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September 24, 2007

Daily Care, Insulin

Question from Chicago, Illinois, USA:

My seven-year-old son has had diabetes for a little over a year and is on insulin injections. His doctor does not use the carbohydrate counting method. He put my son on an insulin dose based on his blood sugar reading and A1c results and said my son can have any healthy food he wants as long as we make sure he has enough insulin based on his blood sugar, which we test before breakfast, dinner and bedtime. He gets two shots of insulin each day, before breakfast and before dinner. He has said that as long as his sugar is between 100 mg/dl [5.6 mmol/L] and 200 mg/dl [11.1 mmol/L], he’s fine. I have heard and read a lot about carbohydrate counting and how that is the way we should control diabetes. I have asked my son’s doctor about it but he says it’s not necessary, that as long as he has enough insulin and his numbers are good, he’ll be fine. I’ve also asked if we need to see a dietitian and they said it is not necessary, that what we are doing is good. On our own, we try to have him eat as healthy as possible and to control his food intake so he doesn’t overeat or so he eats enough. And, of course, no concentrated juices or pop as we were instructed by the doctor. What are the pros and cons to each way of treating diabetes, the carbohydrate counting method versus the method my son’s doctor is using? I just want to make sure we are doing the right thing for my son and not putting him at risk of any kind.


In many ways, I do not disagree with your doctor. There is nothing particularly “magic” about carbohydrate counting, but it does allow you (and your son, even though he is only seven) to begin to recognize those foods that can impact his glucose more. I would suggest you see a Registered Dietician, however.

I think that the insulin plan has to match the meal plan. You did not indicate which types of insulin you have been prescribed. I have many, many patients on a “fixed” dose of insulins whereby certain insulins are mixed and given regardless of the food intake. If your son is getting only two shots daily, I am assuming that each shot is a combination of NPH insulin and a short-acting insulin (such as Humalog, NovoLog, Apridra, or Regular). If this is the case, then carbohydrate counting is NOT so critical to the daily care (but it IS important for future, more sophisticated ways of giving you insulin, such as an insulin pump). But, you can still practice carbohydrate counting.

On the other hand, for an insulin pump or any other intensive insulin plan that tries to “mimic mother nature” and give “basal-bolus” insulin, then I think carbohydrate counting is very important, but not necessarily critical in certain situations. Basal-bolus insulin either by multiple daily injections or by insulin pump provides a background, always present, baseline (basal) amount of insulin for typical routine daily activities, but, to this, you add additional insulin (“bolus”) for meals.

In the non-diabetic, if one only has a piece of toast with coffee at breakfast, they don’t make much more insulin than their basal insulin. But, if they eat a large pancake breakfast with all the trimmings, then they’ll make much more insulin for this food “bolus.” So, the patient with diabetes can do this, too, using a basal-bolus plan. Not eating a lot? Then, you don’t need as much insulin. Eating large amounts? Then, take more insulin to “cover” the meal. This type of insulin plan also allows more flexibility in meal planning and timing: late dinner after practice? You can dose insulin then.

In sum, for a child as young as yours, a fixed regimen of insulin seems to be holding him and there is no special advantage of carbohydrate counting, other than the practice and knowledge it brings for future insulin options later. Going on a basal-bolus insulin plan? Carbohydrate counting allows for proper insulin dosing and allows flexible schedules.