CARBOHYDRATE COUNTING AND DOSE ADJUSTMENT OF INSULIN

CARBOHYDRATE COUNTING AND DOSE ADJUSTMENT OF INSULIN Information Leaflet Your Health. Our Priority.

of 11 Information for children and young people with Type 1 Diabetes on Carbohydrate Counting Insulin Regimens Contents 1. Why Is Carbohydrate Important? 2. Guide To Identifying Carbohydrate In Your Diet. 3. Types of Carbohydrate. 4. Examples of High Sugar Foods And Low Sugar Alternatives. 5. Why Is Insulin Needed? 6. Types of Insulin. 7. What Is Carbohydrate Counting? 8. Why Is Carbohydrate Counting Helpful? 9. How to Work Out Your Bolus Insulin. 10. How Do You Know If Your Ratio Is Correct? 11. Insulin Correction Factor. 12. Practising Calculating Your Mealtime Insulin Dose. 13. Snacks. 14. Being Active 1. Why is Carbohydrate important? Carbohydrate is an essential nutrient that is an important source of energy in the diet. It must not be excluded from the diet.

of 11 It is important to learn more about carbohydrate because carbohydrate is the main nutrient in food that causes your blood glucose level to rise. Carbohydrate foods include all starches and sugars. Starchy carbohydrate includes bread, pasta, chapattis, potatoes, yam, noodles, rice and cereals. Sugars include table sugar such as caster and granulated (sucrose) and natural sugar in fruit and some dairy foods (see the table in section 2 which is a guide to identifying Carbohydrate in the diet). The actual amount of carbohydrate the body needs varies depending on age, weight and activity levels but it should make up about half of what you eat and drink. For good health, most of this should be from starchy carbohydrate, fruit and dairy, with a small amount of total carbohydrate from sucrose. After eating, carbohydrate is digested (broken down) into glucose which then goes into your blood causing your blood glucose level to rise. The more carbohydrate you eat the more your blood glucose will rise. Glucose is needed by the body s cells to produce energy for all activities, including breathing, walking, running, football and dancing. 2. Guide to identifying Carbohydrate in your diet Foods containing Carbohydrate These foods contain significant amounts of carbohydrate and need to be counted in your diet (see section 7 ) Foods containing little or no Carbohydrate These foods do not need to be counted in your diet.

of 11 Cereal starch Breakfast cereals Bread Flour products e.g. pizza Rice and grains Pasta Noodles Couscous Oats Protein Meat Fish Eggs Cheese Nuts Soya Tofu Quorn Vegetable starch Potatoes and potato products Beans and pulses Sweet potato Yam Natural sugars and Added sugars Fruit and fruit juices Milk and milk products e.g. yogurts Foods containing added sugar e.g. cakes, sweets, chocolates, biscuits, jams, marmalades, Sweet puddings, desserts Fat Butter Margarine Cream Oils Mayonnaise Most vegetables Salads 3. Types of Carbohydrate Some carbohydrates are fast acting; they are quickly digested and make your blood glucose level rise quickly. Some carbohydrates act more slowly; they are slowly digested and make your blood glucose level rise gradually. It is best to include slow acting carbohydrates to help keep your blood glucose levels stable (those in italics below are particularly slow acting) Slow acting Carbohydrates Breakfast cereals: Weetabix, Porridge, Shreddies Breads: wholegrain, granary Pasta and noodles Rice Basmati Beans Milk Fast acting Carbohydrates Sugary drinks(including fruit juice) Sweets Table sugar Lucozade/Energy drinks

of 11 Fruit A diagram to show the impact on blood glucose levels of fast acting and slow acting carbohydrates. Blood Glucose Normal ---- Blood Glucose Range ---- Time after meal 4. Examples of high sugar foods and lower sugar alternatives Foods high in sugar (fast acting carbohydrate) need to be replaced with lower sugar alternatives. It is however quite acceptable to include occasional treats of foods containing sugar. It is best to have such foods after a meal which contains slow acting carbohydrate and to always ensure they are carbohydrate counted. (See Section 7) High Sugar Foods Ordinary fizzy drinks, Coca-Cola, Lemonade, Lucozade Fresh Fruit Juice Ordinary Squash Ordinary Hot Chocolate and Malted Milk drinks Sugar, Glucose Sugar, Chocolate or Honey Coated breakfast cereals e.g. Coco Pops, Frosties, Ricicles, Sugar Puffs, Honey Nut Loops, Frosted Shreddies Ordinary Jam and marmalade, honey, treacle, syrup Low Sugar or Sugar-Free Alternatives Diet, Low Calorie, Slim-line or Sugar free fizzy drinks e.g. Diet Coke, Pepsi Max, Sprite Light Dilute with water Sugar free squash Reduced sugar hot chocolate drinks e.g. Highlights, Options Artificial sweeteners in tablet or granulated form e.g. Canderel, Sweetex, Hermesetas Shredded Wheat, Weetabix, Shreddies, Bran Flakes, Fruit and Fibre, Porridge, Ready Brek Pure fruit spreads or small amounts ordinary jam, marmalade

