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## by Gary Scheiner MS, CDE

For those who take rapid-acting (Humulin R, Novolin R) may carbohydrate as you choose
insulin at mealtimes and want be used, but it tends to be less while still maintaining good
any degree of meal planning effective because of its slower blood sugar control. It is
flexibility, it is necessary to action. common to require different
apply something known as I:C ratios at different times of
insulin-to-carb (I:C) ratios. Whichever insulin is used, day due to changes in hormone
Now, if the mere thought of success comes from matching levels (which affect insulin
having to do math at every the dose to the amounts of sensitivity), physical activity
meal sends shivers up your carbohydrate eaten. This is (which enhances insulin
spine, dont despair. This is where I:C ratios come in. The sensitivity) and the amount of
something that even the I:C ratio specifies how many basal / long-acting insulin
mathematically challenged grams of carbohydrate are overlapping with the mealtime
can master in no time. covered by each unit of insulin. For most people,
insulin. For example, a 1-unit- insulin sensitivity tends to be a
The Method Behind the per-10-grams-of-carb (1:10) bit lower in the morning than
Mathematics ratio means that one unit of later in the day. For example, I
insulin covers 10 grams of require a 1:10 ratio at breakfast,
One of the basic assumptions carbohydrate. A 1:20 ratio 1:12 at lunch, and 1:15 at
we make in the use of I:C ratios means that each unit covers 20 dinner and in the evening. But
is that dietary carbohydrates, grams. Calculating a meal or if I exercise after dinner, my
which include sugars, starches snack dose becomes simple I:C ratio drops to 1:25.
and fiber, are responsible for when you know your I:C ratio:
raising blood sugar levels after Simply divide your carbs by Initial I:C Ratios
meals. Fiber, however, is your ratio. If each unit covers
usually not counted since it 10g and you have a modest 20g Two methods exist for
does not break down meal, you will need only 2 choosing an I:C starting point.
completely and does not raise units of insulin (20 10 = 2). Whichever method you choose,
blood sugar levels. And fat and If you devour 120g, you will it is best to begin with a
protein have minimal short- need 12 units (120 10 = 12). conservative approach (i.e.
term effects, particularly when lower insulin doses) in order to
consumed as part of a Note that using an I:C ratio of prevent hypoglycemia. It is
carbohydrate-containing meal. 1:10 will result in larger doses easier to tighten up than it is
than if you use a ratio of 1:15. to try adjusting when youre
The rapid-acting insulin that we A 30g snack will require 3 constantly recovering from low
give at mealtimes is designed units if using a 1:10 ratio, but blood sugar.
to offset the blood sugar rise only 2 units if using a 1:15
induced by the carbohydrates. ratio. As the second number in The 500 Rule
In most cases, insulin analogs the ratio goes up, the amount of
such as aspart insulin goes down. This approach is based on the
(Novolog/Novorapid), lispro assumption that the average
(Humalog) or glulisine The beauty of an I:C ratio is person consumes (via meals
(Apidra) are used at meals. that it gives you the flexibility and snacks) and produces (via
However, Regular insulin to eat as much or as little the liver) a total of
www.healthcentral.com: November, 2007.
Copyright 2007, Gary Scheiner MS, CDE Integrated Diabetes Services LLC Page 1
approximately 500 grams of overestimate their mealtime Fine-tuning I:C ratios is best
carbohydrate daily. By insulin requirements. done empirically (through trial
dividing 500 by the average and error). And dont forget
number of units of insulin you The Weight Method to verify the I:C ratio at each
take daily (basal insulin plus meal and snack separately, as
mealtime insulin), you can get This approach is based on the they can vary by time of day.
a reasonable approximation of general observation that insulin
your I:C ratio. sensitivity decreases as body Keep detailed written records
size increases. Thus, each unit when testing your I:C ratios.
For example, if you take a total of insulin will cover less Track your blood sugar level
of 25 units of insulin in a carbohydrate in a heavier before each meal and then
typical day, each unit of insulin person than in a lighter person. again 3-4 hours later (to give
should cover approximately 20 the insulin a chance to work
grams of carbohydrate (500 Weight (lbs) Approx. I:C Ratio fully) with no other food,
25 = 20). If you take 60 units <60 1:30 exercise or rapid insulin given
daily, your I:C ratio would be 1 60-80 1:25 between the two blood sugar
unit per 8 grams of carb (500 81-100 1:20 readings. It is best to eliminate
60 8). 101-120 1:18 factors other than food that
121-140 1:15 might be affecting the results of
Avg. Units Approx. I:C 141-170 1:12 the tests. For example, do not
Insulin Daily Ratio 171-200 1:10 include data collected during or
(basal + bolus) 201-230 1:8 immediately after strenuous
8-11 1:50 231-270 1:6 exercise. Also, dont count
12-14 1:40 >270 1:5 data collected during an illness
15-18 1:30 or major emotional stress, at
19-21 1:25 One of the potential problems the start of a menstrual cycle or
22-27 1:20 with this system is that it fails after a low blood sugar. Meals
28-35 1:15 to consider body composition. with very high fat content or
36-45 1:12 An individual who weighs 250 unknown carb content (such as
46-55 1:10 lbs but is very muscular will be restaurant meals) should not be
56-65 1:8 much more sensitive to insulin used as part of your analysis.
66-80 1:6 than a person of similar weight
81-120 1:5 who has a great deal of body Because strange things can
>120 1:4 fat. happen on any given day, I like
to consider 10-14 days of data
The major weakness to this Fine-Tuning and Verifying I:C when coming to a decision
approach is that it assumes that Ratios regarding the I:C ratio. Allow
all people eat about the same the carb content of your meals
amount of food and produce It is best to confirm your basal to vary somewhat, and continue
the same amount of glucose insulin levels before attempting to adjust your insulin doses
each day. Those who are heavy to fine-tune your mealtime I:C based on your pre-meal blood
and those who eat relatively ratios. Any basal insulin glucose levels during your
large amounts of carbohydrate changes made after fine-tuning evaluation phase. Then go
will underestimate their insulin your mealtime doses might back and assess: Which I:C
requirement with this approach; send you right back to the ratios tend to result in a blood
those who are lean, active or drawing board. sugar rise from one meal to the
light eaters will tend to next? Which ratios result in a

