# What is an Insulin-to-Carb Ratio?

If you use fast-acting insulin and count carbohydrates, you want to know your insulin-to-carbohydrate ratio. An insulin-to-carb ratio allows you to easily figure out how much of your fast-acting insulin is needed for the amount of carbohydrate you consume.

You can talk to your health care provider or certified diabetes educator (CDE) to help you know where to start and then through trial and error you can figure out the right ratio for you.

An example of an insulin-to-carb ratio is 1:15 meaning one unit of insulin is needed for every 15 grams of carbohydrate. Someone needing more insulin may have a ratio of 1:10 and someone needing less insulin may have a ratio of 1:20.

When you are trying to figure out your correct ratio, it is helpful to write down your blood sugar levels and check more frequently to see how the insulin-to-carb ratio you used affected your blood sugar levels two hours after eating.

### How to Figure Out Your Insulin-to-Carb Ratio:

Calculating the best insulin-to-carb ratio is a process of trial and error:

1. Check your blood sugar before eating and write down your result.
2. Count your carbs and give your insulin and write down the insulin-to-carb ratio you are using.
3. Check your blood sugar 2 hours after eating and write down your result.

Try this process out a for a few days before adjusting your ratio. When you do adjust your ratio, do so in small, safe increments. When an insulin-to-carb ratio works consistently well, keep it! But remember that factors like illness, skipping a meal, extra exercise, stress and other changes in routine may cause your insulin-to-carb ratio to change.

#### The 450/500 Rule for People with Type 1 Diabetes

In the book Using Insulin, the authors share the Rule of 500 to figure out a good starting ratio. This applies to people with type 1 diabetes who are taking multiple daily injections of insulin. They write:

The 500 Rule:

• estimates grams of carb per unit of Humalog or Novolog insulins (the 450 Rule is used with Regular insulin)
• 500 divided by your TDD (Total Daily Dose of insulin) = grams of carb covered by one unit of Humalog or Novolog

Example:
Someone’s TDD = 50 units (i.e., the total amount of say Humalog and Lente insulins they used per day).
500/50 = 10 grams of carbohydrate covered by each unit of Humalog insulin

TDD = all fast insulin taken before meals, plus all long-acting insulin used in a day. If Humalog is used everyday to correct high readings, this may also need to be factored into the TDD. For instance, if someone’s TDD is “30 units” (5 H before each meal, plus 15 Lantus at bedtime), but they need 8 to 12 units more almost every day to bring down highs, at least some of this 8 to 12 units will need to be factored into a new TDD.

Caution: The 500 Rule will be most accurate for those who make no insulin of their own and receive 50% to 60% of their TDD as basal insulin. It works best for those who are using a basal/bolus approach. For others, such as those who use two injections a day with the morning basal insulin covering carbs at lunch, the 500 Rule works only as a rough guide for matching carbohydrate.

#### Insulin-to-Carb Ratios May Vary

Your body is often more resistant to insulin during different parts of the day or month. Therefore, it is common to have different insulin-to-carb ratios that are set in your routine.

For example,  an insulin-to-carb ratio may be greater for breakfast versus lunch to help manage the dawn phenomenon they may experience each morning.

For women in the week before menstruation, insulin-to-carb ratios may be adjusted each month to cope with these hormone changes and their effects on blood sugar levels.

Different people need different insulin-to-carb ratios, so don’t worry if your ratio is different from another person with diabetes. The key is to find a ratio that works well for you.

### Calculate Insulin Doses Using Your Insulin-to-Carb Ratio

The Academy of Nutrition and Dietetics clearly explains how to calculate an insulin dose for food:

1. Add up the grams of carbohydrate in the foods you will eat.
2. Divide the total grams of carb by your insulin-to-carb ratio.

“Let’s say you plan to eat 45 grams of carbohydrate and your insulin-to-carb ratio is 1 unit of insulin for every 15 grams of carbohydrate eaten. To figure out how much insulin to give, divide 45 by 15.”

This equals 3 units of insulin needed for this amount of carbohydrate.

The Diabetes Care of Nova Scotia provides a more complicated example:

If you count 72 grams of carbohydrate and your insulin-to-carb ratio is 1:15 then you need to divide 72 grams of carbohydrate by 15. (Don’t hesitate to use a calculator.) This give you 4.8 units of insulin. If you take injections you can round the 4.8 to 5 units.