of 11 Ordinary tinned or instant puddings made with sugar e.g. milk puddings, instant custard, whips and jellies. Ordinary Yogurts and Fromage Frais Fruit stewed with sugar. Fruit tinned in syrup. Rich Fruit or Iced Cakes Cream filled or chocolate biscuits Sugar free tinned or instant puddings made with artificial sweetener, sugar free instant custard, sugar free whips and sugar free jellies. Home made milk puddings/custard made with a sweetener. Diet yogurts and Fromage Frais Fruit stewed without sugar(add artificial sweetener to taste if required) Fruit tinned in natural juices. Fresh Fruit. Plain sponge cake, malt loaf, tea cakes, malt loaf, hot cross buns, crumpets, scones Plain biscuits e.g. Digestives, Rich Tea, Ginger Snaps, Hobnobs, Marie, Garibaldi, Cereal Bars(Harvest, Quaker) 5. Why is Insulin needed? When you have Type 1 Diabetes you do not have any insulin being produced by the pancreas and the glucose cannot get into the cells to produce energy. Insulin acts like a key to open the lock on the cell doors to get glucose from the blood into the body s cells. You need to give insulin to get the glucose into the cells for energy and achieve good glucose control. When insulin is not present, glucose cannot enter the cells and it builds up in the blood. 6. Types of Insulin There are 2 main types of Insulin: Basal (background) or long acting Insulin (Levemir,Glargine) Bolus or fast acting (Novorapid, Apidra,Humalog) The aim of insulin treatment is to mimic normal insulin production as in someone without Diabetes. Basal (background) insulin is slowly absorbed and helps to keep blood glucose levels stable throughout the day and night. It mimics how the body produces a trickle of insulin throughout the day and night in someone without Diabetes. The Diabetes team will work out a starting dose of basal insulin. It is important to give basal insulin at approximately the same time each day. Bolus insulin deals with the glucose produced when carbohydrate food and drink is eaten/drank. It is a fast acting insulin that tries to mimic what your body would normally do following a meal and works quickly to lower your blood glucose level. As a general rule, give bolus insulin just before a meal/large snack.

of 11 7. What is Carbohydrate counting? Carbohydrate counting means learning how to work out the actual amount of carbohydrate in the foods you eat. Firstly, it is important to identify which foods contain carbohydrate.(see Section 2) Following on from this, there are various tools available to help to calculate the carbohydrate in food e.g. food labels, books, phone apps, internet sites, food weighing scales, calculators.(see separate information leaflet) 8. Why is Carbohydrate Counting helpful? Counting carbohydrate allows you to match the Bolus insulin (fast acting) for the carbohydrate you decide to eat. The more carbohydrate you eat, the more bolus insulin you need, that is, the more keys you need to open the cells to let glucose in. This means that you can be more flexible about: What you eat How much you eat When you eat It is a great tool for achieving better blood glucose control and greater flexibility. 9. How do you work out your Bolus Insulin (Fast acting Insulin) Everyone has a different insulin requirement e.g. 1 unit fast acting insulin required for every 10g carbohydrate. This is known as the Insulin to Carbohydrate Ratio. For an individual, this can be different for different times of the day. For example, a young person may have an insulin to carbohydrate ratio of 1 unit for 10g at breakfast and 1 unit for 15g at Evening meal. Insulin to carbohydrate ratios do change, especially in the first few months of diagnosis and at times of growth. The Diabetes Team will help you work out these ratios and alter them when indicated 10. How do you know if the ratio is correct? If the ratio is correct and you have estimated the amount of carbohydrate correctly, you would expect to see blood glucose level 2 hours after the meal to be about the same as before the meal. i.e. the blood glucose level will have returned to the target range (4-8 mmol/l for children)

