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TARGET THERAPY

Staying on Target

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Your Insulin Adjustment Workbook

Yes, You Can Do It!

YES, YOU CAN DO IT!

Your How-To Guide for
Adjusting Basal and Bolus Insulin

This workbook will help you learn new skills so that you can you live a
healthier life with your diabetes. What is Basal-Bolus? introduces
flexible insulin therapy, (also called intensive therapy) as a way to correct
your blood glucose levels. Terms to Learn First gives you the definitions
that you will need. Making Bolus Insulin Changes, outlines how to
make changes to rapid and short acting insulin doses. Putting it All
Together gives you a plan to get started. Adjusting for Basal Insulin,
explains changing long acting insulin doses. Trouble-Shooting, tells
what to do when you are having a hard time. Problem-Solving and
Exercises gives you a chance to practice what you learned. Use this guide
as you work with your diabetes health care team to help you avoid the
complications of diabetes.

BD provides this workbook for informational purposes only. It is not intended to be a substitute for professional
medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified healthcare
provider with any questions you may have regarding a medical condition. Never disregard professional medical advice
or delay in seeking it because of something you have read in this workbook

INTERACTIVE TABLE OF CONTENTS

To go directly to the topic of interest, click on the link below.

Managing Your Blood Glucose....................2

Calculating Your Insulin

Sensitivity Factor (ISF)................................19

Practicing Flexible / Intensive Therapy..........2

Insulin/Blood Glucose Formula ............19

Responsibilities / Rewards of Basal-Bolus ....2

Rule of 1500 ......................................21

Normal Insulin Delivery ............................3

Rule of 1700 ......................................23

TERMS TO LEARN FIRST ..........................4

Correcting for Known Changes

in Meals or Exercise ..................................25

Blood Glucose Goals ..................................5

Correcting for a Change in Meals ......25

Target Glucose............................................5

Calculating Your Carb:Insulin Ratio ....25

Algorithm ..................................................5

Method I ............................................26

Basal Insulin................................................6

Method II ............................................26

Bolus Insulin ..............................................6

Correcting for a Known

Change in Exercise ..............................29

WHAT IS BASAL-BOLUS? ........................1

Insulin Adjustment and

Pattern Management..................................7
Insulin Sensitivity Factor (ISF)
and Correction ..........................................7

PUTTING IT ALL TOGETHER ..................30

Getting Started: A Five-Step Plan ..............31

Peak Action ................................................8

Practice Problems......................................31

MAKING BOLUS INSULIN CHANGES ......9

ADJUSTING THE BASAL DOSE ..............34

Understanding How Insulin Works ............10

Testing the Nighttime Basal ......................35

Blood Glucose Monitoring:

When to Test ............................................12

Testing the Daytime Basal ........................37

Making Changes Using

Pattern Management................................13

Option II..............................................38

Correcting for Blood Glucose

That is Out of Range ................................17
Correction Method I............................18

Option I ..............................................37

Option III ............................................38

TROUBLESHOOTING ..............................39
PROBLEM SOLVING AND EXERCISES ....44

Correction Method II ..........................18

Correction Method III ..........................19

SEE YOU REALLY CAN DO IT! ............49

WHAT IS BASAL-BOLUS?

WHAT IS BASAL-BOLUS?
When you have diabetes, it is important
to avoid high and low blood glucose
(sugar). This section reviews how outof-control blood glucose can lead to
diabetes complications. It also introduces
flexible/intensive therapy with basal-bolus
insulin adjustment1 as a way to help
keep you healthy.

Managing Your Blood

Glucose Keeping in control means
that your blood glucose is always in a
range that is not too high or too low.
Controlling blood glucose helps you stop
or delay the risk of developing eye, kidney,
nerve, foot and heart disease caused by
blood glucose that is too high for a long
period of time. It can be hard to stay
in control with one, two, or even three
injections of insulin a day. You can still
have many times when the insulin does
not match your food or exercise, so your
blood glucose gets too high or too low.

Practicing Flexible / Intensive

Therapy Research shows that flexible
(also called intensive) insulin therapy can
work to control blood glucose levels in
most people. With this therapy you:
1. Take four or more insulin injections a
day, adjusting your insulin doses as
needed to keep your blood glucose
within your goal range OR

2. Use an insulin pump.

The goal is to keep your blood glucose close
to normal by taking insulin to match the
quantity of food you eat and also meet your
bodys needs at other times. The insulin
that works between meals and through the
night is called basal. The insulin that
works to match food or lower high blood
glucose is called bolus. Basal-bolus is
a term used by health care professionals
to describe flexible therapy.

Responsibilities / Rewards
of Basal-Bolus Before starting
flexible (basal-bolus) therapy, you
should think about its pros and cons.
Pros You will have more freedom
and other benefits, such as:
Ability to eat when and how
much you want
Freedom to skip a meal
Better diabetes control
Feeling of greater well-being
Reduced risk of complications
Cons You will have more work,
including:
Checking blood glucose four or more
times a day, and sometimes during
the night
Learning and practicing carbohydrate
(carb) counting

1 All glucose values used in this workbook are plasma values. If you use a blood glucose meter that reads whole
blood values, you should decrease them by about 10%.

Deciding on your insulin dose

according to the amount of carb
you expect to eat and the exercise
or activity you plan

Although some people can have frequent

or severe hypoglycemia (low blood
glucose) with this therapy, most people
have less because there is a better match
between their insulin and food. You can
adjust flexible therapy for your lifestyle,
eating and sleeping schedules and
physical activity. You will learn to match
your insulin to your food, exercise, and
adjust for high or low blood glucose
when it happens.

This insulin is released as a squirt

or a pulse that is called a bolus. In
someone without diabetes, a bolus of
insulin keeps blood glucose levels in
range after meals.
Figure 1 shows normal insulin delivery
in a person without diabetes. The top
portion shows the blood glucose curves
during a day in which someone eats
three meals. The bottom portion shows
the blood insulin levels for the same
three meals. In basal-bolus therapy, the
insulin doses and times are designed to
match normal insulin delivery as closely
as possible.
Figure 1
Normal Insulin Delivery in People
without Diabetes

1. Blood glucose rises.

2. The pancreas releases an extra burst
of insulin that in turn helps to deliver
blood glucose into the bodys cells,
where it is used for energy.

High
Normal
Low

Blood Insulin

A diabetes-free pancreas releases a small

amount of insulin throughout the day
and night. This insulin is described as
basal and is steadily discharged from the
pancreas so that there is always some
available. At night and between meals,
basal insulin works with a small amount
of glucose made by the liver that is also
being constantly released. After eating a
meal or snack with carb in it, two things
happen:

Blood Glucose

Normal Insulin Delivery

Bolus
Basal
Midnight

3
AM

6
AM

9
AM

Noon

3
PM

6
PM

9
PM

Midnight

If you have type 1 diabetes, your pancreas

cannot make insulin. To use flexible
therapy with basal-bolus insulin, you will
decide how much insulin to take to keep
blood glucose within your goal range.
3

TERMS TO LEARN FIRST

TERMS TO LEARN FIRST

The goal of flexible therapy is to imitate
the way a normal pancreas works. In
someone who does not have diabetes,
insulin automatically works at the right
times, matching meals, activity or stress.
When you have diabetes and use flexible
therapy, you have to figure out and
deliver the correct dose of bolus insulin
yourself. Your Diabetes Team will guide
you along the way. Your Diabetes Team
may include your doctor, certified
diabetes educators such as a diabetes
nurse educator and a registered dietitian.
Some teams also include an exercise
physiologist, social worker and
pharmacist. This section teaches
you words you need to know before
you begin.

Blood Glucose Goals The range

your blood glucose should fall into most
of the time. The American Diabetes
Association (ADA) recommends the
following blood glucose goals of
90-130 mg/dl before meals and less
than 180 about 2 hours after a meal.
Your Diabetes Team will help you set
your goals, for your blood glucose.

Target Glucose A single number

that falls within your blood glucose
goals. The target glucose is used to
adjust your insulin dose.

Algorithm A formula that helps

you determine the amount of insulin
that you take before eating based on
your current blood glucose level. Some
people may have a different algorithm
for each meal. Think of it as following
a recipe. A sample algorithm looks like
the chart below. This is only a sample.
You should not use this table for
treatment.

SAMPLE ALGORITHM
Pre-Breakfast Algorithm For Rapid Or Short
Acting Insulin
If your Blood
Glucose is:

Your Rapid-Acting
Insulin Dose should be:

0-100:

2 units

101-150

3 units

151-200

4 units

201-250

6 units

251-300

8 units

Over 300

12 units

STEPS FOR USING A ALGORITHM

1. Test your blood glucose.
2. Find your reading in the blood glucose
column.
3. Check the rapid-acting insulin dose
column to see how many units to take.
For example, according to the algorithm if
your blood glucose level were 184 mg/dl,
you would need to take 4 units of rapid or
short acting insulin before breakfast.

