CDA Professional Conference October 2004 Making Carbs Count: Advanced Carbohydrate Counting for Intensive Diabetes Management Case Study #1
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1 CDA Professional Conference October 4 Making Carbs Count: Advanced Carbohydrate Counting for Intensive Diabetes Management Case Study #1 Guy is a pleasant 3 year old male who has had type 1 diabetes for years. Last year he came to see you to learn about basic carbohydrate counting. He has been carbohydrate counting and trying to follow a consistent carbohydrate meal plan since that time. Guy is coming to learn advanced carbohydrate counting skills because he wants to improve his glycemic control and have a more flexible lifestyle. Ht: 6 (183 cm) Wt: 183 lbs. (83 kg) BMI = 4.8 Guy s insulin: u intermediate-acting insulin bid 8 u -acting insulin with meals Total daily dose (TDD) = 48 u/day Guy s target blood glucose levels: ac meals 4-7 mmol/l hr pc meals 5-1 mmol/l Guy s latest HbA1C = 7.9 Guy brings detailed food records to his appointment. Questions/Problems 1) Examine Guy s initial food records of August 19, and 1. What are the first steps that should be taken in teaching Guy advanced carbohydrate counting? (5 min) Calculating insulin:carb ratios ) Calculate Guy s insulin:carb ratio using all 3 methods. (6 min) a) Method 1: Pattern Management for any meals that are applicable (i.e. when # units of insulin taken seem to give appropriate control for grams of carbohydrate eaten) b) Method : 5 TDD c) Method 3: TDD basal insulin requirement = bolus requirement Average CHO eaten/day bolus requirement = insulin:carb - 1 -
2 CDA Professional Conference October 4 Case Study #: Determining insulin to carb ratio using Pattern Management and carb choices Samantha is Guy s supervisor at work (weight 6 lbs/118 kg; math reluctant ). She has type diabetes, is on an insulin pump and prefers to work in carbohydrate choices. (1 carb choice = 15 g carbohydrate) 3) Examine Samantha s food record. Calculate her insulin:carb choice ratio at all meals. ( min) Calculating Insulin Sensitivity Factors (ISF) 1 TDD for R/A (-acting) insulin OR 85 TDD for R(Regular) insulin or insulin-resistant individuals 4) Calculate Guy s ISF from his food records. (1 min) Using ISF to calculate a supplemental dose (Current BG goal BG) ISF = supplemental dose 5) Guy s BG before lunch is 1. mmol/l but his pre-meal target is 6 mmol/l. If his ISF is, what is his supplemental dose at lunch? (1 min) Applying the Principles 6) Using the following information and the food lists provided, calculate Guy s lunch time insulin dose. (5 min) Pre-meal target BG = 6 mmol/l insulin:carb ratio = 1 ISF = # grams of carbs Ham & cheese sandwich :3 ml juice box (orange) ml strawberry yogurt medium apple 5 g bag chips 7) Examine Guy s follow-up food record. Assess it for how well Guy has applied the information he has been taught. What changes can you find? ( min) - -
3 CDA Professional Conference October 4 Advanced Carbohydrate Counting Daily Worksheet: Grams of Carb DATE Thursday August 19, 4 For: Guy (Initial) 7: am 6.3 Two hour BG: 7.8 * 1: am :45 pm 6.9 Two Hour BG: 7. :45 pm 7. 6:3 pm 6.9 Two hour BG: 3.8 1:3 pm 9.8 Bedtime Glucose: 9.8 1:3 pm toastª + 1 tsp margarine slices cheddar cheese coffee with 1 tsp sugar 1 cup 1% milk 1 medium orangeª At work (sitting) Coffee with 1 packet sweetener and 1 milker Tuna sandwich on ww breadª Tossed salad with oil & vinegar 5 g bag chipsª 1 medium appleª diet pop # grams of carbs At work (sitting) Diet pop Hamburger on bun with mustard Tossed salad w. Italian dressing +1/ c. croutonsª Small cob of cornª ½ c fruit saladª + whipped cream ate chocolate bar to treat low Bowling for 1 hour (7-8 pm) 1 cup milk 1 toastª with peanut butter Bolus: 8_ Total Taken: Bolus: 8_ Total Taken: Bolus: 8 Total Taken: ª Nutritional information from resource My Insulin:Carbohydrate ratio is: unit for grams of carbohydrates (breakfast) My Insulin:Carbohydrate ratio is: unit for grams of carbohydrates (lunch) My Insulin:Carbohydrate ratio is: unit for grams of carbohydrates (supper) My Insulin:Carbohydrate ratio is: unit for grams of carbohydrates (bedtime snack) - 3 -
