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Calculating Bolus Doses: Keep it Simple!

I have a well-established Type 2 patient who uses oral medication and is on a basal-bolus insulin routine. We have gone over all of the basics of diabetes self-management and how to use medications, and this education has been reinforced at regular intervals. His A1c has never been less than 7%….

He comes in to his appointments on time and with his meter to download his data. He appears quite compliant and says that he takes his medications regularly. His meter is downloaded since he doesn’t keep a written log book (average 2.3 values per day). I ask him if he takes his insulin and meter with him to restaurants. He says, no, not usually. He doesn’t want to inject in front of the family and doesn’t know how much he is going to eat anyway. As we explore this further, he admits to often waiting until after the meal, and may forget altogether to take his prandial insulin. He is also blind bolusing (giving injections without testing first). I then ask him to show me how he would calculate his dose for the lunch that he ate earlier in the day. I give him a carb counter, pad of paper, calculator and pen but he just says, “10.” How did he arrive at that number? He says that he has a ratio of 7 (he only ate 30 grams of carb). It becomes apparent after asking him to do this with another meal that although he can sit down and say that he divides his food by 7, he neither looks up the carbohydrate content nor is he dividing correctly. What’s more, he is also not using his correction dose anymore. So I asked him if he would prefer a table to look up how much to give instead (sliding scale based on estimated carb intake of 45g, and 1:7g and 1:25 correction) and he said yes. I quickly made up the table and he looked at it and smiled, “Now, this I can do!”

Lesson Learned:

Never presume that verbalization of understanding translates to ability to perform the lesson on their own. I frequently discover patients who verbalize that they are doing something when a download of pump, meter or logbook demonstrates otherwise.

When educating a patient on how to dose his meal insulin, your patient should demonstrate how he calculates his dosage for different meals.

Valerie Spier, MPH, RD, CDE

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