NOTE: For an algorithm to work you

need to eat the same amount of food
and carbohydrate every day. (If you
always have a sandwich with 2 slices of
bread, a piece of fruit, a glass of milk
and a small bag of chips for lunch, this
method will be fine.) If you eat a big
salad one day and a plate of spaghetti
the next, these foods have different
effects on your blood glucose and you
would need different doses of insulin, so
this is not the best way for you to decide
how much insulin to take before meals.

Basal Insulin Works steadily day

Ultralente - occasionally used as

basal insulin, does have some peak
action. (See Peak Action.)
Short or rapid-acting insulin (see
below) given by an insulin pump
tiny amounts of rapid acting insulin
are delivered throughout the day
and night. This is the best example
of basal insulin and may be closest
to imitating the way the pancreas
normally works. Another advantage
is that basal rates on a pump can
be changed to meet your needs at
different time periods of the day
and night.

and night to keep your blood glucose

within your goal levels. Taken as an
injection, basal insulin is long acting and
works around the clock. Taken via insulin
pump, a very small amount of basal
insulin is released constantly at fractions
of a unit per minute. The goal is to
match the amount of insulin with the
low level of glucose produced by your
liver. This helps your blood glucose levels
remain stable day and night - even if you
dont eat anything. Types of basal insulin
include:

eat and to correct for a high blood

glucose, it is released in a squirt or pulse.
This allows the insulin to provide a rapid
burst of action. Bolus insulin acts as the
extra insulin that is released by a
normal pancreas to help your body use
the glucose from a meal or snack. The
extra insulin will bring your blood glucose
levels down before they climb too high.
Types of Rapid-acting insulin used for
bolus insulin are:

Long-acting insulin such as insulin

glargine (Lantus) is often used for
basal insulin because they last a long
time and have no peak action.

Bolus Insulin Taken before you

Insulin Lispro (Humalog), Insulin

Aspart (Novolog), Insulin glulisine
(Apidra) or
Regular insulin, which is referred to
as a short-acting insulin.
6

Insulin Adjustment and

Pattern Management

Insulin Sensitivity Factor

(ISF) and Correction

Adjusting insulin doses based on a

pattern of blood glucose readings over
three days or more is called Pattern
Management, or Pattern Control.
If your blood glucose is too high or too
low at certain times of the day or night,
an adjustment to your insulin dose may
be needed. In this case it is helpful to
look for patterns in your blood glucose
readings over three days or more. For
example, take a look at Jeans blood
glucose readings before dinner for the
past three days:

JEANS THREE-DAY BLOOD GLUCOSE RECORD

(Goal 90 mg/dl-130 mg/dl)
Breakfast Lunch

Dinner

98 mg/dl

129 mg/dl

250 mg/dl 150 mg/dl

89 mg/dl

105 mg/dl

225 mg/dl 111 mg/dl

102 mg/dl 88 mg/dl

Bedtime

240 mg/dl 138 mg/dl

You can see that her dinner numbers are all

too high. The problem may be related to
how much carbohydrate (carb) she ate at
lunch, snacking, schedule or basal insulin.
However, it is most likely that her food at
lunch did not match her pre-lunch bolus.
She ate too much carb for her insulin bolus
dose. For more information on Pattern
Control or Pattern Management, see the
BD Publication: Pattern Control.

ISF is the amount that one unit of

rapid- or short-acting insulin will
lower your blood glucose reading.
It is used to calculate your correction
or supplemental dose.
Correction dose is the amount of
insulin you need to correct a high
blood glucose level and bring it into
the range your blood glucose should
fall into most of the time.

Once you know your ISF, you can give

yourself the right dose of insulin to keep
you within your blood glucose goals. The
ISF is different for different people and
your Diabetes Team will help determine
it for you. For instance, if your blood
glucose at lunch is 200 mg/dl and your
goal is 90-130 mg/dl, you will learn to
take a correction dose, an extra amount
of rapid- or short-acting insulin to bring
your high blood glucose down to the
range your blood glucose should be in
most of the time. Correction is usually
required before a meal, so you will need
to add or subtract this dose of insulin to
the amount of insulin needed for your
carbohydrate intake. The correction dose
is extra insulin if your blood glucose is
too high or a lower insulin dose if your
blood glucose is to low.
7

EXAMPLE:
Calculating Lauries Correction Dose
Lauries ISF is 1 unit of rapid or short
acting insulin for every 50 mg/dl of
blood glucose.
Her target pre-meal blood glucose is
100 mg/dl, but her pre-dinner blood
glucose reading is 250 mg/dl.
She is 150 mg/dl over her target level.
Current blood glucose target blood
glucose = amount of glucose over target
[250 mg/dl 100 mg/dl = 150 mg/dl]

Using Lauries ISF, she would divide

150 mg/dl by 50 to find that she
would need to add an extra 3 units
of rapid or short acting insulin to her
meal-time dose to correct the blood
glucose to 100 mg/dl.
Amount of glucose
over target
= correction dose
ISF

150 = 3
50

If Lauries pre-dinner blood glucose was

75, she would reduce her insulin dose in
the same manner as outlined above.
Her target pre-meal blood glucose is
100 mg/dl, but her pre-dinner blood
glucose reading is 75 mg/dl.
She is 25 mg/dl below her target level.
Current blood glucose target blood
glucose = amount of glucose over target

Using Lauries ISF, she would divide

25 mg/dl by 50 to find that she would
need to subtract 0.5 units of rapid or
short acting insulin to her meal-time
dose to correct the blood glucose to
100 mg/dl.
Amount of glucose
over target
= correction dose
ISF
= -0.5 units
[-25
]
50

Peak Action The time when insulin

is working the hardest to bring blood
glucose down. It is essential to know
when your insulin peaks so that you can
prepare for possible low glucose levels at
these peak times. Types of insulin with
peak action times are:

Name of
Insulin

Type of
Insulin

Peak Action

Humalog,
Novolog,
Apidra

Rapid

30 min. to
1 1/2 hours

Lantus

Long

No peak action

*Regular

Short

2 to 4 hours

*UltraLente

Long

8 to 30 hours

*NPH

Intermediate

4 to 12 hours

*Lente

Intermediate

7 to 15 hours

*Not commonly used in Flexible Insulin Therapy

[75 mg/dl 100 mg/dl = -25 mg/dl]

MAKING BOLUS INSULIN CHANGES

MAKING BOLUS INSULIN CHANGES

Your first step in learning how to make
these adjustments should be to consult
with your Diabetes Team. This section
will give you the tools you need to adjust
your bolus insulin effectively using
flexible insulin therapy.

Understanding How
Insulin Works
Different types of insulin work at
different speeds. Their action can be
described as basal (steady and longacting), bolus (rapid burst of action) or
somewhere in between. They also act
differently in how fast they start working,

when they are at their peak and the

length of time they last. It is important
to understand these differences in order
to make the best decisions possible when
adjusting your insulin dose. By knowing
which insulin peaks and is active you will
know which insulin to change if you are
having hypoglycemia (low blood sugar)
or hyperglycemia (high blood sugar).
View the chart(s) and graph(s) below to
help you understand the actions of many
different types of insulin including
Humalog, Novolog, Regular, NPH,
Ultralente, Lantus, etc.

INSULIN ACTION CURVES

Type of Insulin

Onset of Action

Peak Action

Duration

RAPID ACTING
(Used for bolus
insulin taken
before eating
and to correct
for a high blood
sugar)

Insulin lispro
(Humalog),
Insulin aspart
(Novolog),
Insulin glulisine
(Apidra)

15 minutes

1/2 to 1-1/2
hours

3 to 5 hours

SHORT ACTING

Regular

1/2 hour

2 to 4 hours

6 to 8 hours

Blood Insulin Level

Insulin Action

6AM

9AM

Noon

3PM

6PM

9PM

MidN

3AM

6AM

9AM

Insulin Commonly Used in Flexible

Insulin Therapy for a bolus dose:
Rapid-acting insulin is the most
common insulin used, but shortacting insulin is also used for
this purpose.

10

Insulin Action

Type of Insulin

Onset of Action

Peak Action

Duration

LONG ACTING
(Use for basal
insulin taken
in injection or
in a pump to act
through day and
night to keep
blood glucose
levels stable)

Ultralente

Approx.
4 to 8 hours

12 to 18 hours

Approx.
24 to 28 hours

Lantus

2 to 4 hours

No peak, stable

24 hours

Blood Insulin Level

The most common insulin used for

basal doses is Lantus, although
Ultralente can also be used.

6AM

9AM

Noon

3PM

6PM

9PM

MidN

3AM

6AM

9AM

Insulin Action

Type of Insulin

Onset of Action

Peak Action

Duration

INTERMEDIATE

NPH, Lente

1 to 3 hours

6 to 12 hours

18 to 24 hours

Blood Insulin Level

NPH insulin may be used as a partial

basal dose in the evening. This is
most commonly used with shortacting (regular) insulin as a bolus dose.

