Diabetes Notebook TABLE of CONTENTS

Home , Diabetes, Diabetes management, History of diabetes, Pediatric endocrinology

MOUNTAIN STATES MEDICAL GROUP-PEDIATRIC ENDOCRINOLOGY Pediatric Diabetes Notebook TABLE OF CONTENTS

GETTING STARTED FOOD Discharge checklist...... 3 What are carbohydrates?...... 38 Mountain States Medical Group-Endocrinology References...... 39 contact information...... 4 Reading the food label...... 40 Phone call guidelines for newly diagnosed A handy guide to portion sizes...... 41 patients with diabetes...... 5 What if I don’t have a nutrition label?...... 42 Campus map and driving directions...... 6 Portion sizes for 15 grams of carbohydrates...... 43 Diabetes “survival skills”...... 7 Favorite foods reference guide...... 44 Let’s plan some meals!...... 46 DIABETES BASICS Carb counting for recipes...... 48 What is diabetes...... 8 I’m hungry….but it’s not meal or snack time...... 50 The difference between type 1 and type 2 diabetes...... 10 Ideas for 10 gram snacks...... 51 Diabetes basics...... 11 Ideas for 15 gram snacks...... 51 Keeping in balance...... 12 Ideas for 30 gram snacks...... 52 45 gram breakfast ideas...... 53 RECORDS 60 gram breakfast ideas...... 54 Blood sugar log sheet...... 13 45-60 gram lunch and dinner ideas...... 55 Happy Holidays!...... 57 BLOOD SUGAR MEASUREMENT What’s on your plate?...... 58 Measuring blood sugar...... 18 The A1C blood test...... 19 EXERCISE Diabetes routine (Lantus & Humalog/Novolog before meals)...... 20 Physical activity...... 60 Diabetes care record...... 22 Carbohydrate replacement for activity...... 61 INSULIN RESOURCES Insulin products...... 23 Taking diabetes to school...... 62 More about insulin...... 24 Resources for people with diabetes...... 63 Basal bolus regimen...... 25 Pharmacy list...... 64 Directions for drawing a single dose of insulin...... 26 Diabetes and driving...... 65 Directions for giving insulin...... 27 Traveling with diabetes...... 66 Tips for family coping...... 67 LOW BLOOD SUGAR Top 10 diabetes self-management strategies...... 68 Low blood sugar (hypoglycemia)...... 28 Diabetes glossary...... 69 Glucagon injection...... 30 Alcohol and diabetes...... 74 Diabetes identification...... 31 Drug use and diabetes...... 75 HIGH BLOOD SUGAR High blood sugar (hyperglycemia)...... 32 Ketones/DKA...... 33 Urine ketones...... 34 Pediatric sick day guidelines...... 36 Sick days for older children...... 37

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 2 DISCHARGE AND FOLLOWUP CHECKLIST

DISCHARGE CHECKLIST

 Finished “Survival Skill” education  Check take-home supplies against list  Glucagon emergency kit is packed  Next dose of insulin is written on record form or phone contact arranged before dose time  Diabetes school orders prepared and signed if necessary  Set up phone contact with Dr. ______

FOLLOW UP APPOINTMENTS WHAT TO BRING TO APPOINTMENTS

Physician follow-up appointment  Blood glucose management records with ______ Meter(s), including school meter on ______ A list of questions First education follow-up appointment  A list of supplies you need with ______ Diabetes Notebook on ______ Diabetes ID and treatment for low blood sugar Second education follow-up appointment with ______on ______

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 3 HOW TO CONTACT US

MOUNTAIN STATES MEDICAL GROUP PLEASE NOTE: Prescription refills and routine blood PEDIATRIC ENDOCRINOLOGY sugar check-in should be completed during normal Located on the third floor of the 408 building business hours. behind Niswonger Children’s Hospital 408 N. State of Franklin Road, Suite 31B EMERGENCY & AFTER HOURS: Phone: 423-431-4946 Call Niswonger after hours on the nursing line: Fax: 423-431-4947 423-431-4946

WHEN YOU NEED HELP: OUR PEDIATRIC ENDOCRINOLOGY PROVIDERS Call Morgan Armentrout Diabetes Educator, • George Ford, MD, MS at 423-431-2370 during office hours, • Evan Los, MD Monday–Friday, 8:30 a.m. – 4:30 p.m. • Alexis Duty, MSN, FNP-BC HOW TO MAKE AN APPOINTMENT: • Morgan Armentrout, RN-BSN, CDE The clinic is open Monday – Friday, 8:30 a.m. – 4:30 p.m. Please call 423-431-4946 for current available days and times.

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 4 PHONE CALL GUIDELINES FOR NEW PATIENTS

You have learned a lot about diabetes during your child’s hospitalization and will continue to learn more over the next several months with the help of your diabetes team. We will talk with you often by phone after leaving the hospital and follow up in clinic within 2-4 weeks.

ROUTINE BLOOD SUGAR MANAGEMENT PHONE CALLS EMERGENT PHONE CALLS Initially, you will be asked to call the diabetes educator or nurse practitioner daily 9 a.m. – 12 p.m. EMERGENT PHONE CALLS to speak with a diabetes provider. The purpose There may be times when you will need to of these phone calls are to review blood sugars reach the diabetes team urgently. There is and adjust insulin doses as needed. If your child’s always a pediatric provider available 24-hours provider is not available, your call will be sent to a day including weekends and holidays for the on-call pediatric diabetes provider. You should emergencies. Times that you may need to reach expect a call back by the end of the day. If you have a diabetes provider urgently would include: not heard back by 5 p.m., please call and ask to speak with the on-call provider. • Advice for managing sick days • Positive urine ketones with illness or THE PROVIDER YOU WILL BE CALLING IS moderate to large ketones without illness MORGAN ARMENTROUT, RN-BSN, CDE. • Recurrent low blood sugar that does not correct with usual oral treatment** EDUCATION PHONE FOLLOW-UP • If your child will be out of insulin for the next A diabetes educator will contact you about one scheduled injection week after discharge from the hospital. We will answer questions and discuss concerns you may **IF YOUR CHILD IS EXPERIENCING A SEIZURE have regarding your child’s diabetes, prescriptions, DUE TO LOW BLOOD SUGAR, CALL 911 school issues, low blood sugar management and IMMEDIATELY! follow-up visits. These phone calls may continue until your child’s first follow-up appointment at the Diabetes Center.

