Counting

Carbohydrates
and
Dosing Insulin
for School Nurses
Presented by:
Megan Porter, RD, LD,CDE
Randall Children's Diabetes and Endocrine
Center
 Carbohydrate Counting:
How does it help?

 Fewer high blood sugars

 Fewer low blood sugars
 More accurate dosing of insulin whether your using
syringes, pens or the pump!
 Lower blood sugar values overall
 No “off limits” foods
 Flexibility in meal and snacks

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First, let’s review what foods are counted as carbohydrates:

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 Approximate Carbohydrate
Amounts by Age

Approximate Carbohydrates by Age

Boys < 5 years old 5–12 years old Teens

30 to 45 grams of carb at 45 to 60 grams of 60 to 75+

each meal carb at each meal grams of carb
at each meal

Girls 30 to 45 grams of carb at 45 to 60 grams of 45 to 75 grams

each meal carb at each meal of carb at each
meal

Snacks, if needed, are usually 15 to 30 grams of carb.

For active children, more carbohydrates at each meal/snack are usually needed.

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 Types of Insulin Plans
There are 2 methods of insulin dosing using carbohydrate
counting:
Set Dose: A child follows a consistent carb meal plan with a consistent
amount of insulin.
1. Usually the child will not take any insulin during lunch, possibly,
only if blood sugars reach a designated level, s/he may get a
correction shot of insulin.

Basal/Bolus: uses a changing carb intake with an adjustable amount

of insulin.
1. Child will be receiving an insulin injection, or insulin through a pump for
all carbohydrates that are eaten at lunch and possibly for snack times.
With this plan, their insulin dose is determined by:
1. The amount of carbohydrates that they will consume
2. Their blood sugar prior to the meal

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 So How do you figure out or teach
another person to find out how many
carbohydrates are in their lunch?

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Where to find information:
Look on the internet to see if there is any carbohydrate information for their school:
http://www.mesd.k12.or.us/shs/hss/Nutrition/nutritionlinks.shtml
Or
http://www.pps.k12.or.us/departments/nutrition/8142.htm

To view the major Lunch Menus

allergens or K-5, K-8 and
carbohydrate counts for Middle School High School
menu items, place your Author: PPS Nutrition Services Subject: Bean and
September 2013 September 2013 Cheese Burrito Date: 10/1/2013 9:36:36 AM
cursor over the (*) Allergens
asterisk next to the October 2013 October 2013
menu item. After each November 2013 November 2013
Beans and Cheese - Gluten, Milk, Soy and Wheat
menu, there is a
printable list of the December 2013
   December 2013 Tortilla -
Gluten, Soy and Wheat
Carbohydrates
allergens and
carbohydrate counts   January 2014    January 2014 Total - 44g
for that month. Menus
may not have all   February 2014    February 2014 Beans and Cheese - 18g
allergens and are subject   March 2014   March 2014 Tortilla - 26g
to change.  
    April 2014   April 2014
Breakfast 2013-14 (all May 2014 May 2014
grades) June 2014 June 2014
 
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When visiting this website:
You will find that the average Carbohydrate amount in a
school lunch is about 95-100g CHO. With a minimum of 60g
CHO to a maximum of 125g CHO.

Average lunch entrée contains:

 two starches = about 30g CHO
High carb. Entrees = 45-50g CHO
White milk carton = 11g CHO
Chocolate milk carton = 22g CHO
1 fruit serving = 15g CHO
1 vegetable serving = 5g CHO
1oz bread = 15g CHO (rolls are 2oz and = 30g CHO)

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 If available, the Nutrition Facts
Label is a great resource
Labels are the best resource for carbohydrate counting

Pay attention to:

 Serving Size

 Total Carbohydrate

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How to get more information?

PPS nutritional services usually maintains accessibility to

carbohydrate amounts for individual entrees and keeps a
record of the food labels used.

For more information you can contact:

Ben Dandeneau, RD @ bdandene@pps.net

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Carbohydrate Counting Using Books

Use when eating foods without a Nutrition Facts Label:

•Fresh fruits
•Fresh Vegetables
•When eating casseroles, mixed food items

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 Carbohydrate Counting Using the Internet
There are many great websites that offer carb counting calculators, but make sure that
the website is credible:

American Nutrient Database

www.ars.usda.gov/main/site_main.htm?modecode=12-35-45-00

Calorie King
www.calorieking.com

GoMeals
www.gomeals.com

Many great smart phone applications are out there to assist you in carb counting:
GoMeals
CalorieKing
Carb Counting with Lenny

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 Portion Estimation Method
This method is best used when unable to measure out or if the serving
size is not know. It involves estimating the portion of the food using
your hands as a guide.