6AM

9AM

Noon

3PM

6PM

9PM

MidN

3AM

6AM

9AM

Fill in the chart/graph below to show the action of the types of insulin you are taking now:
My Bolus __________________ insulin:

Starts to work at: ____________________________

Peaks (Works hardest from) __________________
Lasts until: ____________________________________

My Basal__________________ insulin:

Starts to work at: ____________________________

Peaks (Works hardest from) __________________
Lasts until: ___________________________________

Graph your insulin curves below:

7AM

Noon

6PM

12MN

7AM

11

Blood Glucose Monitoring:

When to Test
Checking your blood glucose levels is
important. You need the information
to 1) Make insulin changes, and
2) See if you made the correct
adjustments.
Many people using flexible insulin
therapy check their blood glucose
before each meal and at bedtime.
Your Diabetes Team may also ask you
to check your blood glucose two hours
after a meal. (This reading will show
how well the mealtime insulin dose is
working.) In addition, to make sure
that you are not having hypoglycemia
at night, it is sometimes important
to check blood glucose at 3AM.
The 3 AM blood glucose, although
inconvenient, is important because
it can help guide the decision to
change your nighttime basal insulin.
It is common for blood glucose to
drop before 3 AM and then to rise
by morning. Figure 3 shows the
effects of different types of insulin
on your blood glucose at different
times of day.

Figure 3
Effects of Previous Insulin Dose on
Blood Glucose Readings Tested at
Mealtimes and Bedtime

Insulin Dose

Blood Glucose

Breakfast Lispro

Breakfast BGM

Lunch Lispro

Lunch BGM

Supper Lispro

Supper BGM

Bedtime Lantus

Bedtime BGM

HINT: If your blood glucose meter can

do mealtime averaging, this can help you
find the times of day that your blood
glucose levels are usually too high or low.
Along with your careful reflections about
your carbohydrate intake, stress and
activity levels, this may also guide
your insulin adjustments.

12

Making Changes Using

Pattern Management
You can learn to adjust your insulin
dose by looking at your pre-meal blood
glucose levels over three or more days to
see if you notice any special pattern. In
the following example and throughout
the workbook, assume that the blood
glucose goals recommended by the
American Diabetes Association are in use
(pre-meal plasma values of 90-130 mg/dl,
blood glucose 2 hours after meals less
than 180 mg/dl.)2 and a target of
100 mg/dl.

How to Evaluate Your Blood

Glucose Record:
Record your blood glucose levels in
column format (as below) to more
easily identify a pattern. Many of the
data management software programs
will do this for you automatically
when you download the data.
Look at the readings by group
according to the time of day.
Select the blood glucose readings
by group that are out of your goal
range.

Three-day Blood Glucose Record:

Pre-meal Goals 90-130 mg/dl
Post-meal Goals < 180 mg/dl
Day #

Breakfast
Pre

Lunch
Post

Pre

Dinner
Post

Pre

Bedtime

3 AM

Post

Day 1
Day 2
Day 3

Guidelines for Pattern Management

Any time you see a consistent pattern of
either high or low blood glucose levels
over a period of three days, you could
adjust your insulin by:
Increasing the appropriate insulin or
decrease the food eaten if the blood
glucose levels are too high.

Decreasing the appropriate insulin or

increasing the food eaten if the blood
glucose levels are too low.

Most of the time the appropriate meal

to change or insulin to adjust is the rapid
or short-acting insulin taken the meal
before the out of goal values appeared.

2 American Diabetes Association, Standards of Medical Care for Patients With Diabetes Mellitus. American

Diabetes Association: Clinical Practice Recommendations, Diabetes Care. 27:Supl:10, 2005.

13

Q&A PRACTICE PROBLEMS

Q What is the Pattern in Janes Three-day Blood Glucose Record?
Pre-meal goals 90-130 mg/dl
Day #

Breakfast
Pre

Post-meal goals < 180 mg/dl

Lunch
Post

Pre

Dinner
Post

Pre

Bedtime
Post

1 Mon

90

125

110

189

2 Tues

75

134

116

210

3 Wed

100

141

131

196

133

119

198

Average 88

3 AM

A Janes pre-breakfast, pre-lunch and pre-supper readings are in goal blood glucose
range, but her bedtime readings are all high and out of range.
Q Does Jane Need an Insulin
Adjustment?
A Maybe! But first she should think
about whether she had eaten too much
carb at dinner. Over the next few days,
she should decrease her portion sizes of
food at dinner she is eating (which will
decrease the amount of carb). If there
is no improvement in her blood glucose
readings, Jane should look for other
possible causes and solutions.

Q Could Janes dinner insulin

(Humalog) be the reason that her
bedtime glucose is out of range?
A If Jane suspects her dinner insulin
needs to be adjusted, she could try
increasing it by 0.5-1 unit. Over the
next three to five days she would need
to observe whether her bedtime blood
glucose readings are improved.
NOTE: It is very important to consider
all possible causes for an out-of-goal
blood glucose reading before you adjust
your insulin dose. The nice thing about
pattern management is that you can
make a small change every few days
with great safety!

14

Q What is Different About Toms Three-day Blood Glucose Pattern?

Pre-meal goals 90-130 mg/dl
Day #

Breakfast
Pre

Post-meal goals < 180 mg/dl

Lunch
Post

Pre

Dinner
Post

Pre

Bedtime
Post

1 Mon

90

125

110

239

2 Tues

75

134

116

73

3 Wed

100

141

131

266

133

119

193

Average 88

A In this record, the breakfast, lunch

and dinner values are in the goal range.
However, the bedtime values are not
only too high on average, but also too
variable. Tom needs to look for and
understand what caused the low value
of 73 at bedtime on Tuesday.
Any time you see a consistent pattern of
either high or low blood glucose levels
over a period of three days, you could
adjust your insulin as follows. Either
increase the appropriate insulin if your
blood glucose levels are too high, or
decrease it if your blood glucose levels
are too low.
REMEMBER:
Most of the time, the appropriate insulin
to adjust is the rapid or short-acting
insulin taken at the meal before the
out-of-goal values.

3 AM

The change should be only 1 or 2

units or 10% of the usual dose at
that time of day and can be as small
as 1/2 unit.
You can make changes every three
days.
Make a change, evaluate the effect
for a few days and then make a
change again. You do not need to
make big changes. (When blood
glucose values are quite variable,
extra caution is needed because
making even a small change in insulin
under these conditions might be
dangerous).

HINT: Sometimes it is too early for you

to see a real pattern. In this case you
should probably not make any changes
and wait a few more days to see if a
pattern emerges. Or, by waiting a few
days you might find that your blood
glucose levels came back into the goal

15

range without any insulin changes.

Always make insulin dose changes only
after a full examination of the blood

glucose levels and do it carefully!

If you are unsure, consult with your
Diabetes Team.

Record Your Blood Glucose for the Past 3 Days and Pick Out the Patterns You See
Pre-meal blood glucose goals:________
Post-meal blood glucose goals:________
Day #

Breakfast
Pre

Lunch
Post

Pre

Dinner
Post

Pre

Bedtime

3 AM

Post

1 Mon
2 Tues
3 Wed
Average

Based on your results, fill out the answers

to the following questions:
1. Do you see a consistent pattern?
________________________________
2. Which insulin is affecting the pattern
of your glucose levels?_____________
3. What kind of change might have
helped bring your blood glucose
levels into goal range?_____________
4. Do you want to wait a few more days
before you make any change to see if
there really is a pattern?____________
5. Have you experienced changes in
your stress and/or activity levels over
the past three days?_______________
6. Have your food choices or amounts
been different than usual for you?
________________________________

7. Are you experiencing hormonal

changes (such as those during
menstruation or perhaps related to
any medication you may be taking)?
________________________________
8. Is your pattern of values before
breakfast out of the goal range?____
(If YES, this indicates that you need
to change your basal insulin. Please
refer to p. 37 for a discussion of this
topic.)
HINT:
Some people find it easier to use a
computer program to identify blood
glucose patterns. If you are interested
in this type of a program, contact your
meter manufacturer for information
on how to obtain one.

16

Correcting for Blood Glucose

That is Out of Range
Know Your Blood Glucose Goals
In this workbook, the American Diabetes
Association (ADA) recommended premeal blood glucose goals of 90 to 130
mg/dl will be used. If you are above 130
mg/dl, you will increase your insulin;
if you are less than 90 mg/dl you will
decrease the insulin. Many people use
a target of 100 and make adjustments
if they are above or below this target.
Correcting The term used for an
immediate change in your insulin dose
based on one event, such as a:
Single out-of-target blood glucose
level.
Change in a single meal (you are
invited out to a French restaurant
for dinner).
Change in your exercise routine
(you are going for a bike ride).
Correcting means you make a minor
change in your insulin dose based on the
event now, but go back to your usual
insulin dose tomorrow.
EXAMPLE:
If you wake up and your blood glucose
reading is 200 mg/dl but you want it to

be 100 mg/dl, you would make an

immediate insulin correction. To do
this you would take a certain dose of
short or rapid-acting insulin to bring that
blood glucose value down to 100 mg/dl.
NOTE:
Correction doses of insulin are calculated
for each person and may change
throughout the day. People usually
need a bigger correction dose at
breakfast than at lunch and dinner.
Methods of Correction There are
many ways to correct for an abnormal
blood glucose value. The three most
common methods will be discussed here.
Check with your health care professional
to see which method is best for you.
Correction Method I Fixed Insulin
Dose Based on Blood Glucose Value.
Uses an algorithm (formula) to tell you the
amount of insulin to take based on your
blood glucose levels before meals and at
bedtime. The carb you eat at each meal
should be the same from day to day.
EXAMPLE:
Kens Diabetes Team gives him an
algorithm of blood glucose values and
insulin doses. Ken will give the insulin
dose that corresponds to his current
blood glucose.