4 CDA Professional Conference October 4 Advanced Carbohydrate Counting Daily Worksheet: Grams of Carb DATE Friday August, 4 For: Guy (Initial) 7: am 9.3 Two hour BG: 6.4 * 1: am 4. :45 pm 3.5 Two Hour BG: 5.1 :45 pm 5.1 6:3 pm 3. Two hour BG:.1 1:3 pm 1.5 Bedtime Glucose: 1. midnight toastª 1 tbsp peanut butter coffee with 1 tsp sugar 1 cup 1% milk 1/ medium grapefruitª 3 (moved boxes and furniture in office) Coffee with 1 packet sweetener and 1 milker Ham and cheese sandwich on ww breadª 3 c.c. cookiesª 1 medium appleª diet pop # grams of carbs At work (sitting) Diet pop Steak 1 cups rice pilaf (long-grain brown) ª Caesar salad (no croutons) 1 cup orange and mango juiceª 3 cc cookies (ate extra for low BG) 1 cup milk 1 toastª with peanut butter Bolus: 8_ Total Taken: Bolus: 8_ Total Taken: Bolus: 8 Total Taken: ª Nutritional information from resource My Insulin:Carbohydrate ratio is: unit for grams of carbohydrates (breakfast) My Insulin:Carbohydrate ratio is: unit for grams of carbohydrates (lunch) My Insulin:Carbohydrate ratio is: unit for grams of carbohydrates (supper) My Insulin:Carbohydrate ratio is: unit for grams of carbohydrates (bedtime snack) - 4 -
5 CDA Professional Conference October 4 Advanced Carbohydrate Counting Daily Worksheet: Grams of Carb DATE Saturday August 1, 4 For: Guy (Initial) 8: am 6.3 Two hour BG: 6.4 1: am 6.4 :45 pm 4.6 Two Hour BG: 6:3 pm 1.8 Two hour BG: 9.5 1:3 pm 8.5 1:3 Bedtime Glucose: 9.9 midnight 1 english muffin 1 tbsp peanut butter tsp diet jam coffee with 1 tsp sugar 1 cup 1% milk 1/ medium grapefruitª # grams carbs Grocery shopping for 1 hour ml juice box (orange)ª Hamburger with mustard Small French friesª 5 g chocolate barª diet pop Watching TV (Olympics) Diet pop while watching TV. Forgot to test hours after lunch. Nibbled on a few snack items. BBQ chicken breast Medium baked potatoª ½ c green beans 1 large cob of cornª 1 c raspberriesª 1 cup milk 1 toastª with peanut butter Bolus: 8_ Total Taken: Bolus: 8_ Total Taken: Bolus: 8 Total Taken: ª Nutritional information from resource My Insulin:Carbohydrate ratio is: unit for grams of carbohydrates (breakfast) My Insulin:Carbohydrate ratio is: unit for grams of carbohydrates (lunch) My Insulin:Carbohydrate ratio is: unit for grams of carbohydrates (supper) My Insulin:Carbohydrate ratio is: unit for grams of carbohydrates (bedtime snack) - 5 -
6 CDA Professional Conference October 4 Advanced Carbohydrate Counting Daily Worksheet: Carb Choices DATE Friday August For: Samantha 7:3 5.9 Two hour BG: 7.4 * 1:3 : Two Hour BG: 7.1 3: :3 pm 1.6 Two hour BG: 8.1 1: Bedtime Glucose: 7.3 midnight 1 English muffin with peanut butter 1 medium orange tea with s/a skim milk 5 g fruit yogurt Walked to work (1/ hour) # carb choices Tea with 1 milker Hamburger Chicken noodle soup (1 cup) Celery sticks and cucumber slices 1 small apple 1 c. skim milk sugar-free cookies plain tea 1 pork chop w. ½ c applesauce 1 medium baked potato w. yogurt tossed salad w. light dressing diet soda ½ c frozen yogurt Walked home from work (1/ hour) 1 cup skim milk 1 slice ww toast with peanut butter Bolus: _16.4_ Total Taken: 16.4 Total Taken: Bolus:_15.5 Correction: Total Taken: 15.5 Total Taken: Bolus: _14.4_ Correction: _4.4 Total Taken: 18.8 Bolus: Total Taken: 51 units/d basal My Insulin:Carbohydrate ratio is: unit for 1 carbohydrate choice (breakfast) My Insulin:Carbohydrate ratio is: unit for 1 carbohydrate choice (lunch) My Insulin:Carbohydrate ratio is: unit for 1 carbohydrate choice (supper) My Insulin:Carbohydrate ratio is: unit for 1 carbohydrate choice (bedtime snack) - 6 -
