II. Management: Step 1a  Determine Carbohydrate to Insulin ratio
 Determine total Insulin used per day
 Option 1: Known dose from multiple daily doses or Insulin Pump
 Option 2: Calculate based on patient weight
 Type I: Total daily Insulin (TDI)
 TDI = WtKg x 0.1 to 0.3 units/kg (start low)
 Type I: Total basal dose (TBD)
 TBD = WtKg x 0.2
 TBD = 0.4 x Total Daily Insulin (TDI)
 Type II: Total daily Insulin (TDI)
 TDI = WtKg x 0.3 units/kg: Underweight, advance age, Dialysis
 TDI = WtKg x 0.4 units/kg: Normal weight
 TDI = WtKg x 0.5 units/kg: Overweight
 TDI = WtKg x 0.6 units/kg: Obese, steroid use, high Insulin Resistance
 Type I: Total daily Insulin (TDI)
 Option 3: Simple Carbohydrate basedmethod (below in Step Ib)
 Plan to split the basal Insulin and Bolus Insulin evenly (50% to each)
 Calculate Insulin to Carbohydrate ratio or ICR (g carb per one unit Insulin)
 Calculate correction factor (CF)
 Blood Glucose drop expected per unit of Insulin (using the Insulincarb ratio or ICR above)
 Formula
 CF = ICR * 4.5
 For example
 Given Insulin to Carbohydrate ratio of 6 g carb/unit
 Blood Glucose would correct 27 mg/dl with one unit Insulin
 Interpretation
 Ratio is Carbohydrate grams covered by 1 unit Insulin
 Type I Diabetes
 One unit per Carbohydrate (15 grams) is typical
 Effect of one unit Insulin on Glucose lowering
 Typically 1 Unit Bolus Insulin lowers Glucose 2060 mg/dl
 Estimate: 1800/(daily Insulin dose)
 Example
 Type I Diabetes patient weighs 110 kg and uses ~35 total units of Insulin per day (0.3 units/kg)
 One unit Insulin covers 500/35 or 14 g Carbohydrates
 One unit Insulin would be expected to lower Glucose 1800/35 or 50 mg/dl (in Type I Diabetes Mellitus)
 Lantus: Takes 18 units of Lantus per day
 Lispro: Takes 16 units total (4 units for each of 3 meals and 2 units for each of 2 snacks)
III. Management: Step 1b  Alternative to Step 1a (Simple Method)
 Dietician directs grams of Carbohydrate per meal
 Estimate Daily Energy Allowance (calories)
 Estimate percentage of calories in diet (5060%)
 Calories per gram of Carbohydrate = 4
 Calculate total daily Carbohydrate grams
 Daily Carbs (grams) = (Total Calories x 0.5) / 4
 Example = (1800 x 0.5)/4 = 225 Carbohydrate grams
 Spread out Carbohydrate grams across meals
 Example: 70 grams per meal, and two 20 gram snacks
 Choose Carbohydrate servings to meet needs
 Each serving contains 1215 grams Carbohydrate
 Choose servings from 3 groups
 Breads and starches
 Fruit
 Milk
 Vegetables are not counted
IV. Management: Step 2  Predict Carbohydrate effect on Serum Glucose
 Glucose rises at constant rate per gram Carbohydrate
 Other modifiers of Carbohydrate effect on Serum Glucose
 Glycemic Index
 Percentage of food from Protein and fat
V. Management: Step 3  Count Carbohydrates
 Indications
 Techniques
 Food labels (use grams of Carbohydrate per serving)
 Food tables (e.g. cookbooks, references)
 Food weight
 Determine Carb Factor for particular food
 Percentage of given food from Carbohydrate
 Weigh food on gram scale
 Carbohydrate grams = (food weight) x (carb factor)
 Determine Carb Factor for particular food
VI. Management: Step 5  Summary: Combining Insulin protocols
 Basal Insulin (Maintenance, covers between meals and ovenight)
 Once daily: Lantus
 Twice daily: Levemir, NPH Insulin

Bolus Insulin (premeal Insulin, covers postmeal Blood Sugars)
 Units per Carbohydrate of planned meal AND
 Units of Correctional Insulin Dosing based on Blood Sugars over 149 before the meal
 Example
 A 70 kg man with Type II Diabetes Mellitus
 Insulin Glargine (Lantus)
 Uses 14 units per day at dinner
 InsulinHumalog (Lispro) with coverage
 Uses 1 unit per Carbohydrate PLUS 1 unit per 50 over 150
 Blood Sugar of 200 at lunch and having prepared a 4 Carbohydrate meal
 Takes a total of 6 units: 4 units (4 carbs) plus an additional 2 units (for Blood Sugar of 200)