17

Kens Algorithm for Correction Method 1

Blood Glucose Values

Insulin Dose (Rapid or Short -Acting)

Breakfast

Lunch

Supper

Bed

<50

50-69

10

11

70-89

11

12

90-130

10

12

13

131-160

11

13

14

161-190

12

14

15

191-220

13

15

16

221-250

14

16

17

251-280

15

17

18

281-310

16

18

19

Over 310

18

20

20

Correction Method I How to Use

an Algorithm
1. Use the algorithm for a week or two.
2. Monitor your blood glucose often.
3. Record every reading in your logbook.
4. Share your results by fax, phone or
in person with your health team member.
5. Your health team member will work
with you to make any needed
adjustments to your algorithm.
6. After a little practice, you will be able
to use the algorithm with confidence
on your own.
HINT:
Remember, for this method to work well
you need to eat the same amount of
carbs at breakfast, lunch and dinner
from day to day!

Correction Method II Change

in Insulin Dose Based on Blood
Glucose Value
Your Diabetes Team prescribes a fixed
amount of pre-meal insulin to use for
every high, out-of-goal blood glucose
reading. Uses an algorithm that tells
you how much insulin to add or subtract
from your usual dose, depending on
your current blood glucose value.
EXAMPLE:
Joes fixed dose of rapid or short acting
insulin before breakfast and lunch is 6
units, and his pre-dinner dose is 8 units.
His doctor gives him an algorithm of
blood glucose values and pre-meal
rapid- or short-acting insulin.

18

Joes Algorithm for Correction Method II

Blood Glucose Values Pre-meal rapid or
short acting insulin
Less than 60

Subtract 3 units

60-90

Subtract 1 unit

90-130

Take usual dose

130-200

Add 1 unit

200-250

Add 2 units

250-300

Add 3 units

300-350

Add 4 units

350-400

Add 6 units

Over 400

Add 8 units

Correction Method III Change in

Insulin Dose Based on Your Insulin
Sensitivity Factor
As you learned earlier, your Insulin
Sensitivity Factor (ISF) tells you how many
points lower your blood glucose will go for
every 1 unit of short or rapid acting insulin
you take. Method III uses your ISF to figure
out how much to raise or lower your
insulin dose to bring your blood glucose
back to goal range. If you use Correction
Method III before a meal you will need to
add the correction amount of insulin to the
amount of units needed to cover the
number of carbohydrates you will eat. (See
p. 28 for a discussion of carbohydrates.)
REMEMBER:
The ADA recommended pre-meal values
of 90-130 mg/dl as a goal range are used
in this workbook. Your Diabetes Team
may set a different pre-meal goal for you.

Calculating Your Insulin

Sensitivity Factor (ISF)
Your Diabetes Team may use any of the
following methods to help find your ISF:
1. Insulin/Blood Glucose Formula
(One unit of rapid or short-acting
insulin for every 50 mg/dl increase or
decrease in your blood glucose level).
2. Rule of 1500 - if you are using shortacting insulin (Regular).
3. Rule of 1700 - if you are using rapidacting insulin (Humalog, Novalog,
Apidra).
ISF Method I Insulin/Blood
Glucose Formula
With ISF Method I, you take one unit
of rapid or short-acting insulin for every
50 mg/dl increase or decrease in your
blood glucose level.
EXAMPLE:
Blood glucose target is 100 mg/dl.
Johns pre-lunch blood glucose is 180
mg/dl and his Insulin Sensitivity is 50.
His reading shows that he is above
his target by 80 mg/dl.
[180 mg/dl 100 mg/dl = 80 mg/dl]

He should take 1 (1.5 if you measure

1/2 units) extra units at lunch.
If his usual dose of rapid or short-acting
insulin at lunch were 12 units, he
would increase it by one and take
13 or 13.5 units.
19

PRACTICE PROBLEMS:
Blood glucose target: 100 mg/dl
Susans pre-lunch blood glucose
is 205 mg/dl.
Her reading shows that she is above
her target by 105 mg/dl
[205 mg/dl 100 mg/dl = 105 mg/dl]
Q How many extra units should
Susan take?
105 mg/dl = 2 units
50
A She should take 2 extra units. In this
case she should take a total of 14 units.
Bobs pre-lunch blood glucose
is 60 mg/dl.
His reading shows that he is below his
lower target by 40 mg/dl
[100 mg/dl 60 mg/dl = 40 mg/dl]
Using ISF Method I he would:
40 mg/dl = .8 units
50
Round .8 units to 1 unit
Decrease his insulin dose by 1 unit.
Take a total of 11 units.
Find Your Correction Dose for the
Highest Pre-Meal Blood Glucose you
had yesterday:
ISF = 50 mg/dl Target = _____ mg/dl
Pre-Breakfast

Pre-Lunch

Pre-Dinner

Record yesterdays pre-meal blood

glucose readings.
Take your highest pre-meal blood
glucose and subtract your target goal:
[_______ ________ mg/dl = _________.]
Target Goal

Divide your answer by 50 and add the

number to your usual insulin dose:
[__________ divided by 50 = _________.]
Add to your usual pre-meal dose.
If You Had a Low Blood Glucose
Yesterday, Figure out the Insulin
Dose You Need:
Record yesterdays pre-meal blood
glucose readings.
Take your lowest pre-meal blood glucose
reading and subtract your target goal:
[_______ ________ mg/dl = _________.]
Target Goal

This will be a negative number.

Divide your answer by 50 and subtract
the number from your usual insulin dose.
[__________ divided by 50 = _________.]
Subtract from your usual pre-meal dose.
The corrections above using ISF Method I
should bring your blood glucose back to
normal at the next meal if you make no

20

other changes. Although any single meal

may not correct properly, if after a few
days they do not, you may have the
wrong ISF or the wrong carb-to-insulin
ratio for you. Work with your Diabetes
Team would have to adjust the ISF and
carb-to-insulin ratio.

EXAMPLE:
Calculate Ritas ISF Using the Rule of
1500.
If Rita took 10 units of Regular insulin at
breakfast, 12 at lunch, 13 at supper, and
15 units of Lantus at bedtime, her total
would = 50 units a day.

ISF Method II Using the Rule of

Dividing 50 units into 1500 would = 30.

1500 To get a good first guess at your

insulin sensitivity, divide the sum of all of
your daily insulin doses into 1500.3

So as a first guess, each unit of insulin

would lower Ritas blood glucose by
30 mg/dl. (See Rule of 1500 box below)

Rule of 1500
1) Add all insulin doses
10 units Insulin Regular
12 units Insulin Regular
13 units Insulin Regular
+ 15 units Insulin Lantus
50 units

2) Divide sum of insulin

doses into 1500
1500
= 30 mg/dl
50 units of insulin

PRACTICE PROBLEMS:
1. Calculate your ISF using the Rule
of 1500.
Fill in all the insulin doses you take in one
day and add them up:
# of units

Type of insulin

3) Answer = ISF
Insulin Sensitivity Factor =
1 unit of short or rapid acting insulin will lower
blood glucose 30 mg/dl

Divide 1500 by your total units of

insulin/day
1500
=
(your total units of insulin/day)

The answer is your ISF (the number of

points one unit of insulin will lower your
blood glucose).

Total units/day

3 Klingensmith, GJ. American Diabetes Association, Intensive Diabetes Management, Third Edition, 2003.

p. 107. 2003.

21

Fill in your pre-meal blood glucose

values from yesterday and calculate
your adjusted insulin dose using the
steps below:
Pre-Breakfast Pre-Lunch

Fill in the table below with your

calculations using your own
information:
Usual Insulin
Dose

Pre-Dinner

Adjusted
Insulin Dose

Pre-Breakfast
Pre-lunch

Circle your high pre-meal blood glucose.

Subtract your target goal from your high
pre-meal blood glucose.
[_______ ________ mg/dl = _________.]
Target Goal

Divide this number by your insulin

sensitivity factor (ISF)
= ________
(ISF)

Add the answer to your usual insulin dose.

If you had a low blood glucose
yesterday find the insulin dose that
should be given:
Take your low pre-meal blood glucose
your target = ____________.
This will be a negative number. You will
need to subtract insulin for correction.
[_______ ________ mg/dl = _________.]
Target Goal

Divide the number by your ISF and subtract

answer from your usual insulin dose.
[__________ divided by _____ = ______.]