# Diabetes educators review 2012 National Standards.

Last revised in 2007, the National Standards for Diabetes Self-Management Education have served as the acceptable guide for providing consistency and quality through the delivery of diabetes education. At the American Association for Diabetes Educators annual meeting, certified diabetes educators discussed the recently updated standards, emphasizing support and a continuum of self-management, as well as a widened criterion for eligible instructors.

One obvious revision includes a change in the standard’s title. Formerly known as the National Standard for Diabetes Self-Management Education, the guide is now known as the National Standard for Diabetes Self-Management Education and Support (DSMES).

Donna Tomky, MSN, RN, C-NP, CDE, FAADE, immediate past president of AADE and nurse practitioner and diabetes educator from ABQ Health Partners in Albuquerque, NM, said support is a very important part of the change.

Donna Tomky

“It really defines those activities that assist the person with prediabetes or diabetes in implementing and sustaining the behaviors needed to manage his or her condition on an ongoing basis. It really looks at the continuum instead of just a one-time effort,” Tomky said during a presentation.

Tomky said there are misunderstandings surrounding the standards. For example, an RN, RD, pharmacist, medical director or CDE are not needed for a diabetes education program. The revisions will be published in the October issue of Diabetes Care, she said.

Co-presenter, Melinda Maryniuk, RD, Med, CDE, director of clinical education programs for the Joslin Diabetes Center in Boston, Mass., said the revisions are aimed to ensure wide applicability and to ensure quality care.

“There aren’t revolutionary new things that have come out, but we have more research to support the information,” Maryniuk said.

In a survey of 225 public comment reviewers consisting of RNs, RDs, pharmacists, MD/DO/Endo, mental health professionals, and other providers, 82% said the standards were applicable to them, Tomky and Maryniuk said. Additionally, 74% agreed the document was clear. Many of the comments received mentioned satisfaction with a wider focus on support and prevention, while looking for more information.

Other revisions include increased clarity to ensure broad-based relevance in institutional and solo-based providers, an increased attention to behavior change and added examples of who can offer diabetes education, including occupational therapists and certified health education specialists. – By Samantha Costa

For more infromation:

Tomky D. #F03. Presented at: The American Association of Diabetes Educators 2012 Annual Meeting & Exhibition. August 1-4, 2012; Indianapolis.

Disclosure: Ms. Tomky and Ms. Maryniuk report no relevant financial disclosures.

Perspective

• I attended this session so I could be as current and up-to-date with what the new standards will be forthcoming. I thought it was a great overview with realistic discussions in regard to the different organizations that I work with, and what challenges they might potentially have when it comes to interpreting the standards.

The fact that a credentialed CDE person who isn’t a nurse, dietician, or pharmacist can be in solo practice is really great. I have a lot of exercise physiology friends and I can’t wait to share that information with them. They will be so excited. They, too, are potentially masters-prepared and certified.

• Source: Endocrine Today.

# Diabetes management enhanced through successful home health care.

According to Karen A. McKnight, RD, LD, CDE, and Mary Teipen, RN, CDE, from the Indiana HomeCare Network, home health care is an effective and cost-effective option for patients with diabetes.

Using their personal experiences as home health providers, McKnight and Teipen shared insight on their home health care company, and made suggestions on how others can successfully handle the sometimes challenging feat of managing diabetes and other chronic illnesses in a home care setting.

“We all know that patients do better in their home setting, it’s a lot safer for them, there’s less risk for infection and it’s more cost-effective,” Teipen said during a presentation.

While the benefits seem obvious, Teipen said many patients and physicians aren’t even aware this form of health care is available.

“A lot of our elder Americans don’t take advantage of their home health benefit in Medicare because medical providers don’t refer them. Providers are so confused about that terminology – being ‘homebound,’” Teipen said. “Homebound doesn’t mean that you’re bedridden or that you can never leave your home. It basically means that they (patients) need assistance to leave the home, or when they do leave the home it’s a very taxing effort.”

McKnight said that one of the biggest challenges of home care is not getting patients interested in the opportunity, but reimbursement. Since 2006, McKnight said, home health reimbursement has declined by 8.5%.