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 5 AERIAL CAMPUS MAP OF JCMC

11E Aerial Campus Map of JCMC 36 Exit 19 Exit 20 E. Oakland Ave. 26 To: I-26 Exit 19 381 Princeton Rd. (3 miles)

N. Roan St.

Sunset Dr. W. Market St. 26 Knob Creek Rd. N. State of Franklin Rd. 11E Central N. Roan St. RV Parking Billing 381 E. UnakaE. Ave. Watauga Ave. 36 W. Market St. Exit 22 Hospitots 91

11E S. Roan St. Exit 24 26 Johnson City Medical Center 11E W. Market St. H W. State of321 Franklin Rd. . Team Member Parking 321 381 y 381 381 kw U y P niversit

Ronald McDonald House MAIN ENTRANCE • Emergency Room Entrance • Patient Drop-o/Pick-up • Patient/Visitor Parking – • Niswonger Children’s Hospital • Same Day Surgery Rd. of Franklin N. State A • 408 Medical O ce Building • Ronald McDonald House Veterans Aairs Medical Center

Medical Center Drive North B Dr. George Ford, Dr. Evan Los and Alexis Duty, FNP Mountain States Medical ER Group-Pediatric Endocrinology Parking 408 Medical O ce Building C Third Floor

Woodridge Hospital

PATIENT ENTRANCE • Patient Drop-o/Pick-up G • Patient/Visitor Parking – • Team Member Parking – • Cardiovascular Health D • Surgery Tower • Radiation Oncology E • 310 Building F

r. 2 D k ar l P na io ss Profe 381 310 Building 1 3 To: I-26 Exit 24 (4 miles)

Regional Cancer Center at JCMC American Cancer Society

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 6 DIABETES “SURVIVAL SKILLS”

OTHER INFORMATION YOU’LL NEED FOLLOWSURVIVAL UP SKILLS APPOINTMENTS TO UNDERSTAND • What is diabetes, causes, risk factors and You need to learn these things before you will warning signs feel prepared to leave the hospital and manage • How the body processes food, what has changed diabetes at home: during the past few weeks and months, and the reasons for those changes • How and when to check blood sugar • Factors the affect blood sugar • Keep written records (blood sugar, urine, • How injected insulin works ketones, insulin doses, carbohydrate intake) • Pattern management • How and when to check urine ketones • What to do about physical activity • Count carbohydrates using food labels • High blood sugar and ketoacidosis: recognition, • Measure and inject insulin prevention, when to test for ketones and sick • Discuss a consistent daily routine for day care diabetes care at home • Feelings about diabetes • Identify, treat and prevent low blood sugars • Diabetes and school, baby sitters, vacations • Review how and when to use the Glucagon and camp emergency kit • Resources: groups, websites, books, and • Review what to do about diabetes during community organizations an illness • Potential long-term complications of diabetes, risk factors and preventative care • Diabetes research: what does the future hold? • Follow-up care: next visit, continuing care

This is a long list. It represents far too much information for you to completely understand until you live with diabetes for a while. You will have lots of help. A member of the diabetes care team will be available by phone when needed. It is safe for you to learn as you take care of your child.

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 7 WHAT IS DIABETES?

Diabetes is a condition in which the body does not produce or use insulin properly. Insulin is a hormone that is needed to change sugar, starches and other food into energy for daily life. The cause of diabetes is somewhat of a mystery, although both genetics and environmental factors appear to play a role. There are two major types of diabetes.

TYPE 1 DIABETES: TYPE 2 DIABETES: An autoimmune condition in which the body does The most common type of diabetes, in which the not produce insulin, often occurring in children and body does not make enough insulin or does not use young adults. People with Type 1 diabetes must insulin properly. Type 2 diabetes accounts for 90- take insulin injections to stay alive. Type 1 diabetes 95% of all diabetes. Type 2 in children and teens is accounts for 5-10% of all diabetes. increasing due to obesity and inactivity.

RISK FACTORS FOR TYPE 1 DIABETES: RISK FACTORS FOR TYPE 2 DIABETES: • 5% risk of a sibling also getting diabetes • Over age 45 (increasing in teens) • 50% chance of an identical twin also being • Family history of diabetes diagnosed with Type 1 diabetes • Being overweight and/or inactive • Children who have a parent with Type 1 diabetes • Higher incidence in African Americans, Hispanic • Peak incidence occurs during puberty Americans, Asian and Pacific Islanders and • Highest incidence in Caucasians Native Americans • Women who had gestational diabetes (diabetes WARNING SIGNS OF TYPE 1 DIABETES: during pregnancy) • Frequent urination • Increased thirst WARNING SIGNS OF TYPE 2 DIABETES: • Extreme hunger • Any of the Type 1 symptoms • Unusual weight loss • Frequent infections (skin, gums or bladder) • Lack of energy • Blurred vision • Irritability • Slow healing cuts • Tingling/numbness of hands or feet GRADUAL ONSET OF TYPE 1 DIABETES • Acanthosis: discoloration of skin on the neck and armpit Pancreas is working fine 100% Autoimmune process (damage to Beta cells) 75%

50% Diabetes (onset of symptoms) “Honeymoon” (temp. recovery of Beta cells)

% = INSULIN PRODUCTION 20%

0% TIME (IN MONTHS OR YEARS) Type 1 diabetes develops gradually over many months or years. Once diabetes is diagnosed and treatment with insulin begins, beta cells can “rest”. Once these cells have had time to rest, they may start to make insulin again. This is the honeymoon phase. It can begin between 2–8 weeks after starting insulin and can last from 6 months up to 2 years. This is a time when people may think their diabetes has gone away. Not everyone diagnosed with diabetes will have a honeymoon.

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 8 WHAT IS DIABETES? (CONTINUED)

HOW YOUR BODY USES FOOD: WHERE DOES INSULIN COME FROM? All parts of your body are made of cells. Your body Insulin is made in the pancreas by special cells needs sugar for energy so that you can do things called beta cells. like walk, talk and think. Sugar comes from the foods that you eat, primarily carbohydrates. After you WHAT HAPPENS WHEN THERE IS NOT eat carbohydrate, it is broken down into sugar. This ENOUGH INSULIN? sugar is absorbed into your bloodstream and blood 1. The blood sugar level goes up because the sugar level rises. In order to use sugar for energy you sugar cannot get out of the bloodstream into need insulin. Insulin is the “key” that allows sugar the cells. to pass into the cells where it is used for energy and 2. Sugar begins to spill over into urine causing you growth. When your blood sugar rises, the insulin- to urinate more frequently. producing cells in the pancreas can sense this and 3. You become thirsty. This is your body’s way of will release insulin into the bloodstream so the blood trying to replace all the fluid that is being lost by sugar does not get too high. increased urination. 4. You lose weight because fats are being used for energy instead of sugar. If your body is INSULIN DOES THREE THINGS: not making enough insulin, sugar cannot be used for energy and your body breaks down 1. Insulin is the “key” that lets sugar enter the fat instead. When fat is used for energy cells where it is used for energy. ketones are produced. Too many ketones can lead to a dangerous condition called diabetic 2. Insulin allows the liver to store sugar. ketoacidosis. 3. Insulin stops your body from breaking down fat.