Pre-dinner

REMEMBER:
Guidelines for Taking Correction
Doses for Out-Of-Goal Blood Glucose:
1. Check your blood glucose about 2
hours later. Use your post-meal blood
glucose goal. In this booklet, the
ADA recommendation of less than
180 mg/dl is used.
2. If your blood glucose is still not within
your range of blood glucose goals,
lower your ISF number (try changing
by 5).
3. If you have hypoglycemia (low blood
sugar), increase your insulin sensitivity
number.
ISF Method III Using the Rule of
1700 Another way to get a good
first guess at your insulin sensitivity is
to divide the sum of all of your insulin
doses into 1700.4

Subtract from your usual pre-meal dose.

[Usual dose __________ = __________.]
4 American Diabetes Association, Intensive Diabetes Management, third Edition, p. 107. 2003.

22

EXAMPLE:
If you take 10 units of Humalog at
breakfast, 12 at lunch and 13 at dinner,
and you take 15 units of Lantus at
bedtime, your total would = 50 units a

day. Dividing this into 1700 would give

you 34 (this number can be rounded up
to 35). So as a first guess, each unit of
insulin would lower your blood glucose
by 35 mg/dl.

Rule of 1700
1) Add all insulin doses
10 units Insulin Humalog
12 units Insulin Humalog
13 units Insulin Humalog
+ 15 units Insulin Lantus
50 units of insulin/day

2) Divide sum of all insulin

doses into 1700
1700
= 34 mg/dl
50 units of insulin

Now you try it using the 1700 rule.

PRACTICE: Calculate Your ISF Using
the Rule of 1700.
Using the chart below, fill in all the
insulin doses you take in one day and
add them up:
# of units

3) Answer = ISF
Insulin Sensitivity Factor =
1 unit of short or acting
insulin will lower blood
glucose 34 mg/dl

Figure out your adjusted insulin dose

based on your pre-meal blood
glucose readings:
Target Goal = ______________
Pre-Breakfast Pre-Lunch

Pre-Dinner

Type of insulin

Fill in your pre-meal blood glucose values

from yesterday in the chart above.
Circle your high pre-meal blood glucose.
Total units
per day =

Divide 1700 by your total units of insulin/day.

1700

= ________

Subtract your target goal from your high

blood glucose reading.
_______ ________ mg/dl = _________
Target Goal

Divide this number by your ISF.

= ________

(your total units/day)

The answer is your ISF (the number of

points one unit of insulin will lower your
blood glucose).

(ISF)

Add the answer to your usual pre-meal

dose.
23

If you had a low blood glucose

yesterday, figure out your correction
insulin dose.
Subtract your target goal from your low
pre-meal blood glucose.
_______ ________ mg/dl = _________
Target Goal

This will be a negative number. You will

need to subtract insulin to make the
correction.
Divide your answer by your ISF and
subtract answer from your usual insulin
dose.
= ________
(ISF)

Subtract the answer from your usual

pre-meal dose.
________ _________ = _____________

Every time you take a correction dose for

an out of goal blood glucose you should
note the effect on your blood glucose. If
your glucose correction doses never bring
you back to your goal range, you should
lower your sensitivity number. If you
are under-correcting you are not giving
enough insulin. You will know this
because your high blood glucose
readings will remain high and the low
blood glucose readings will stay low.
This means you need a larger correction
dose, so reduce your ISF by 5.
If you are over-correcting you are taking
to much insulin. You will know this
because your high blood glucose values
will become low and your lows may
become high. This means you need
to decrease your correction dose,
raise the ISF by 5.

Fill in the table below with your

calculations using your own
information:
Usual Insulin
Dose

Adjusted
Insulin Dose

Pre-Breakfast
Pre-lunch
Pre-dinner

24

Correcting for Known

Changes in Meals or Exercise
You have learned to adjust insulin to stay
within your blood glucose goals. Insulin
doses are also commonly adjusted for
changes in diet or exercise. Changing
your insulin dose based on what you will
eat and the activity you plan to do is
often called insulin dosing.
Correcting for a Change in Meals
Since most people do NOT eat the same
thing every day, you need to learn how
to calculate your short or rapid acting
(bolus) insulin for different meals and
different amounts of carbohydrates.
If you are not sure about which foods
are carbohydrates, discuss this with
your diabetes educator. As with insulin
correction for out-of-goal blood glucose,
different methods are available for insulin
dosing for a change in the food that is
usually eaten at meals. One method
involves adding or subtracting insulin for
more or less food. Another way is to
take a certain amount of insulin for a
specific amount of carbohydrate. Check
with your Diabetes Team to see which
method they recommend for you.

Both methods require that you learn how

to count carbohydrates. In addition, you
also need to learn how sensitive your
insulin dose is to the carb you eat. This
is called your Carb:Insulin Ratio. For
information about carb counting, see the
BD Publication Carbohydrate Counting:
Eat to Win and talk to your diabetes
educator.
Calculating Your Carb:Insulin Ratio
A carb:insulin ratio is the amount of
rapid or short acting insulin you need
to match or cover the amount of
carbohydrate you eat. Your ratio
depends on how sensitive your blood
glucose is to insulin. The more you
weigh, the less sensitive your body is
to insulin. The more sensitive you are
to insulin, the more carbohydrate that
will be covered by one unit of insulin.
Knowing your ratio and how to
calculate your mealtime insulin to
match the carbohydrate in your meal
gives you the greatest flexibility with
improved glucose control. You will
be much freer to eat what you want,
when you want, with fewer concerns
about high or low blood glucose.

25

Method I: A Quick and Easy Way

to Start
Before you begin, keep the following
guidelines in mind. Use 1 unit of insulin
for every 15 grams of carbohydrate
(1:15). Some people will need more
insulin (1 unit for every 10 grams of
carbohydrate). Others will need less
insulin and use 1 unit for every 20 grams
of carbohydrate. Most people with type
1 diabetes have ratios between 6 and
10, but you may want to start with
a very sensitive level of 15 grams of
carbohydrate per unit of insulin and
see if this works for you.
Method II: The Rule of 500:5
Add up all the insulin given for 24 hours
and divide it into 500. The answer is
your carb:insulin ratio.
EXAMPLE:
Your total insulin dose is 50 units.
500 divided by 50 = 10
Your carb: insulin ratio is 10:1
Again, this is a starting point, you
need to start with this ratio and adjust
it based on your blood glucose records.
Your Diabetes Team can guide you in
this process.

Keep Detailed Records for About

One Week
The best way to find your carb:insulin
ratio is to use the following Food and
Carbohydrate Counting Record below
and write down:
1. Everything you eat and how much
you eat - you will need to weigh and
measure! (If you know how to count
carbs, include them. Otherwise, use
tables or a calculator to figure out the
carbs in all of the food you eat and
record each amount.)
2. Your insulin dose for each meal.
3. Your blood glucose levels before
the meal.
4. Your blood glucose records after
the meal. (Your blood glucose level
should increase about 50 mg/dl
2 hours after you eat. If it is much
higher or lower than that, your
Insulin:Carb ratio will need to
be adjusted.)
NOTE:
If you have never used a carb:insulin
ratio, discuss this with your Diabetes
Team and let them guide you through
this process. Also, like the ISF, you may
have a different carb: insulin for each
meal. Typically, this ratio is lower at
breakfast.

5 Warshaw, H.S. and Kulkarni, K., Complete Guide to Carb Counting. P. 146. American Diabetes Association 2001.

26

Food and Carbohydrate Counting Record

Brkfst
time:

AM Carb
PM goal:
gms

BG before
meal

Food Eaten
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________

BG 2 hours
after meal

Insulin

Comments:

Amount
Grams Carb
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
Total: _____________________________

Snack Time: Food Eaten

Amount
Grams Carb
_______________ __________________________________ ____________________________ ______________________________________
_______________ __________________________________ ____________________________ ______________________________________
Total: ____________________________
Lunch
time:

AM Carb
PM goal:
gms

BG before
meal

Food Eaten
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________

BG 90 min
after meal

Insulin

Comments:

Amount
Grams Carb
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
Total: _____________________________

Snack Time: Food Eaten

Amount
Grams Carb
_______________ __________________________________ ____________________________ ______________________________________
_______________ __________________________________ ____________________________ ______________________________________
Total: ____________________________
Supper
time:

AM Carb
PM goal:
gms

BG before
meal

Food Eaten
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________

BG 90 min
after meal

Insulin

Comments:

Amount
Grams Carb
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
____________________________ _______________________________________
Total: _____________________________

Snack
BG before snack_________
Time:
Food Eaten
Amount
Grams Carb
_______________ __________________________________ ____________________________ ______________________________________
_______________ __________________________________ ____________________________ ______________________________________
Total: ____________________________
27

Method I Insulin Dosing Based on

Carb Intake A set dose of insulin is
given for a meal and a specific amount
of carbohydrate is eaten at the meal. If
you eat the usual amount of carbs, you
take the usual amount of insulin. Your
health provider will prescribe a specific
amount of carbohydrate for each meal.
If you eat more carbs, you take more
insulin, as determined by your prescribed
carb:insulin ratio. If you eat less carbs,
you reduce your insulin, again using
the ratio.
EXAMPLES:
Georges Health Team prescribed
carbohydrates for his meals as
follows:

60 grams of carbohydrate for

breakfast and lunch.
70 grams of carbohydrates for
supper.

