
46
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
12 grams of carb
per unit of insulin
=10 units]
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 only result in higher bolus
doses and perhaps a weight gain, neither
of which is desired. Choice 4 – changing
the insulin sensitivity factor will result in
higher doses of insulin and lower blood
glucose values.
47
Juan Has Had a Change in His
Blood Glucose Levels
Juan has had blood glucose levels within
his goal range for the past several
months on his basal/bolus insulin
regimen of 10 units insulin glargine
(Lantus®) and pre-meal insulin doses
of 6 units of insulin aspart (Novolog®).
He uses an ISF of 1 unit for every 50
mg/dl and a target of 100 mg/dl.
For the past 4 days his blood glucose
values have increased to over 140 mg/dl
consistently. He has not changed
anything in his routine and is not sick.
He always carries his insulin aspart with
him in the car so it is available if he
decides to stop and eat.
Q – What Could Have Made Juan’s
Blood Glucose Reading So High Over
the Past Four Days?
1. His car might have been too hot,
causing his insulin not to work.
2. Juan might have been under a great
deal of stress.
3. His blood glucose test strips might
have expired.
A – Any or all of the above choices could
be correct. Choice 1 – Insulin must
always be kept at least at room
temperature. Juan would have to
open a new bottle and watch his
glucose levels closely. Choice 2 – If
Juan is having unusual stress, he might
need a small adjustment in his insulin
while this is going on. Choice 3 –
Expired blood glucose test strips could
be giving him inaccurate readings.
48
SEE – YOU REALLY CAN DO IT!
49
SEE – YOU REALLY CAN DO IT!
This workbook is only a starting point
and guideline in your move to flexible
therapy with basal-bolus insulin
adjustment. The best approach is to
consult your Diabetes Team and work
on this together. If things go out of
control, refer back to this “how-to”
guide and do some of the exercises.
Like anything new, basal-bolus therapy
is not easy at first and you will need help
in learning how to adjust your insulin
for food, activity, sleeping and waking.
However, once you have learned these
skills, you should be able to get your
diabetes under excellent control and
live a more flexible, healthy life.
Written by:
Marjorie Cypress, RN, MSN, C-ANP, CDE
Albuquerque, NM
We wish to acknowledge the following health professionals for reviewing this publication and providing their valuable insights:
Jean E. Betschart Roemer, CPNP, MSN, MN, CDE
Pittsburgh, PA
Linda Urso, APRN, BC-ADM
Warren, MI
Kathleen C. Arnold, CS-ANP, BC-ADM, CDE
Gulfport, MS
BD and BD Logo are trademarks of Becton, Dickinson and Company. ©2005 BD.
All other brands are trademarks of their respective owners.
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