Can be used when a child

reports how much eaten.

Can be used to tell the child to

only self serve this amount of
fruit.

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*Based on an adult hand

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If a child packs a
lunch to school

You can ask that the

parents/guardians put notes on
each food item with the
grams of carb. This will help the
child, teacher, school nurse or
cafeteria aid to figure out how
many carbs the child is eating or
ate during school lunch.
 Let’s do this together:
2 Cookies = 20g CHO White milk = 11g CHO

Small fruit =
15g CHO
Total Carb.s =
95g CHO
Tater Tots =
25g CHO

Chicken nugget = 15g CHO

BBQ Sauce = 9g CHO
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 Once we determine the amount of
carbohydrate the child will eat, or has eaten,
we need to determine the insulin dose:
1.All students who take insulin at school should have written
school insulin orders signed by their MD
2.Follow insulin directions given by MD
3.It is up to the parent/guardian to keep you posted on any
changes made to their child’s insulin directions & to keep
supplies stocked

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How to determine their insulin dose
Factor
How the insulin directions are written:

Insulin-to-Carb Ratio = 1 unit of rapid- or short-acting

insulin for each ____grams of carb

High Sugar Correction Factor = 1 unit of rapid- or short-

acting insulin for every____ points (mg/dL) blood sugar
level is over the target of ____ mg/dL

*These two independent calculations determine the total

insulin dose the child will take
You fi

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 You figure the dose in a
3-step process:

1st Step: Child takes blood sugar, and counts

carbohydrates to be eaten.

Insulin-to-Carb Ratio:
Determine how much rapid- or short-acting insulin is needed for
the amount of carbs the child is going to eat.

For example, using a 1:20 insulin to carb ratio:

Determined carbs= _95__ grams divided by _20_ grams = _4.75_

units

Round up to the nearest 0.5 unit for 5 units

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 Or we have provided you with an insulin dosing spread sheet:
Second:
Find their insulin to
carb. Ratio then
scroll down and
across to determine
the dose.
I:C ratio = 1:20

First:
Find the amount of carb.s
the child will eat or has
eaten. For our example:
95g CHO

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 2nd Step:
Blood Glucose Correction Factor or High Sugar
Correction (HSB)

High Sugar Correction is usually written as:

1 unit of rapid- or short-acting insulin for every____ points (mg/dL) blood sugar level is over the target of ____ mg/dL
Example: 1:50>150

What this means:

1 unit of rapid- or short-acting insulin for every 50 mg/dL above 150 mg/dL
Remember: It is important that a pre-meal blood sugar is used to determine the HSB

Example:
Premeal Blood Blood Sugar (mg/dL) Insulin Dose (units)
sugar = 150-200 1
273 mg/dL 201-250 2
251-300 3
301-350 4
351-400 5
401-450 6
451-500  7
 500 8
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 3rd Step: Total Dose

Add the number of units from the 1st and 2nd steps together to get
the total dose:

Total Dose = __5__ + __3__ = __8__ units (amount of rapid- or short-

acting insulin needed for carbs+high blood glucose)

Determined in Step Determined in Step

1 using the I:C 2 using the HSB or
ratio or dosing correction chart
chart

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 Let’s Review

Jimmy’s Insulin to Carb ratio is 1:15 and his

HSB is 1:50>150
He comes before Breakfast and his BG = 215 mg/dL and he’s going
to eat 60g carbohydrate

Answer: 4 units to cover carbs PLUS 2 units for the high blood sugar =
6 units insulin

Determined in Step 1 Determined in Step 2

using using
HSB chart:
I:C ratio:
151-200 = 1 unit
60g CHO divided by
201-250 = 2 units
15 = 4 units

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 For this to happen accurately the child must have
available at all times during school:
Test strips
Blood sugar meter
Syringes/pen needles
Insulin delivery device
Glucagon
Up-to-date school insulin orders

Other items:
Ketone strips
Low blood sugar treatments
15g CHO snacks + Protein

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 Diabetes management is time consuming and can be
overwhelming for some. If your school needs further
assistance you can:

Talk with the child’s caregivers/family

Contact the American Diabetes Association, Safe at School

Program
Website: http://www.diabetes.org
Email: oregonswwashington@diabetes.org
Contact: 503-736-2770

Contact their endocrinologist/diabetes educator

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 Thanks for your time
I’m happy to answer any questions you may have