If George expects to eat more carbs, he

will take more insulin, as determined by
his prescribed carb:insulin ratio. If he
plans on eating less carbs, he will reduce
his insulin, again using the ratio.

What should George do if he is going

to change the amount of food he is
going to eat? (George usually eats
70 grams of carb for dinner, and he
takes 7 units.)

If George is very hungry today and

plans to eat 90 grams of carb for
dinner, he would eat an extra 20
grams of carb.
If his carb:insulin ratio is 10:1, for
every 10 extra grams of Carb, he
needs 1 extra unit, so for an extra
20 grams, he needs 2 extra units
of insulin.
In this case, for a 90-gram dinner,
he would take 9 units of insulin
(see the chart below).

Usual Grams of
Carbohydrate
Carb:Insulin Ratio: 10:1

Usual Dose of
Insulin

70 Grams Carb

7 Units Humalog

90 Grams Carb

9 Units Humalog

28

Method II Insulin Dosing Based on

Carb:Insulin Ratio
Unlike Method I, you do not have a
usual amount of food that you take or
a usual insulin dose. You simply use
the Carb:Insulin Ratio to determine
your dose.
EXAMPLE:
Marys Carb:Insulin Ratio is 10:1
Mary is meeting an old friend at a
favorite restaurant and she is planning
to eat a 90-gram lunch. To figure out
her insulin dose, knowing that her ratio
is 10:1, all she has to do is to divide
the number of carb by her ratio as
follows:
90 grams of carbohydrate divided
by 10 units of insulin = 9 units of
Humalog
90
[ 10

= 9 units of Humalog

Correcting for a Known Change

in Exercise
Exercise lowers your blood glucose levels.
If you have started an exercise program
and your blood glucose levels are too low
and you are using an insulin pump, you
will need to adjust your basal insulin.
(See Adjusting the Basal Dose p. 37).
This is the hardest of the adjustments
because everyone responds to exercise
differently. If you are giving bolus
injections of insulin, you should lower
your bolus dose before exercise. An
example of how to do this can be found
on p. 37.
Try to measure your exercise by intensity
(how hard you work) and how much
time it takes. Think of your exercise
as mild, moderate or intense.
Mild exercise you will not sweat at
room temperature, no matter how
long you do it.

Moderate exercise you will sweat

after 15-30 minutes.
Intense exercise you will start to
sweat almost right away.

The more intense your exercise and the

longer it lasts, the more you will need to
decrease you insulin.

29

PUTTING IT ALL TOGETHER

30

PUTTING IT ALL TOGETHER

You have learned a lot of information
about making changes to your bolus
insulin doses. Now it is time to put
these facts to work for you. This
section will help you practice using
your new knowledge in your
everyday routine.

Getting Started:
A Five-Step Plan
1. Define your target blood glucose
level.
2. Calculate your insulin sensitivity
factor (ISF).
3. Try starting a carb:insulin ratio of 10
or 15 grams of carb:1 unit of insulin.
4. Count the number of carbohydrates
you will be eating.
5. Reduce, if necessary for exercise.

PRACTICE PROBLEMS:
Toms Night Out
Lets look at how Tom uses the 5-step plan
above to calculate his insulin adjustment.
Tom has a fun evening planned. He is
going out to an Italian restaurant for dinner
with some friends after a game of singles
tennis. When he tests his blood glucose
before dinner, he finds it is 190 mg/dl.
Here is his information for the five steps.
Blood Glucose Goals: 90-130 mg/dl
Target blood glucose level is 100 mg/dl
The initial ISF is 1 unit for every
30 mg/dl of blood glucose. Toms
total insulin dose is 50 units/day.
Using the rule of 1500, 1500/50 = 30
The initial carb:insulin ratio is 10:1,
1 unit of Regular insulin for every
10 grams of carb. Using the rule
of 500, 500/50 = 10
Tom is planning on eating about
90 grams of carbohydrates
See below for step 5

Toms Calculations:
Insulin needed for carbohydrates

9 units (90 divided by 10)

Insulin needed to correct for high blood glucose

(190-100=90) divided by 30 (ISF)=3

Total insulin for food and carb

9 + 3 = 12 units

Reduction for high intensity exercise (Step 5)

3 units

TOTAL amount of pre-dinner insulin

9 units

31

Your Night Out

Using the Five Steps, calculate the answers in the chart below:
Planned Food (Carbs)

________ Carbs

Divided by Carb/Insulin Ratio

________ Carbs/U of Insulin =

________ Units of Insulin

Current Blood Glucose

________ mg/dl

Your Target Blood Glucose

________ mg/dl

Current Blood Glucose Target Blood Glucose

________ mg/dl

Your Insulin Sensitivity Factor?

________

Divide your Blood Glucose Calculation by Insulin Sensitivity

________ U of insulin

Subtract for Exercise if Necessary

________ U of insulin
________ Total Dose

Your Morning Breakfast and Run

Lets say you are going to eat 2 slices
of toast (30 grams), a fried egg, hash
browns (15 grams) and a 1/2 glass of
juice (15 grams). This is a total of (60
grams of carb), but you are going to run

2 miles before lunch. Using the five

steps, use the space below to figure out
your insulin adjustment based on your
plans for breakfast and exercise:
Now check the following chart and
see how well you did!

Your Morning Breakfast and Run

Planned Food (Carbs)

60 Carbs

Divided by Carb/Insulin Ratio

60/8

8 Carbs/U of Insulin
7.5 U of Insulin

Current Blood Glucose

180 mg/dl

Current Blood Glucose Target Blood Glucose

180 100 = 80

Insulin Sensitivity

30

Current BG Target BG
_______________________
Insulin Sensitivity

80
__
30

+ 2.5 U of insulin

Reduction for Exercise (Should be Negative)

-3 U of Insulin

Add Units of Insulin (7.5 U + 2.5 U -3 U) =

7 U TOTAL DOSE

32

After correcting for food, elevated blood

glucose and expected exercise, you
would take 7 units of short-acting
insulin.
IMPORTANT REMINDERS:
After adjusting your insulin dose for
exercise you must check to see if the
insulin given was too much or too

little. (Checking your blood glucose

level before, during and after exercise
will provide the information you need
to change future doses.)
Talk to your Diabetes Team about
how your doses are working for you.

Be sure to test for urine ketones

if blood glucose levels are over
250 mg/dl.6 Do not exercise when
you have ketones in your urine.
Eat a carb food if blood glucose levels
are <100 mg/dl.

This is a lot to take in at first, but most

people get very good at doing these
calculations and quickly learn to keep
their blood glucose levels very close to
normal. It is helpful to have a small
calculator when you begin.

6 American Diabetes Association, Position Statement: Physical Activity/Exercise and Diabetes. American Diabetes

Association: Clinical Practice Recommendations, Diabetes Care. 27:Sup1:1, S58-S62. January 2004.

33

ADJUSTING THE BASAL INSULIN DOSE

34

ADJUSTING THE BASAL INSULIN DOSE

Adjusting the basal dose is more
challenging than changing the bolus
dose. Basal insulin is designed to always
be working in the background to keep
your blood glucose steady when you are
not eating. The basal insulin has the
major job of keeping your blood glucose
normal during the night, if you do not
eat or if you delay a meal. Insulin used
to provide a basal dose include Lantus
and Ultralente insulin and the basal
setting on an insulin pump. This section
will help explain how to make changes
to your basal insulin.

How to Test and adjust The Basal

Insulin To Normalize Your Morning
Blood Glucose
1. Check your blood glucose at bedtime,
at 3 AM and in the morning before
you eat.
2. Pick a day when your bedtime
glucose is close to your goal range.
3. Set your alarm for 3 AM and write down
your blood glucose value after you test
(it is too easy to go back to sleep and
forget the reading you got at 3 AM).
Bedtime

3:00 AM

Pre-Breakfast

Testing the Nighttime Basal

Figure 4
Graph for Adjusting Basal Insulin
400

300

Blood Glucose

Adjusting the basal insulin is done

much less often than the bolus insulin
corrections. The best way to check your
basal insulin is to look at your nighttime
and morning glucose readings first. It
is easier and more important to be sure
that the basal is correct at night, since
you may be hypoglycemic (have a low
blood sugar) at night but not know it!
Many people become less sensitive to
insulin between 3 AM and 7 AM. As
a result, you could have a high blood
glucose value when you wake up in the
morning or you could have a low blood
glucose level in the middle of the night.

4. In the morning check your prebreakfast reading.

5. Using the graph below (Figure 4),
put a dot that matches each of your
blood glucose readings - at bedtime,
3 AM and fasting (pre-breakfast).
6. Connect the dots.