KEY TO SYMBOLS CELL

Sugar

Insulin

Blood cell

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 9 THE DIFFERENCE IN TYPE 1 AND TYPE 2 DIABETES

TYPE 1 DIABETES “JUVENILE” TYPE 2 DIABETES “ADULT ONSET” 5–10% OF ALL DIABETES 90–95% OF ALL DIABETES 1:400 children Adults Average onset age 10–12 girls Age of onset Increasing in youth Average onset age 12–14 boys More common in: African Americans More common in: Ethnic factors Native Americans Caucasians Hispanic Pacific Islander Autoimmune Disease Autoimmune? Not an Autoimmune Disease (celiac, thyroid) Pancreas loses ability to Pancreas still makes insulin but cells in the Effect on pancreas produce insulin body don’t use it correctly Genetics (gene cell types DR3/DR4) Strong family history + + Environmental factors Obesity and inactive lifestyle Cause Beta Cell destruction Insulin resistance = = Type 1 Diabetes Type 2 Diabetes

Insulin shots 3–6 times per day Oral medication, sometimes insulin Blood glucose monitoring Blood glucose monitoring 4–6 times per day Treatment 2–4 times per day Carbohydrate counting Meal planning – weight loss Regular, active lifestyle Exercise – 30 minutes daily

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 10 DIABETES BASICS

IN A PERSON WITHOUT DIABETES SYMPTOMS

LIVER HIGH BLOOD SUGAR CARBS • Increased thirst • Increased urination • Increased hunger • Blurry vision • Tired • Dehydration SUGAR ENERGY “GLUCOSE” STOMACH • Weight loss

CELL DKA – DIABETIC KETOACIDOSIS FAT • Nausea/vomiting • Dehydration PANCREAS • Urine ketones • Decreased pH KIDNEY • Deep/labored breathing • Coma • Fruity breath

IN A PERSON WITH DIABETES

FOOD LIVER CARBS CARB FAT PROTEIN

KEY TO SYMBOLS SUGAR ENERGY “GLUCOSE” STOMACH Sugar CELL Insulin FAT

PANCREAS

KIDNEY

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 11 KEEPING IN BALANCE

FOOD STRESS

Type Physical/Illness Amount Emotional Time Desired Blood Sugar Range ______

Type Amount Type Time Intensity Site Time

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 12 BLOOD SUGAR LOG SHEET Comments Emotional distress? dose. Feelings? Illness? Illness? dose. Feelings?

physical activity, changes in insulin changes activity, physical Changes in amount or timing of food, in amount or timing of food, Changes BT D L B Blood Sugar/Urine Ketones Blood Sugar/Urine 2am BT D S L S B Insulin Type H/NL Lantus Carbs H/NL Lantus Carbs H/NL Lantus Carbs H/NL Lantus Carbs H/NL Lantus Carbs H/NL Lantus Carbs H/NL Lantus Carbs Date Friday Sunday Tuesday Monday Saturday Thursday Wednesday ______Range Target

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 13 BLOOD SUGAR LOG SHEET Comments Emotional distress? dose. Feelings? Illness? Illness? dose. Feelings?

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 14 BLOOD SUGAR LOG SHEET Comments Emotional distress? dose. Feelings? Illness? Illness? dose. Feelings?

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 15 BLOOD SUGAR LOG SHEET Comments Emotional distress? dose. Feelings? Illness? Illness? dose. Feelings?

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 16 BLOOD SUGAR LOG SHEET Comments Emotional distress? dose. Feelings? Illness? Illness? dose. Feelings?

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 17 MEASURING BLOOD SUGAR

WHY? HOW? To make sure all factors that affect blood sugar are 1. Wash hands in warm water or use an in balance. You will find, as researchers have, that alcohol swab. feelings are not a reliable way to determine blood 2. Poke the topsides of your fingers. sugar levels.

HOW OFTEN? Several times per day, since blood sugar changes constantly. Common times people check: • Before breakfast, lunch and dinner • At bedtime • At 2 a.m. 3. Hang hand down and use a “milking” action to • If feeling symptoms of low blood sugar get a drop of blood. • After treating symptoms of low blood sugar 4. Touch the strip to the blood drop. Be sure the • Around the time of physical activity blood is the only thing that touches the strip. • When ill 94 M

WHAT IS MY TARGET RANGE? BEDTIME/OVERNIGHT HEMOGLOBIN AGE DAYTIME SUGAR SUGAR A1C% Infant, toddler and up to 100-180 mg/dL 100 or ______ADA 7.5% or less age 5 School age: 6-12 years 80-180 mg/dL 100 or ______ADA 7.5% or less Teens: 13-19 years 70-150 mg/dL 100 or ______ADA 7.5% or less

OTHER HELPFUL INFO • Keep the lid on your test strips closed tight — • Meters estimate blood sugar level, +/– 5-15%. they are sensitive to light and moisture. • Each meter has a toll free number listed on the • Keep strips and meter out of extreme back of the meter in case of questions. temperatures — learn the limits of your meter. • You can check the accuracy of your meter and test strips by using control solution.

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 18 THE A1C BLOOD TEST

The A1C blood test gives you a picture of your blood sugar level over a period of three to four months. As red blood cells move through your blood, sugar sticks to them. Very simply, the A1C is a measure of how much sugar is sticking to your red blood cells.

Since each red blood cell lives for about three months, the A1C shows your average blood sugar for the past three months. Maintaining your A1C at ADA recommended targets can help keep you healthy. Discuss with your doctor what an appropriate A1C goal would be for you.

RELATIONSHIP BETWEEN YOUR A1C AND NORMAL A1C YOUR BLOOD SUGAR

ESTIMATED AVERAGE RED BLOOD CELL A1C% BLOOD SUGAR MG/DL GLUCOSE 6.0 126 6.5 140 7.0 154 7.5 169 8.0 183 8.5 197 9.0 212 HIGH A1C 9.5 226 10.0 240 10.5 255 11.0 269 11.5 283 12.0 298 12.5 312 13.0 327 13.5 341 The A1C blood test gives you a picture of your blood 14.0 356 sugar level over a period of three to four months.