7 CDA Professional Conference October 4 Advanced Carbohydrate Counting Daily Worksheet: Grams of Carb DATE Saturday August 8, 4 For: Guy (Follow up) 8:3 am 6.9 Two hour BG: 7.7 waffles (frozen) ª 1 tsp margarine tsp maple syrupª coffee with 1 tsp sugar 1 cup 1% milk 1 cup orange and mango juiceª * Shopping (1:15) 1:3 am 7.7 1:3 pm 5.9 Two Hour BG: 7.5 7: pm 9.8 Two hour BG: 8.1 9: pm 8.1 # grams of carbs ml juice box (orange) ª club sandwich on wwª bread 1 cup bean saladª 1 cup fruit saladª diet pop Watching football on TV Diet pop cups spaghettiª+ ¾ cup meat sauceª 1 slice garlic bread Tossed salad w. Italian dressing 1 glass red wine ½ c fruit saladª + whipped cream Went to the movies Diet pop 9 cups popcornª (estimated medium size) Bolus: 11_ Total Taken: 11 Total Taken: Bolus: 1_ Total Taken: 1 Total Taken: Bolus: 1 Correction: Total Taken: Bolus: Total Taken: Bedtime Glucose: :3 pm (note: usual bedtime snack = 8 g carbs with no RA insulin if BG <7.) ª Nutritional information from resource My Insulin Sensitivity is: 1 unit drops blood glucose mmol/l. My Insulin:Carbohydrate ratio is: 1 unit for 8 grams of carbohydrates (breakfast) My Insulin:Carbohydrate ratio is: 1 unit for 1 grams of carbohydrates (lunch) My Insulin:Carbohydrate ratio is: 1 unit for 11 grams of carbohydrates (supper) My Insulin:Carbohydrate ratio is: 1 unit for 15 grams of carbohydrates (bedtime snack) - 7 -
8 CDA Professional Conference October 4 Carbohydrate Resource Sheet: Making Carbs Count Workshop Guy used different resources in addition to food labels and the basic information that he learned using the Good Health Eating Guide Resource to look up carbohydrate values for the items he consumed over the week. Resource Item Portion Listed Grams Carb Apple 7 in diameter 1g.6 g fibre = 18.4 g Orange 1 medium 15.4 g fibre =.6 g Grapefruit ½ medium g fibre = 8 g Nutrient Value of Raspberries, raw 5 ml 8 3. g fibre = 4.8 g Some Common Foods Corn cm cob g fibre = 5.5 g Croutons 5 ml.8 g fibre = 11. g Popcorn 5 ml g fibre = 5.7 g Potato, baked, flesh only Rice, long grain brown, cooked cm long g fibre = 31.6 g 5 ml g fibre = 44.9 g Spaghetti, cooked 5 ml 4.4 g fibre = 39.6 g Syrup, maple 1 ml 9 g Chocolate bar (from package) 5 g bar 6 g Chips, potato (from package) 5 g bag 31 g Cookies, Chocolate chip (from package) 19.8 g Carbs, Carbs and More French Fries (favourite fast food restaurant) Small 3 g Fruit salad, fresh 1 cup g Juice, orange ml g Salad, bean 1/ cup 19 g 4 g fibre = 15 g Sauce, tomato with meat ½ cup 9.8 g Waffles, frozen (from package) g fibre = 3.3 g yogurt, strawberry, low-fat 5 g 19.7 g - 8 -
9 CDA Professional Conference October 4 Carbohydrate Resource Sheet: Making Carbs Count Workshop Granny s Whole Wheat Bread Nutrition Facts Valeur nutritive Per 66 g = slices / par 66 g tranches Paradise Orange and Mango Juice Nutrition Facts Valeur nutritive Per 175 ml serving / par portion de 175 ml Amount % Daily Value Amount % Daily Value Teneur % valeur quotidienne Teneur % valeur quotidienne Energy/Énergie 19 Cal/8 kj Energy/Énergie 87 Cal / 36 kj Fat/Lipides 4 g Protein/Protéines.7 g Saturated/saturés 3 g Fat/Lipides g + Trans/trans 1 g % Carbohydrate/Glucides 1 g 5% Cholesterol / Cholesterol mg Sugars/Sucres 1 g Sodium/Sodium 384 mg 15% Vit C 3% Carbohydrate/Glucides 36 g 9% Fibre/Fibres 4.1 g 16% Sugars/Sucres Protein/Protéines 1.3 g 6.8 g Vit A % Vit C % Calcium.5 % Iron/Fer 18% - 9 -
10 CDA Professional Conference October 4 Advanced Carbohydrate Counting Daily Worksheet: Grams of Carb DATE: FOR: # grams carb Bolus: Two hour BG: Bolus: Two Hour BG: Two hour BG: Bedtime Glucose: My Insulin:Carbohydrate ratio is: unit for grams of carb (breakfast) My Insulin:Carbohydrate ratio is: unit for grams of carb (lunch) My Insulin:Carbohydrate ratio is: unit for grams of carb (supper) My Insulin:Carbohydrate ratio is: unit for grams of carb (bedtime snack) - 1 -
11 CDA Professional Conference October 4 Advanced Carbohydrate Counting Daily Worksheet: Carb Choices DATE: FOR: # carb choices Bolus: Correction: Total Taken: Two hour BG: Bolus: Correction: Two Hour BG: Dinner Correction: Two hour BG: Bedtime Glucose: My Insulin:Carbohydrate ratio is: unit for 1 carb choice (breakfast) My Insulin:Carbohydrate ratio is: unit for 1 carb choice (lunch) My Insulin:Carbohydrate ratio is: unit for 1 carb choice (supper) My Insulin:Carbohydrate ratio is: unit for 1 carb choice (bedtime snack)
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DAY 1 DAY 2 DAY 3 DAY 4. Cereal with Fruit: 1 cup toasted oat cereal 1 medium banana ¼ cup lowfat milk 1 hard-cooked egg Beverage: Water, coffee, tea
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