200

100

0
Bed

3 AM

Time

Fasting

35

7. Your graph should look like one of the 6 patterns shown in the next graph
(Figure 5) and labeled A-F.
Figure 5
Patterns of Overnight Blood Glucose Values
Blood Glucose

400

300

200
100
0
Bed

3 AM
Time

Fasting Bed

3 AM
Time

Fasting Bed

3 AM
Time

Fasting Bed

3 AM
Time

Fasting Bed

3 AM
Time

Fasting Bed

3 AM
Time

Fasting

8. Select the example that looks the closest to the pattern of your Basal Insulin in
Figure 4.
9. Look up the change in Table 1 below. The table below will indicate the change to
your basal dose that is needed.
Table 1: Changes to Basal Insulin
Changes to Basal for an Insulin Pump
Pattern What to do...

Expected Pattern

Normal leave alone

Pattern A

Increase 10 PM - 3 AM

Pattern A

Increase 10 PM - 3 AM

Pattern A

Decrease 10 PM - 3 AM

Pattern A or E

Increase 3 AM - 7 AM

Pattern A

Decrease 3 AM - 7 AM

Pattern B or C

Changes to Basal for Lantus or Ultralente

Pattern What to do...

Expected Pattern

Normal leave alone

Pattern A

Increase Lantus or Ultralente

Pattern A

Reduce bedtime snack, keep insulin dose the same

Pattern A

Decrease Lantus or Ultralente

Pattern A or E

Increase or add bedtime Lantus or Ultralente

Pattern A

Decrease bedtime Lantus or Ultralente

or reduce bedtime snack

Pattern A

36

For many people, the suggestion under

the column, What to Do will correct the
problem and give an expected normal
pattern A. In some cases, the pattern
may require more than one change.
The result of the first, usually safer
change is shown under the column,
Expected Pattern. You may want to
make a second change based upon the
new problem. Talk to your Diabetes
Team about how that change should be
made. Changing more than one dose of
insulin at a time can be complicated and
should be left to your Diabetes Team.
How much to change the insulin is
very individual, please check with your
Diabetes Team for advice. It is safest to
make small changes often rather than
big changes infrequently.

Testing the Daytime Basal

Your health care provider may ask you
to check your daytime basal dose. Here
are a few methods to use. Follow your
providers best recommendation for your
individual case.
Option I: Skip a meal
(the simplest method).
Day 1 - skip breakfast, then check
your blood glucose every 2 hours,
until lunch)
Day 2 skip lunch and check your
blood glucose every 2 hours, until
dinner
Day 3 skip dinner, again checking
your blood glucose every 2 hours,
until bedtime
In all cases, if your blood glucose
is rising, your basal is too low; if
it is falling, your basal is too high.

Blood Glucose Results to Test Daytime Basal Rate

Time of Day
Meal
Breakfast - Day 1
Lunch - Day 2
Lunch - Day 3

37

Option II: See if your basal rises after

your last bolus has finished working.
(This only works with rapid or shortacting insulin.)

Measure your blood glucose four

hours after you take your rapid or
short-acting insulin.
Continue to measure your blood glucose
every hour until you are sure that your
blood glucose is not rising or falling.

Blood Glucose Results to Test Daytime Basal Rate

Time of Day
Meal
Breakfast - Day 1
Lunch - Day 2
Lunch - Day 3

Option III: Delay a meal and measure

the effect on your blood glucose.

have a BIG effect on your blood glucose

levels!

Whichever method you choose, decide

if you need a change in your basal dose
and do it very carefully. Your Diabetes
Team may recommend that you collect
data over two time periods before
making a change. It is also advised that
this process be used on nights or days
when your activity level is similar to your
usual pattern. Small dose changes can

After you make your adjustments, keep

checking your blood glucose closely for
the next few days. You need at least 4
days to 1 week to see if your adjustment
resulted in better blood glucose control.
An adjustment on the basal rate for
an insulin pump may take less time to
evaluate. Use a chart like the following
to write down your blood glucose results.

Day

Breakfast

Lunch

Bedtime

3 AM

38

TROUBLESHOOTING

39

TROUBLESHOOTING
Sometimes you may find your blood
glucose levels go up and down wildly,
without any pattern that you can figure
out. This might make you feel like giving
up at times. Getting caught up in the
frustration and anger just makes you feel
more upset and hopeless. This section
can help you cope with these feelings
and put you on the right track to finding
the answers you need.
I am doing everything right and my
blood sugars still arent in my goal
I just dont understand it anymore!

Go back to the drawing

board with a record log that
includes:

Pre-meal, 2 hours post-meal and

bedtime blood glucose levels.
Time you eat.
Amount of carb you eat.
Amount and type of insulin you take.

The Food and Carbohydrate Counting

Record on p. 30 may be helpful.

Now it is time to begin your

detective work

If this sounds like you its time to:

Take a deep breath.

Take a step back.
Put on your detective hat.
Figure out what is going on!

Here are some guidelines to help you

in your search for the answer. (There is
an answer - really!) Although you may
groan at the suggestion, the best way
to figure out your problem is to keep
written records.

Round up the usual suspects and

concentrate. Then ask yourself a few
easy questions. Any time your answer
is YES, place a checkmark in the
appropriate box:
1. Insulin:
Is there something wrong with
your insulin? Was it allowed to
get to warm or freeze?
Is it expired?
Are you giving it at the same time
of day? Are you missing doses or
giving it after a meal because you
forgot to give it before?

40

2. Absorption of Insulin
Are your injection sites lumpy
or scarred?
Do you have any redness around
your injection sites? Are you
having trouble with your insulin
pump infusion site or are you
injecting in a scarred area? (This
could affect how your body is
absorbing the insulin and can
lead to problems with control.)
Have you changed how you
give insulin?
Have you changed the brand of
syringe or size of insulin needle?
If you are using an insulin pump,
is the tubing clogged?
3. Stress
Are you experiencing unusual
stress?
Did you know both physical and
emotional stress could affect your
blood glucose levels?
4. Infection
Do you have an infection?
Did you know infections are
a stress to the body and can
increase blood glucose levels?
5. Illness
Are you ill? Do you have a fever,
a cold, or a virus?
Did you know illness could
increase blood glucose levels?

6. Physical Activity
Have you changed your physical
activity a lot?
Are you more or less active than
usual? (If so, this can increase or
decrease your blood glucose levels)
7. Food
Are you eating more carb and not
taking enough insulin?
Is it possible you are not counting
your carbohydrates accurately?
Are you eating at the same time
of day or does it vary?
Are you eating less and taking too
much insulin?
8. Self-Monitoring of Blood Glucose
and Test Strips
Are your test strips outdated or
have the strips been outside the
vial? (This will make your glucose
readings inaccurate.)
Are you checking at the right
time of day to understand the
effect of your insulin, food and
physical activity?
Did you clean your hands before
checking your blood glucose?
Even small amounts of food
residue can affect results.
If you answered YES to any of the above
questions, correct the problem, give
yourself a few days and see if your
blood glucose levels out.
If you answered NO to all of the above
questions, your next step is to sort
through your insulin doses.

41

Which Insulin is the

Problem?

Read the following problem and see if

it can help you figure out your basalbolus questions. Sam takes 19 units of
insulin glargine (Lantus) at bedtime and
insulin boluses of insulin lispro (Humalog)
in the following amounts: 10 units for
breakfast; 8 units for lunch, and 12 units for
dinner. His mealtime carb amounts are 75
at breakfast; 60 at lunch; and 100 grams
at dinner. His insulin/carb ratio is 8:1 and
his correction dose is 1 unit for every 50
mg/dl and his target glucose is 100 mg/dl.
On days 1-3 he always eats his normal
amount of carb. He does not eat an
afternoon snack. Look at his blood glucose
values and insulin doses in the chart below.

1. Basal Insulin
Am I taking enough or too much
basal insulin?
Are my blood glucose levels
always too high or too low?
2. Bolus Insulin
Is my bolus insulin dose correct?
Are my blood glucose levels
too high or too low 2 hours
after eating?

8 AM

12 noon

6 PM

10 PM

BG

Ins

BG

Ins

BG

Ins

BG

Ins

Day 1

94

10 L

104

8L

205

13 L

150

1 LP
19 G

Day 2

108

10 L

103

8L

197

13 L

155

1 LP
19 G

Day 3

97

10 L

112

8L

215

14 L

125

19 G

Now, read the questions below and circle

the letter that you think is the correct
answer to each question.
1. What is the problem?
A. Blood glucose too low at
breakfast?
B. Blood glucose too high at lunch?
C. Blood glucose too high at supper?
D. Blood glucose too low at
bedtime?

2. Which of the following types of

problems does Sam have?
A. A basal problem?
B. A bolus problem?
C. An eating problem?
3. What should Sam do?
A. Change the basal insulin glargine?
B. Change the breakfast bolus?
C. Change the lunch bolus?
D. Change the supper bolus?
42

4. How much of an adjustment is

needed?
A. Decrease 1-2 Units
B. Increase 1-2 Units
C. Increase 3-4 Units
D. Increase 5-6 Units
ANSWERS:
1. C Sam has detected that he is
always too high at supper.
2. B This is a bolus pattern that
requires adjustment.
3. B He should change his lunch bolus
4. B He should increase his lunch bolus
(insulin lispro Humalog) by 1 Unit.