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 19 DIABETES ROUTINE

LANTUS & HUMALOG/NOVOLOG BEFORE MEALS FOLLOWKEY POINTS UP APPOINTMENTS  Get up – new day • Lantus Insulin needs to be given at the same time every day Check blood sugar  • Humalog/Novolog – 2–3 hours  Measure and inject insulin between doses (Humalog/Novolog ICR*) • Snacks – 2 hours between eating snacks and checking next routine blood sugar  Breakfast

 Snack (≤ ______grams carb)

 Check blood sugar  Measure and inject insulin (Humalog/Novolog ICR*)  Lunch

 Snack (≤ ______grams carb)

 Check blood sugar  Measure and inject insulin (Humalog/Novolog ICR*)  Supper

 Check blood sugar  Snack (≤ ______grams carb)

 Sleep

 Check blood sugar nightly for the next month and anytime: • your blood sugar was less than ______at bedtime • your Lantus dose was increased • you had extra physical activity during the day • when your child is sick

*ICR = INSULIN TO CARB RATIO

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 20 DIABETES ROUTINE

 Snack (≤ ______grams carb)

 Check blood sugar  Measure and inject insulin (Humalog/Novolog ICR*)  Lunch

 Snack (≤ ______grams carb)

 Check blood sugar  Measure and inject insulin (Humalog/Novolog ICR*)  Supper

 Check blood sugar  Snack (≤ ______grams carb)

 Sleep

*ICR = INSULIN TO CARB RATIO

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 21 DIABETES CARE RECORD Year

Year Year Year Date (as needed) 10 years DM) 10 years Flu shot (annual) Flu Standards of Care Standards HbA1C (each visit) HbA1C (each Celiac screening test screening Celiac Dietitian visit (annual) Blood lipids, cholesterol Injection sites (each visit) (each Injection sites DM and onset of puberty) Foot exam (each visit after (each exam Foot Blood pressure (each visit) (each Blood pressure Self-management (annual) Self-management Psychologist / Social worker / Social worker Psychologist Ht(cm) / Wt(Kg) (each visit) (each / Wt(Kg) Ht(cm) year DM and onset of puberty) year Severe hypo / DKA (each visit) / DKA (each hypo Severe Microalbuminuria (annually, after 5 (annually, Microalbuminuria Thyroid tests (onset, every____ years) every____ (onset, tests Thyroid Dilated eye exam (annually, after 5 year after 5 year (annually, exam eye Dilated Name ______Date Diagnosed ______Age at Diagnosis ______Diagnosed ______Age Date

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 22 INSULIN PRODUCTS

RAPID-ACTING INSULIN • Humalog®(lispro) Rapid-acting insulin–Humalog®(lispro); Novolog® (aspart); Apidra® (glulisine) • Novolog® (aspart) Basal long-acting insulin–Lantus® (glargine); Basaglar KwikPen® • Apidra® (glulisine) Basal long-acting insulin–Levemir® (determir) • Appearance: clear • Onset: 5 to 15 minutes • Peak: 1 hour

• Duration: 3 to 5 hours Insulin Eect Relative

• Take immediately before meal 0 2 4 6 8 10 12 14 16 18 20 22 Time (Hours)

BASAL LONG-ACTING INSULIN Rapid-acting insulin–Humalog®(lispro); Novolog® (aspart); Apidra® (glulisine) Basal long-acting insulin–Lantus® (glargine); Basaglar KwikPen® • Lantus® (glargine) Basal long-acting insulin–Levemir® (determir) • Basaglar KwikPen® (Only available in pen form) • Appearance: clear • Onset: 1 to 2 hours Relative Insulin Eect Relative • Peak: none • Duration: 22+ hours 0 2 4 6 8 10 12 14 16 18 20 22 • Do NOT mix with other insulins Time (Hours)

Rapid-acting insulin–Humalog®(lispro); Novolog® (aspart); Apidra® (glulisine) BASAL LONG-ACTING INSULIN Basal long-acting insulin–Lantus® (glargine); Basaglar KwikPen® • Levemir® (determir) Basal long-acting insulin–Levemir® (determir) • Appearance: clear • Onset: 3 to 4 hours • Peak: blunted (6 to 8 hours)

• Duration: 22-24 hours Insulin Eect Relative

• Do NOT mix with other insulins 0 2 4 6 8 10 12 14 16 18 20 22 Time (Hours)

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 23 MORE ABOUT INSULIN

BUYING AND STORING INSULIN: APPROXIMATE ACTION TIMES OF INSULIN • You will need a prescription for your insulin. At LASTS TYPE OF STARTS MOST the pharmacy, ask for: IN THE INSULIN ACTING ACTIVE  Humalog or NovoLog BODY  Lantus or Basaglar KwikPen Rapid acting (clear) Syringes, BD Ultrafine ______ Humalog 5–15 1 hour 3–5 hours • Unopened vials of insulin should be refrigerated (lispro) minutes (36-46 degrees). They may be kept there until the Novolog 5–15 1 hour 3–5 hours expiration date on the vial. (aspart) minutes • Do not freeze. Apidra 5–15 1 hour 3–5 hours • Open vials may be stored at room temperature (glulisine) minutes (below 86 degrees) or in the refrigerator for one month only. Very long acting (clear) • Date vials once open. Lantus 22+ 1–2 hours None • Do not use insulin that has clumps or crystals on (glargine) hours the bottle. Basaglar 22+ 1–2 hours None KwikPen hours Detemir 22–24 3–4 hours 6–8 hours (levemir) hours

HOME NEEDLE DESTRUCTION DEVICES These destruction devices allow you to destroy needles at home by burning, melting or cutting off the needle, making them safe to throw in the garbage. Prices for devices vary by manufacturer. For more information, visit www.fda.gov/diabetes/lancing.html#5

If these options are not feasible, you may follow these instructions for disposal: • Place sharps in a hard plastic or metal container with a screw-on tightly secured lid. Thick plastic bottles such as detergent bottles or bleach bottles work well. • Do not fill the container more than ¾ full to avoid getting a needle stick. • Before discarding the container, reinforce the lid with heavy-duty tape. • Do not put sharps in a glass container or in any container that you plan to recycle. • Keep all containers with sharps out of the reach of children or pets until you dispose of it in your regular trash.