of 11 It is important not to make changes to the ratio based on one blood glucose reading alone. If there is an obvious trend and blood glucose levels are generally lower or higher than the pre meal level, you can discuss with the team and, if advised, make small changes to the bolus insulin. 11. A note about the Insulin Correction factor If the blood glucose level is too high before a meal, that is 12mmol/l and above, additional fast acting insulin may need to be given to bring it down to within the target range. E,g, 1 unit of rapid acting insulin is needed to lower the blood glucose by 3mmol/l. Aim to correct your blood glucose level back to 7 or 8 mmol/l This is known as the Insulin Correction Factor (also Insulin Sensitivity Factor). It can vary from person to person and sometimes on the time of day. When you are unwell, your blood glucose level may increase and your body may make blood ketones; you will need to give extra insulin to correct this (See separate Patient Information Leaflet) 12. Practising Calculating Your Meal time Insulin Dose Example: Insulin to Carbohydrate ratio 1:10g Insulin correction ratio 1:3mmol/l Blood glucose level before meal Insulin correction Dose Total mealtime carbohydrate Mealtime Insulin Total Insulin to be given 13mmol/l 2 units 60g 6 units 8 units For you to try: Breakfast: Blood glucose level above Target Range Insulin to Carbohydrate Ratio Insulin correction ratio Blood Glucose level before meal Insulin correction dose 15mmol/l

of 11 Total Breakfast Carbohydrate Breakfast Insulin Total Insulin to be given 40g Lunch: Blood glucose level within Target Range Insulin to Carbohydrate Ratio Insulin Correction Ratio Blood Glucose level before meal Insulin Correction dose Total Lunchtime Carbohydrate Lunchtime Insulin Total Insulin to be given 6mmol/l 70g Evening Meal: Blood glucose level below Target Range Insulin to Carbohydrate Ratio Insulin Correction Ratio Blood Glucose level before meal Insulin Correction dose Total Meal time Carbohydrate Meal time Insulin Total Insulin to be given 3.4mmol/l 90g If you are Hypo before a meal, it is important to treat the Hypo immediately. (See Hypo leaflet)

of 11 13. Snacks All food and drink which contain carbohydrate will make your blood glucose level rise and you will usually need insulin. It is good practice to have good sized meals covered with bolus (fast acting insulin) and this will help to reduce hunger in between times and the needs for snacks. You should not usually need a snack but if you feel hungry, choosing one containing small amounts of carbohydrate means you may not need insulin. Your diabetes Team can advise you on a suitable snack. When you are newly diagnosed, it is common to feel very hungry in the first week or two following diagnosis; be reassured, this hunger will pass. However, at this time, you may very well need a large snack covered with insulin but make sure fast acting insulin doses are more than 2 hours apart. Your child can always fill up with salad and crunchy vegetable snacks (e.g carrots) which will not need insulin because these extras have minimal carbohydrate. 14. Being Active Being Active is very important for all children and young people. Activity usually causes blood sugar to fall (increased risk of hypoglycaemia). This is because glucose is needed as fuel for the muscles and so the body removes glucose from the blood more quickly. Managing exercise needs some attention but it is usual to either take extra snacks or reduce insulin at the preceeding meal. It is important to be aware that the effect of exercise may not be seen for several hours after the event. Please ask the Diabetes Team for additional information and help managing Diabetes during activity. Paediatric Diabetes Specialist Nurse Team Leader: Katie Beddows Paediatric Diabetes Specialists Nurse: Sarah Ghezaiel, Francine Lewis Paediatric Diabetes Dietician: Cathy Head Tel: 0161 419 2103 E-mail Address: Snt-tr.cypdiabetes@nhs.net 2 nd Floor Tree House Children s Centre Poplar Grove Hazel Grove Stockport SK2 7JE

of 11 If you would like this leaflet in a different format, for example, in large print, or on audiotape, or for people with learning disabilities, please contact: Patient and Customer Services, Poplar Suite, Stepping Hill Hospital. Tel: 0161 419 5678. Email: PCS@stockport.nhs.uk. Our smoke free policy Smoking is not allowed anywhere on our sites. Please read our leaflet 'Policy on Smoke Free NHS Premises' to find out more. Leaflet number PAED79 Publication date April 2015 Review date April 2017 Department Children & Young Peoples Diabetes Team, Tree House Location Stepping Hill Hospital