“It seems each year Medicare cuts the amount that they’re paying home health, little by little. Some agencies are seeing as much as a 10% decrease, and some are seeing less, depending on certain factors. The National Association for Hospice and Home Care has estimated that this year 53% of the nation’s home care agencies will be operating at break-even or at a loss. It’s a huge issue and a big concern for those of us in this room who work in home care, in terms of what the future holds there,” McKnight said.

When coupled with deductibles and copayments that are beyond the aging patient’s budget, the impact is greater, she said.

McKnight said other issues have plagued the home health arena, despite its benefit. She and Teipen’s home health company has managed to pull through this complex area of disease management by focusing on four main specialties, one of which is diabetes due to its current trend.

“Our diabetes program is customized to meet the specialty needs of home health patients and it is very self-management education-focused for the patient and for the caregiver. In addition to that patient and caregiver focus, we have been advancing in developing the staff training component,” McKnight said.

All of their clinical staff is trained in basic diabetes patient care, Certified Diabetes Educators (CDEs) attend case conferences to discuss ever-changing complex needs of patients, and the RNs and CDEs visit the most challenging patients to develop a team approach.

Looking to the future, McKnight and Teipen said they will utilize technology at the highest level; with tele-health monitoring, video conferencing, web-based resources, physician portals, transitional care through electronic medical records and telephone patient follow-up time.

Their advice to physicians, nurses and other diabetes educators is to “just get started,” and make staff education a priority from orientation to ongoing training. Additionally, they said each home health company needs a champion with leadership and support to influence the process. Communication is the key, they said. – By Samantha Costa

Disclosure: Ms. McKnight and Teipen report no relevant financial disclosures.

McKnight KA, Teipen M. #W20. Presented at: The American Association of Diabetes Educators 2012 Annual Meeting & Exhibition. August 1-4; Indianapolis, IN.

Perspective

• I got into diabetes education through home care. My goal was to provide home care services to the homebound; it’s always been my first love. I really do agree with what they said – people get better when they’re in their own environment. That’s when you’re going to find out what they really have in their cupboards. Do they have the Rice Krispies or the whole wheat cereal, and so on?

With the new health care reform, I think that home care is going to become an entity that needs to be incorporated because it is cost-effective. Monies are going to have to be spent to facilitate the transition from acute care to home care, and yet still have some sort of follow-up.

So, ACOs or whatever we’re going to call them, medical homes, it’s all going to have to be related. They’re going to have to include the home care perspective. Patients appreciate it. I think the expertise that the nurses are going to have to develop is only going to increase. The diabetes field is just exploding with new products and new technologies.

• Anne Cannon, BSN, RN, CDE
• Senior Medical Liaison for Novo Nordisk

• Source: Endocrine Today.

# Diabetes management enhanced through successful home health care.

According to Karen A. McKnight, RD, LD, CDE, and Mary Teipen, RN, CDE, from the Indiana HomeCare Network, home health care is an effective and cost-effective option for patients with diabetes.

Using their personal experiences as home health providers, McKnight and Teipen shared insight on their home health care company, and made suggestions on how others can successfully handle the sometimes challenging feat of managing diabetes and other chronic illnesses in a home care setting.

“We all know that patients do better in their home setting, it’s a lot safer for them, there’s less risk for infection and it’s more cost-effective,” Teipen said during a presentation.

While the benefits seem obvious, Teipen said many patients and physicians aren’t even aware this form of health care is available.

“A lot of our elder Americans don’t take advantage of their home health benefit in Medicare because medical providers don’t refer them. Providers are so confused about that terminology – being ‘homebound,’” Teipen said. “Homebound doesn’t mean that you’re bedridden or that you can never leave your home. It basically means that they (patients) need assistance to leave the home, or when they do leave the home it’s a very taxing effort.”

McKnight said that one of the biggest challenges of home care is not getting patients interested in the opportunity, but reimbursement. Since 2006, McKnight said, home health reimbursement has declined by 8.5%.