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 24 BASAL BOLUS REGIMEN

Humalog peak Humalog peak Humalog peak

Lantus (24 hours)

MEAL: B L D BT

TIME: LANTUS, HUMALOG ROUTINE *4 – 6 INJECTIONS PER DAY

BASAL INSULIN HIGH BLOOD SUGAR CORRECTION Basal means “base or background.” Basal insulin This is a dose of insulin used to lower high blood is used to control the sugar made by your liver sugar before a meal. This is in addition to the during the day and night. Basal insulin is needed mealtime carbohydrate bolus. throughout the day, even when you are not eating. Example: High blood sugar correction — 1 unit for every 50 above 150, written as: BOLUS MEALTIME INSULIN • 151-200 1 unit Bolus means “burst.” Bolus insulin is often called mealtime insulin and/or insulin used to correct • 201-250 2 units high blood sugars. Examples of bolus insulin’s • 251-300 3 units are Humalog (lispro), Novolog (aspart) and • 301-350 4 units Apidra (glulisine). MEALTIME DOSE CALCULATION At mealtimes, the goal is to “match” your bolus To calculate the dose, divide the grams of insulin to the amount of carbohydrate food you carbohydrate by the ratio, then add correction are eating. This should help to keep your blood if needed. Example: If eating 45 grams of sugar in target range 2-4 hours after eating. We carbohydrate and your blood sugar is 200, the use an “insulin to carb ratio” to calculate the dose dose would be: 45 divided by 15 = 3 units for of insulin. the carbohydrate divided by 1 unit for correction = Example: Insulin to Carb Ratio — 1 unit for every 15 4 units. grams of carbohydrate *Humalog/Novolog should be given just before a meal. If blood sugar is too low before a meal, treat as a low blood sugar first, then take your insulin and eat your meal.

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 25 DIRECTIONS FOR DRAWING A SINGLE DOSE OF INSULIN

PREPARING YOUR INSULIN SYRINGE: 5. Turn bottle upside down and pull back on the 1. Gather insulin supplies and wash your hands. plunger to draw insulin into your syringe. 2. Wipe the top of the insulin bottle with alcohol. 3. Draw air into syringe equal to the dose of insulin that will be drawn out of the bottle.

4. Put needle through rubber stopper and push 6. Flush in and out three times to remove air air into bottle. bubbles, and then draw your insulin dose into the syringe. 7. Pull needle out of bottle.

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 26 DIRECTIONS FOR GIVING INSULIN

SELECTING A SITE FOR YOUR SHOT: GIVING AN INSULIN SHOT: 1. Insulin can be injected into the abdomen, 3. Make sure injection area is clean. back of the arms, thighs and buttocks. 2. To prevent the buildup of scar tissue, make sure to rotate to a different site for each insulin injection.

4. Pinch skin. Insert needle straight into the skin and push plunger all the way down to inject the insulin.

5. Let go of the pinch and count slowly to 5. Pull the needle out. (Observe and document any leakback.)

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 27 LOW BLOOD SUGAR (HYPOGLYCEMIA)

FOLLOWCAUSES OF UP LOW APPOINTMENTS BLOOD SUGAR Having low blood sugar or hypoglycemia means • Not eating enough carbohydrates there is not enough sugar (glucose) in your bloodstream. Any blood sugar reading below • Delayed or skipped meal ___ mg/dL is low. Low blood sugar can come • More exercise than usual on very quickly and needs to be treated quickly. • Too much insulin Low blood sugar that is not treated may lead to a seizure or unconsciousness.

HOW YOU MAY FEEL WITH LOW BLOOD SUGAR

shaky hungry irritable

tired/weak crying sweaty

FEELING: SHOWING: • Nervous/anxious • Sweaty • Pounding heart • Fast heartbeat • Upset stomach/butterflies • Pale skin • Change in vision • Confusion/slow speech • Tingling/numbness of mouth • Glassy eyes • Trouble thinking • Mood change (irritable, sensitive, crying) • Weak • Sleepy • Shaky • Seizure or unconsciousness • Hungry

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 28 LOW BLOOD SUGAR (CONTINUED)

TREATMENT FOR LOW BLOOD SUGAR: (Hypoglycemia: Blood sugar below _____)

WHAT TO DO: STEP 1: If able, test blood sugar first. If not able to test, treat per below: STEP 2: If your blood sugar is BELOW ______, take one of the following* based on your weight:

If your weight is… up to 50 lbs 51 lbs or more Orange/apple juice 1/3 cup-½ cup (3-4 ounces) ¾ - 1 cup (6-8 ounces) Grape juice ¼ cup - 1/3-cup ½ - ¾ cup Soda pop (not diet) 1/3 cup – ½ cup ¾ - 1 cup Honey or table sugar 1 tablespoon 1 ½ tablespoons Round glucose tabs 2-4 tablets 4-5 tablets Smarties 2-3 rolls 3-4 rolls

STEP 3: Retest your blood sugar in 15 minutes. If still below ______, repeat same treatment.

STEP 4: When blood sugar is above ______, if it is more than one hour before the next planned meal or snack, eat a snack that contains ______carbohydrate and protein such as:

______Graham cracker squares divided by peanut butter ______Milk ______Squeezable yogurt

*Chocolate, candy bars and cookies should not be used to treat low blood sugar. These items contain fat, which slows the digestion of the sugar and does not raise the blood sugar as quickly.

FOR LOW BG TREATMENT: FOR FOLLOW-UP SNACK IDEAS: • Boxed juice • Graham crackers and peanut butter • Glucose tabs • Milk • Smarties – type candies • Squeezable yogurt

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 29 GLUCAGON INJECTION

WHAT IS GLUCAGON? Glucagon is an injected hormone that is administered if your child’s blood sugar is very low.

WHEN WOULD I GIVE GLUCAGON? You should give Glucagon if your child’s blood sugar is low enough that they become unconscious, are having a seizure, or are unable to take anything by mouth.

HOWFOLLOW DO UPI MIX APPOINTMENTS AND ADMINISTER GLUCAGON?

1. Remove the gray cap from the vial. 2. Inject all the water from the syringe into the vial. 3. Roll the vial for a few seconds until the pill is dissolved. 4. Using the same syringe, for children above 44 lbs take out 1 mg of the medication. For children below 44 lbs take out ½ mg of medication. 5. Give the injection into the top of the thigh muscle. 6. Turn your child onto his/her side in case of vomiting. 7. Call 911. 8. Call your diabetes doctor at 423-431-4946 once your child is awake or before the next scheduled insulin dose.

HOW DO YOU STORE GLUCAGON? Store your Glucagon kit at room temperature (68–77 degrees Fahrenheit). Do not mix the Glucagon until needed – the solution is only stable for 24 hours once mixed.

REMEMBER TO KEEP A CURRENT GLUCAGON KIT (NOT EXPIRED) AND REPLACE KIT IMMEDIATELY IF EVER USED.