Notice that while his dinner glucose

values were too high, Sam was taking
a correction dose of 1 unit of insulin
for day 1 and 2. Since his blood glucose
values were too high by about 75 mg/dl
this was not enough and on day 3 he
increased the correction to 2 units of
insulin lispro (Humalog).
If you have remaining basal-bolus
questions, check back with your
Diabetes Team.

He should check back in 3 days to

see if this was enough.

43

PROBLEM SOLVING AND EXERCISES

44

PROBLEM SOLVING AND EXERCISES

Use the problems and exercises in
this section to help you reinforce and
strengthen what you have learned
about insulin adjustment. The more
experienced you become at spotting
problems and figuring out the answers,
the more rewards you will enjoy from
practicing basal-bolus insulin therapy!

B. Increase the daytime basal rate

by 0.2 units per hour?
C. Set her alarm and check her
blood glucose level at 3 AM?
D. Give a bolus at 10 PM?
A Choice C is the correct answer - the
only way to find out what is happening
to Sallys blood glucose level during the

Sallys on Goal at Bedtime but Gets

High Readings in the Morning
Sally has been using an insulin pump for
3 months. Her basal rate is set at 0.7
units per hour from 10 PM to 3 AM and
her daytime basal rate is 0.5 units per
hour. She has been going to bed with
normal blood glucose values but always
wakes up with blood glucose levels over
165 mg/dl. She increased her basal rate
from 10 PM to 3 AM from 0.6 to the
current rate of 0.7 units per hour but
is still having a problem.

night is to test it at 3 AM. Choice A Increasing the basal rate overnight might
cause hypoglycemia in the middle of the
night. Choice B - Increasing her daytime
basal rate would do nothing to help the
overnight blood glucose levels. Choice D Giving a bolus at 10 PM could cause a
problem with hypoglycemia at midnight.
Q What should Sally do if she
checks her blood glucose at 3 AM
and discovers that it was 60 mg/dl?
A. Lower the 10 PM to 3 AM basal rate?
B. Eat a big snack at 10 PM?
C. Decrease the snack bolus?
D. Increase the 10 PM to 3 AM basal rate?

Q What should Sally do to try to

bring her morning blood glucose level
to her goal range of 90-130 mg/dl?
A. Increase the basal rate from
10 PM to 3 AM?

A Choice A is the correct answer.

Sally has pattern D.

Figure 5
Patterns of Overnight Blood Glucose Values
Blood Glucose

400

300

200
100
0
Bed

3 AM
Time

Fasting Bed

3 AM
Time

Fasting Bed

3 AM
Time

Fasting Bed

3 AM
Time

Fasting Bed

3 AM
Time

Fasting Bed

3 AM
Time

Fasting

45

By lowering the 10 PM to 3 AM
basal rate, Sally can avoid becoming
hypoglycemic at 3 AM. By doing this,
she may find that her fasting blood
glucose level normalizes because she will
not get a rebound high blood glucose in
the morning. The other choices will not
result in preventing hypoglycemia at 3
AM. If her morning glucose rises higher,
she can increase her 3 AM to 7 AM bolus
dose.
Jack Needs Help Figuring Out His
Bolus Dose for Certain Meals
Jack takes a bedtime basal dose of insulin
glargine (Lantus) of 20 units and bolus
meal doses based on a carb:insulin ratio
of 12 grams of carbohydrate/unit and an
insulin sensitivity factor (ISF) of 1 unit for
every 40 mg/dl. His goal blood glucose
range is 90-130 mg/dl, with a target of
100. He exercises regularly and seems
to do well on his current basal dose of
insulin glargine.
Q What should Jacks bolus dose be
for the following breakfast meal?
His pre-meal blood glucose is 112
mg/dl.
He will have 2 slices of toast,
1 orange, 1 slice of cheese,
1 cup of milk and coffee.

A Jack needs 5 units of rapid- or shortacting insulin for his meal of 60 grams
of carb with a blood glucose within his
blood glucose goals.
Q Can you find Jacks bolus dose
for the following dinner?
Jacks pre-dinner meal blood glucose
is 212 mg/dl.
He is planning to eat 2 pieces of
bread, a salad with croutons and
dressing, steak; large baked potato,
side order of peas and broccoli. For
dessert he will have 1/2 cup of vanilla
ice cream with a small cookie.
Use this space to figure out Jacks
bolus dose before peeking at the
following answer!
Planned Food (Carbs) _____Carbs
Divided by Carb/Insulin Ratio _____Carbs/U of
Insulin = ___units of insulin
Current blood glucose _____mg/dl
What is Jacks target blood glucose? _____
mg/dl
Current blood glucose - target blood glucose
_____ mg/dl
What is Jack's Insulin sensitivity factor? _____
Divide Jack's blood glucose calculation by
Insulin sensitivity
_____ U of insulin
_____ Total Dose

46

A Jack needs 13 units of insulin.

Heres why!
His carbs total 120 grams (bread =
30 grams, croutons = 15 grams,
large baked potato = 30 grams,
peas = 15 grams, ice cream and
cookie = 30 grams
His carb:insulin ratio is 12:1
120 divided by 12 grams of carb per
unit of insulin = 10 units.
[

120 grams of carb

12 grams of carb
per unit of insulin

=10 units]

His blood glucose is 82 mg/dl over his

target [212 100 = 112]
112 divided by Jacks ISF of 40 = 2.8
units, round to 3 units.
3 units + 10 = 13 units (Jacks total
bolus insulin dose for dinner)
(correction dose + dose to cover meal
based on carb:insulin ratio = total bolus)

Jack Wants to Exercise More

to Lose Weight Should His
Insulin Dosing Change?
Jack thinks he could look better and
decides to increase the intensity of his
exercise program to lose weight. He has
increased his walking from 20 minutes to
45 minutes of brisk daily walks. Jacks
blood glucose levels for the past 5 days:

Pre-breakfast Pre-lunch Pre-dinner Bedtime

100

70

89

72

85

100

88

65

68

87

92

60

90

68

66

80

83

77

62

79

Q What should he do now?

1. Change his insulin:carb ratio?
2. Increase the amount of food he eats?
3. Lower his basal insulin glargine?
4. Change the insulin sensitivity factor
to 1 unit for every 25 mg/dl?
A Looking at the pattern of blood
glucose levels, it is clear that all the
values are lower than the desired target
of 100 mg/dl. The best response is
Choice 3 to lower the basal insulin
glargine by 1-2 units, which will help
bring the blood glucose levels higher
overall. Choice 1 any change to the
bolus dose from changing his carb:insulin
ratio will have little effect for the entire
day. Choice 2 increasing the amount
of food, will only result in higher bolus
doses and perhaps a weight gain, neither
of which is desired. Choice 4 changing
the insulin sensitivity factor will result in
higher doses of insulin and lower blood
glucose values.

47

Juan Has Had a Change in His

Blood Glucose Levels
Juan has had blood glucose levels within
his goal range for the past several
months on his basal/bolus insulin
regimen of 10 units insulin glargine
(Lantus) and pre-meal insulin doses
of 6 units of insulin aspart (Novolog).
He uses an ISF of 1 unit for every 50
mg/dl and a target of 100 mg/dl.
For the past 4 days his blood glucose
values have increased to over 140 mg/dl
consistently. He has not changed
anything in his routine and is not sick.
He always carries his insulin aspart with
him in the car so it is available if he
decides to stop and eat.

Q What Could Have Made Juans

Blood Glucose Reading So High Over
the Past Four Days?
1. His car might have been too hot,
causing his insulin not to work.
2. Juan might have been under a great
deal of stress.
3. His blood glucose test strips might
have expired.
A Any or all of the above choices could
be correct. Choice 1 Insulin must
always be kept at least at room
temperature. Juan would have to
open a new bottle and watch his
glucose levels closely. Choice 2 If
Juan is having unusual stress, he might
need a small adjustment in his insulin
while this is going on. Choice 3
Expired blood glucose test strips could
be giving him inaccurate readings.

48

SEE YOU REALLY CAN DO IT!

49

SEE YOU REALLY CAN DO IT!

This workbook is only a starting point
and guideline in your move to flexible
therapy with basal-bolus insulin
adjustment. The best approach is to
consult your Diabetes Team and work
on this together. If things go out of
control, refer back to this how-to
guide and do some of the exercises.

Like anything new, basal-bolus therapy

is not easy at first and you will need help
in learning how to adjust your insulin
for food, activity, sleeping and waking.
However, once you have learned these
skills, you should be able to get your
diabetes under excellent control and
live a more flexible, healthy life.

Written by:
Marjorie Cypress, RN, MSN, C-ANP, CDE
Albuquerque, NM
We wish to acknowledge the following health professionals for reviewing this publication and providing their valuable insights:
Jean E. Betschart Roemer, CPNP, MSN, MN, CDE
Pittsburgh, PA
Linda Urso, APRN, BC-ADM
Warren, MI
Kathleen C. Arnold, CS-ANP, BC-ADM, CDE
Gulfport, MS
BD and BD Logo are trademarks of Becton, Dickinson and Company. 2005 BD.
All other brands are trademarks of their respective owners.

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