“It seems each year Medicare cuts the amount that they’re paying home health, little by little. Some agencies are seeing as much as a 10% decrease, and some are seeing less, depending on certain factors. The National Association for Hospice and Home Care has estimated that this year 53% of the nation’s home care agencies will be operating at break-even or at a loss. It’s a huge issue and a big concern for those of us in this room who work in home care, in terms of what the future holds there,” McKnight said.

When coupled with deductibles and copayments that are beyond the aging patient’s budget, the impact is greater, she said.

McKnight said other issues have plagued the home health arena, despite its benefit. She and Teipen’s home health company has managed to pull through this complex area of disease management by focusing on four main specialties, one of which is diabetes due to its current trend.

“Our diabetes program is customized to meet the specialty needs of home health patients and it is very self-management education-focused for the patient and for the caregiver. In addition to that patient and caregiver focus, we have been advancing in developing the staff training component,” McKnight said.

All of their clinical staff is trained in basic diabetes patient care, Certified Diabetes Educators (CDEs) attend case conferences to discuss ever-changing complex needs of patients, and the RNs and CDEs visit the most challenging patients to develop a team approach.

Looking to the future, McKnight and Teipen said they will utilize technology at the highest level; with tele-health monitoring, video conferencing, web-based resources, physician portals, transitional care through electronic medical records and telephone patient follow-up time.

Their advice to physicians, nurses and other diabetes educators is to “just get started,” and make staff education a priority from orientation to ongoing training. Additionally, they said each home health company needs a champion with leadership and support to influence the process. Communication is the key, they said. – By Samantha Costa

Disclosure: Ms. McKnight and Teipen report no relevant financial disclosures.

McKnight KA, Teipen M. #W20. Presented at: The American Association of Diabetes Educators 2012 Annual Meeting & Exhibition. August 1-4; Indianapolis, IN.

Perspective

• I got into diabetes education through home care. My goal was to provide home care services to the homebound; it’s always been my first love. I really do agree with what they said – people get better when they’re in their own environment. That’s when you’re going to find out what they really have in their cupboards. Do they have the Rice Krispies or the whole wheat cereal, and so on?

With the new health care reform, I think that home care is going to become an entity that needs to be incorporated because it is cost-effective. Monies are going to have to be spent to facilitate the transition from acute care to home care, and yet still have some sort of follow-up.

So, ACOs or whatever we’re going to call them, medical homes, it’s all going to have to be related. They’re going to have to include the home care perspective. Patients appreciate it. I think the expertise that the nurses are going to have to develop is only going to increase. The diabetes field is just exploding with new products and new technologies.

• Anne Cannon, BSN, RN, CDE
• Senior Medical Liaison for Novo Nordisk

• Source: Endocrine Today.

# Systemic therapy may boost self-esteem in diabetes.

In addition to clinical support, self-esteem building is also needed to produce positive outcomes among patients with diabetes, according to a presentation by Janis Roszler, MSFT, RD, CDE.

Roszler, diabetes educator, author, and marriage and family therapist in Miami Beach, Fla., said that patients with low diabetes self-esteem are classified as those who doubt their ability to care for their diabetes or feel pessimistic about completing self-care tasks.

This poor self-esteem could result when patients become overwhelmed when their attempts to control their diabetes continue to fail. Negative comments from health care providers, family and/or friends, and the chronic stigma attached to the disease can all have a negative impact on a patient’s self-esteem, according to Roszler.

According to Roszler’s presentation, the poor self-esteem can be caused by:

• Complications with diabetes;
• Symptom visibility, such as blood glucose swings, numbness, fatigue, hypoglycemia;
• Self-care tasks which are too difficult;
• Pre-existing poor self-esteem;
• Depression; and
• Guilt.

Self-esteem can be raised by family, individual or group therapy. Roszler suggested a systemic therapy, with an emphasis on strength-based counseling approaches like narrative therapy, solution-focused therapy, medical family therapy, cognitive-behavioral therapy, experimental family therapy, psychoanalytic family therapy, structural family therapy and strategic family therapy.

Roszler said letting patients know that others share the same difficult issues they face often helps patients feel less alone, less “broken,” and begin to feel more hopeful.

Roszler J. #W04. Presented at: The American Association of Diabetes Educators 2012 Annual Meeting & Exhibition; August 1-4, 2012; Indianapolis.

Source: Endocrine Today.