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 30 DIABETES IDENTIFICATION

N-Style ID Medicharms www.n-styleid.com www.missbrooke.com 1-877-445-0030 1-888-417-7591

American Medical Identifications Laurens Hope www.americanmedical-id.com www.laurenshope.com 1-800-363-5985 1-800-360-8680

MedicAlert® Fiddledee ID’s www.medicalert.org www.fiddledeeids.com 1-800-432-5378 1-972-539-5346

Fifty50 Pharmacy Lifetag www.fifty50.com www.tag.com 1-800-746-7505 1-888-LIFETAG

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 31 HIGH BLOOD SUGAR (HYPERGLYCEMIA)

FOLLOWCAUSES OF UP HIGH APPOINTMENTS BLOOD SUGAR Having high blood sugar or hyperglycemia • Not taking enough insulin means there is too much sugar (glucose) in your bloodstream. Having high blood sugar can make • Eating too much carbohydrate you feel bad, or sometimes you can have high blood • Stress sugar and feel fine. High blood sugar over the years • Illness can lead to problems with your eyes, kidneys, feet • Infection and other parts of your body. • Less exercise • Medications that raise blood sugar

HOW YOU MAY FEEL WITH HIGH BLOOD SUGAR

frequent urination very thirsty hungry

blurry vision moody fatigued weight loss

WHAT IT’S LIKE TO HAVE HIGH BLOOD SUGAR: WHY THIS HAPPENS

Without enough insulin the amount of sugar in the Frequent urination blood increases. The kidneys make more urine to get rid of extra sugar. Thirsty, dehydrated, dry mouth Water is lost because of frequent urination. Hungry Sugar cannot be used as fuel. The body breaks down stored sugar, muscle and fat to Weight loss be used for fuel. The lens of the eye swells. This will slowly get better as Blurry vision the blood sugar level decreases.

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 32 KETONES/DKA (DIABETIC KETOACIDOSIS)

WHAT ARE KETONES AND KETOACIDOSIS? WHAT TO DO IF YOU HAVE KETONES: • Insulin causes sugar to move out of the blood IF KETONES ARE TRACE TO SMALL: and into the body’s cell so that it can be used • Drink calorie-free fluids (water, diet soda, etc). for energy. This will prevent dehydration. • When there is not enough insulin, the body • Take extra rapid-acting insulin as directed by burns fat for energy instead of sugar. your health care provider. • When fats are used, ketones — an acid — • Keep checking blood sugar until in your are produced. target range. • When the blood is acidic, the heart, brain and • Keep checking ketones until negative. other organs don’t work like they should. • Ketoacidosis can lead to coma and/or death. IF KETONES ARE MODERATE TO LARGE: Seek help immediately. • Call your health care provider – this level of ketones could be dangerous. WHEN SHOULD I TEST FOR KETONES? • Take rapid acting insulin as directed by your • When your blood sugar is above 300 mg/dL health care provider. twice in a row • Drink calorie-free fluids. • When you are sick or have an infection (check • Keep checking blood sugar until in your ketones every 2-4 hours), or with each diaper target range. change for babies and toddlers • Keep checking ketones until negative. • If you vomit at any time (even if you don’t feel ill) — symptoms of ketoacidosis may seem like *Do not exercise until ketones are gone. Exercise can the flu make both blood sugars and ketones increase.

HOW DO I FIND OUT IF I HAVE KETONES? • Dip ketone strip into fresh urine, or through urine stream. • Make sure the entire pad is covered with urine. • Tap off excess urine. • In exactly 15 seconds, compare the color on the strip to the guide.

FOLLOWSYMPTOMS UP OFAPPOINTMENTS KETOACIDOSIS

• Increased thirst/dry mouth • Increased urination • Blurred vision FOLLOWKETONES UP CAN APPOINTMENTS HAPPEN FROM: • Rapid/shallow breathing • Fruity/musty odor to breath • Missed insulin • Moodiness • Illness/infection/surgery • Nausea/vomiting • Fasting (not eating) • Body aches/weakness • Stress • Abdominal pain/stomach cramps • Newly diagnosed diabetes • Dizziness • Using old insulin

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 33 URINE KETONES

WHAT DO I DO IF MY CHILD HAS TRACE OR WHAT IF MY CHILD HAS VOMITED MORE SMALL URINE KETONES WHILE ON THE THAN ONCE? INSULIN PUMP? This obviously can occur with an illness such as Ketones are a normal by-product of fat breakdown the stomach flu, but you should check in with and can be detected in everyone’s blood or urine your diabetes doctor to see if there need to be during times when they have not eaten for several any changes in the plan. Make sure you have an hours or if they are sick. Small or trace ketones updated blood sugar and urine ketone check so are not an emergency, but for someone with Type they can help guide you with an insulin plan. 1 diabetes, they can be a sign that there is not enough insulin in the body and thus need close WHAT IF MY CHILD’S BLOOD SUGAR IS LOW monitoring. Oftentimes small or trace ketones clear AND I AM HAVING A HARD TIME BRINGING with a little extra fluid and standard doses IT UP? of insulin. Suspend the pump. This would be a good time to check in with your diabetes doctor and let the staff know this is an urgent message. Make sure your FOLLOWWHAT TO UP DO APPOINTMENTS glucagon kit is close by and get an updated blood sugar and urine ketone check. Continue with the • Troubleshoot the pump site (look for air low blood sugar protocol until your doctor can call or bubbles in the tubing and wetness or you back. a kinked catheter at the infusion site). Change the infusion set if you find anything WHAT IF MY CHILD’S KETONES DO NOT wrong. GO AWAY AFTER TWO CONSECUTIVE TREATMENTS? • Cover any carbohydrates with the usual If the urine ketones are still trace or small, give a carbohydrate ratio and give the usual correction dose by syringe or pen and then change correction factor through the pump. the infusion site with a new catheter set. Continue • Encourage your child to drink additional with hydration and consistent dosing every four carbohydrate-free fluids (good old- hours as described above. fashioned water is great for clearing small and trace ketones). If the urine ketones are now moderate or large and • Re-check blood sugar and ketones every your child still looks well, transition to the moderate four hours and follow the plan above until to large ketone protocol for pumps. they clear. If the ketones are now moderate or large and your child does not look well, call your diabetes doctor so they can help with the insulin plan or direct WHAT IF MY CHILD ISN’T EATING? you to the emergency room. Make sure you have • Give the usual correction dose at meal times an updated blood glucose and ketone check so (at least every four hours) and encourage they can help guide you. If you can’t get through carbohydrate-free fluids if the blood sugar is to your doctor within 30 minutes, go to your local greater than 200 or carbohydrate – containing emergency room. fluids if the blood sugar is less than 200. If your child has vomited, start with small quantities and increase throughout the day as tolerated. TO CONTACT YOUR DIABETES DOCTOR, • Recheck blood sugar and ketones every four CALL 423-431-4946 AND SAY THAT IT IS hours and follow the above plan until they clear. AN URGENT MESSAGE.