## www.healthcentral.com: November, 2007.

Copyright 2007, Gary Scheiner MS, CDE Integrated Diabetes Services LLC Page 2
drop? And which ones tend to readings on most occasions and
Steady is what youre looking diabetes gold.
for when choosing a ratio.
Even if your blood sugar stays Given the complexities of
slightly high or slightly low, if determining bolus formulas, it
it held steady from one reading is usually worthwhile to have a
to the next, the ratio is probably second set of eyes look over
correct. your records. Dont hesitate to
reasonable conclusions. My
Fine-tuning your I:C formulas practice also offers this type of
can be a challenging consulting service via phone,
proposition, even for the most fax and the internet for those
person with diabetes. The intensive diabetes self-
more detailed you keep your management services locally.
records, the better. You might
discover certain factors that
have a subtle influence on your Editors note: Gary Scheiner is a
blood sugar levels: days of the Certified Diabetes Educator with a
week, work/school schedules, private practice near Philadelphia,
specializing in intensive self-
time of the month, management training for children and
changes in pump infusion sets Type-1 diabetes for the past 22 years,
or insulin vials/cartridges, and can be reached at 877-735-3648
injection/infusion sites, dining or gary@integrateddiabetes.com, or
visit his website:
in vs. out, medication www.integrateddiabetes.com.
schedules, and even social
engagements.

## Dont be surprised if there are a

few oddball results when you
analyze your data: an I:C ratio
that makes you rise one day
may make you drop the next.
Remember, diabetes is not an
exact science. There are
countless variables to contend
with, so dont hesitiate to
throw out results that are
highly inconsistent with the rest
of your data. The key is to
look for trends and patterns in
your data. Find an I:C ratio
that produces near-normal
www.healthcentral.com: November, 2007.
Copyright 2007, Gary Scheiner MS, CDE Integrated Diabetes Services LLC Page 3