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 34 URINE KETONES (CONTINUED)

WHAT DO I DO IF MY CHILD HAS MODERATE • Repeat the blood sugar and urine ketone check OR LARGE URINE KETONES WHILE ON THE in 2-3 hours. If your child’s ketones are still large INSULIN PUMP? or moderate, repeat the ketone correction. The presence of moderate or large ketones in your child’s urine may require a call to your doctor WHAT IF MY CHILD ISN’T EATING? to help guide you through the insulin dosing. • Change the infusion set as directed above and Please call us if you feel uncomfortable with the keep activity low. management of moderate or large ketones. Below • If your child’s blood sugar is less than 100, call are helpful steps that you can take at home to your diabetes doctor before giving the ketone clear moderate or large ketones when your child correction. looks well overall. If your child is breathing fast • If your child’s blood sugar is greater than 100, and or vomiting with large or moderate ketones, give the ketone correction by syringe or pen and please call us. We should be involved with the encourage carbohydrate-free fluids if the blood management of you insulin plan and will help sugar is greater than 200 or carbohydrates you decide whether your child needs to go to the containing fluids if the blood sugar is less than emergency room. 200. WHAT TO DO IF YOUR CHILD LOOKS WELL AND • Repeat the blood sugar and urine ketone check HAS MODERATE OR LARGE KETONES: in 2-3 hours. If your child’s ketones are still large or moderate, repeat the ketone correction by • Keep your child out of school and activities syringe or pen. and encourage them to drink additional carbohydrate-free fluids. WHAT IF MY CHILD’S KETONES ARE STILL • Change the infusion set and let the basal MODERATE OR LARGE AFTER TWO KETONE settings run at their programmed rate; all other CORRECTION DOSES? doses need to be given by syringe or pen until Call your diabetes doctor. Make sure you have an the ketones clear. updated blood sugar and urine ketone check so • Take your child’s current weight in pounds and they can help guide you with an insulin plan. divide it by 22. The result will give you the insulin dose of Humalog or Novolog that you will give. WHAT IF MY CHILD HAS STARTED TO VOMIT, This is called a ketone correction and you may BREATHE RAPIDLY OR LOOKS WORSE DESPITE need to give this dose more than once. A KETONE CORRECTION? Call your diabetes doctor. Make sure you have an Ketone correction = (child’s weight in pounds) updated blood sugar and urine ketone check so divided by (22) they can help guide you with an insulin plan and Example: (80 lbs.) divided by (22) = 3.6 direct you to the emergency room. If you can’t get of Humalog or Novolog through to your doctor within 30 minutes, go to your local emergency room. • Round the dose up to the nearest half if your child’s blood sugar is greater than 200 (so for TO CONTACT YOUR DIABETES DOCTOR, this example, 4 units) and round down if your CALL 423-431-4946, AND SAY THAT IT IS child’s blood sugar is less than 200 (3.5 units), AN URGENT MESSAGE. and give this by syringe or pen. • If your child wants to eat, you can add the usual carbohydrate coverage with the ketone correction. The ketone correction takes the place of a high blood sugar correction. Do not give both the ketone and high blood sugar correction.

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 35 PEDIATRIC SICK DAY GUIDELINES

1. Continue to give insulin, even if your child cannot eat. Call your doctor to determine if WHEN TO CALL YOUR DIABETES any dosing changes are needed. FOLLOWCARE PROVIDERS UP APPOINTMENTS ON SICK DAYS: 2. Check and record blood sugars every 2-4 hours, depending on the severity of the illness. • If your child cannot keep down food or 3. Check and record ketones every time child fluids for 2-3 hours because of vomiting urinates or with each diaper change for or diarrhea. toddlers. • If urine ketones are moderate or large or 4. If blood sugar is below 200 drink sugary blood ketones are more than 1.0 mmol/L. liquids (clear juice, regular soda, Gatorade, • If your child has ketones, difficulty Pedialyte, popsicles). breathing, appears drowsy or is difficult 5. If blood sugar is above 200 drink sugar-free to arouse. fluids, up to one ounce per year of age per • If your child is having blood sugar problems. hour. 6. If able to keep food down but unable to follow usual meal plan, eat or drink the carbohydrate portion of meal plan as liquid or soft food in frequent, small feedings. PLEASE HAVE BLOOD SUGAR AND KETONE RECORDS READY WHEN YOU CALL. ASK FOR CARBOHYDRATE CONTENT OF LIQUIDS PEDIATRIC ENDOCRINOLOGIST ON-CALL. AND SOFT FOODS

GRAMS OF FOOD ITEM AMOUNT CARBOHYDRATE Regular soft drink ½ cup 15 Orange or ½ cup 15 apple juice Grape juice 1/3 cup 15 Milk 1 cup 15 Gatorade 1 cup 15 Ice cream, vanilla ½ cup 15 Cereal, cooked ½ cup 15 Gelatin, regular ½ cup 15 Popsicle 1 cup 15 Soup 1 cup 15 Saltines 6 each 15 Pudding, regular ½ cup 30 Pudding, sugar free ½ cup 15

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 36 SICK DAY GUIDELINES FOR OLDER CHILDREN

It is important to have a plan for sick days. It is likely that your parents helped with or managed your sick day for you when you were younger. You may have to talk to them or think back on how that went, and then make a plan to manage your sick days on your own.

SICKFOLLOW DAY UP GUIDELINES APPOINTMENTS

• If you are vomiting, eat bland food and administer insulin after you know it will stay down. • Have liquids with electrolytes nearby to help you stay hydrated. Many people can be dehydrated, which may be the cause of the symptoms. • Check your blood glucose every few hours to watch for lows. • If you absolutely cannot keep food down, consider using glucagon to help elevate your glucose levels. • Call you doctor to inform them of your symptoms and ask for advice. • Remember to test for ketones as they can develop quicker during a period of illness.

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 37 WHAT ARE CARBOHYDRATES?

Carbohydrates, or carbs, are one of three components (called macronutrients) in the foods you eat that provides fuel. The other two macronutrients are protein and fat. Your body needs all three to grow and function at its best.

Many foods are a combination of carbs, protein and fat. Blood sugar, or blood glucose, is made from the carbs we eat and is used by the cells as a source of energy. We focus on carbs with diabetes because they directly affect our blood sugar levels.

Many foods with carbs are healthy, providing fuel for you to learn and play. The foods you eat do not have to change. You will just need to learn to count the amount of carbs that these foods contain to match your insulin. Carb content is counted in units called “grams”.

FOODSFOLLOW WITH UP APPOINTMENTS CARBOHYDRATE FOODSFOLLOW WITH UP APPOINTMENTS NO/LOW CARBOHYDRATE

The foods you will need to count fall into Some foods do not contain carbs, or have such these groups. a small amount we don’t typically count them. • Breads and cereals • Non-starchy vegetables • Fruit and juice • Cheese, nuts and seeds • Dairy and dairy alternatives • Meat, poultry, fish and eggs • Rice, grains and beans • Fats • Starchy vegetables • Sweets and snacks

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 38 REFERENCES

BOOKS & BOOKLETS WEBSITES • ADA Complete Guide to Carb Counting, 2nd • American Diabetes Association, Edition, Hope S. Warshaw www.diabetes.org • The CalorieKing: Calorie, Fat& Carbohydrate • American Diabetes Association MyFoodTracker, Counter, Allan Borushek http://tracker.diabetes.org/myfoodadvisor.html • The Ultimate Guide to Accurate Carb Counting, • Calorie King, www.calorieking.com Gary Scheiner • Ellen Satter’s Division of Responsibility, www.ellynsatter.com MOBILE PHONE APPLICATIONS • Harold Schnitzer Diabetes Center, • Carb Counting with Lenny www.ohsu.edu/xd/health/services/diabetes • My Net Diary: Diabetes Tracker • Lilly Diabetes, www.lillydiabetes.com • The Calorie King • Glu, http://myglu.org/

FEEDING YOUR FAMILY • Recipes (nutrition information provided for all recipes) • Food Hero, https://www.foodhero.org/ • American Diabetes Association, http://www.diabetes.org/mfa-recipes/recipes/

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 39 READING THE FOOD LABEL

On the Nutrition Facts label, pay attention to the serving size and carbohydrate (in grams) to help you count your carbohydrates.

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 40 A HANDY GUIDE TO PORTION SIZES

You can also estimate the grams of carbohydrate in your foods by knowing the portion size.

Your palm, not including fingers and thumb, A fist is about1 cup. is about 3 ounces.

Your thumb is about 1 tablespoon. Your thumb tip is about 1 teaspoon.

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 41 WHAT IF I DON’T HAVE A NUTRITION LABEL?

There may be times when nutrition facts are not available. It is important to know how to estimate carbohydrates in different foods so you can dose your insulin accordingly.

You might hear the term “carbohydrate exchange,” “serving” or “choice” used. For your reference, 1 Exchange/ Choice = 15 grams of carbs. As your insulin dose is dependent on the number of carbohydrates consumed, it is typically better to count your carbohydrates in grams in order to be more precise in your insulin dosing.

Combination and restaurant foods can be estimated although portion sizes and amount of carbohydrate per serving varies.

COMBINATIONFOLLOW UP APPOINTMENTS FOODS RESTAURANT FOODS

Casserole, noodle/bean, 1 cup...... 30g Breakfast sandwich...... 30g Lasagna, 3”x4”...... 30g Hamburger, regular size...... 30g Mac and cheese, 1 cup...... 45g Chicken nuggets, 6 pieces...... 15g Fish sticks, breaded, 3 pieces...... 15g Chicken sandwich, breaded...... 45g Coleslaw, ½ cup...... 15g Burrito, beef and beans, 8 oz...... 45g Pasta salad, 1cup...... 45g Pizza, thin crust,1/8 medium...... 15g Potato salad, ½ cup...... 30g Pizza, thick crust, 1/8 medium...... 30g Soup (cream, noodle, Sub sandwich, 6”...... 45g rice, vegetable), 1 cup...... 15g French fries, each...... 1-2g Ramen, 1 package...... 50g

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 42 THESE PORTION SIZES GENERALLY HAVE ABOUT 15 GRAMS OF CARBOHYDRATE.

BREADSFOLLOW & UP CEREALS APPOINTMENTS STARCHY VEGETABLES

Sandwich bread ...... 1 slice Corn...... 1/2 cup Bagel (large)...... 1/4 each Peas...... 1/2 cup Burger/hot dog bun ...... 1/2 each Potato...... 1/2 cup English muffin ...... 1/2 each Yam/sweet potato...... 1/2 cup Dinner roll (small)...... 1 each Squash...... 1 cup Pita bread, 6”...... 1/2 each Corn bread, 2x2”...... 1 each Biscuit, 2”...... 1 each Tortilla, 6” corn or flour...... 1 each SWEETS & SNACKS Pancake, 4”...... 1 each Toaster waffle ...... 1 each Animal crackers...... 8 each Croutons...... 1/2 cup Graham crackers...... 2 1/2” – 3 each Cereal, unsweetened...... 1/2 cup Popcorn...... 3 cups Oatmeal...... 1/2 cup Saltine crackers...... 6 each Granola...... 1/2 cup Teddy Grahams...... 15 each Brownie, 2” square...... 1 each Cake, frosted 2” square...... 1/2 each Pudding...... 1/2 cup GRAINSFOLLOW & UP BEANS APPOINTMENTS Pie, single crust...... 1/16th pie Syrup...... 1 Tbsp. Rice, cooked...... 1/3 cup Honey...... 1 Tbsp Pasta, cooked...... 1/3 cup Jelly/jam...... 1 Tbsp Beans, cooked...... 1/2 cup Baked beans...... 1/3 cup Refried beans...... 1/2 cup DAIRY & DAIRY ALTERNATIVES

These have about 12 grams of carbs FRUITFOLLOW & JUICE UP APPOINTMENTS Milk, skim...... 1 cup Milk, 1%...... 1 cup Apple (small)...... 1 each Milk,2%...... 1 cup Banana (small- 5 inches)...... 1 each Milk, whole...... 1 cup Blueberries...... 3/4 cup Chocolate milk...... 1/2 cup Strawberries, whole...... 1 1/4 cup Rice milk...... 1/2 cup Melon...... 1 cup Soymilk, sweetened...... 1 cup Grapes...... 15 grapes Yogurt, plain...... 1 cup Peach (small)...... 1 each Yogurt, fruited...... 1/2 cup Pear (small)...... 1 each Ice cream...... 1/2 cup Orange (small)...... 1 each Watermelon...... 1 1/4 cup Dried fruit...... 2 Tbsp Fruit juice...... 1/2 cup

PEDIATRIC DIABETES NOTEBOOK | Mountain States Medical Group-Pediatric Endocrinology | 423-431-4946 | 43 FAVORITE FOODS REFERENCE GUIDE

You don’t need to know the carbohydrates in all foods, just the ones you eat. It might be helpful to make a list of the carbohydrates in some of the foods you eat most often. This will be a big help for when you go home and need a quick reference guide.

BREADS, CEREALS, GRAINS & BEANS