 Hello everyone, this is Dr. Ahmed Ergen, I'm an endocrinologist and founder of Shugremdies.com. Now today we are going to talk about half the car and carbohydrates. Now I have a lot of patience on multiple daily insulin regimen, sometimes you just have to. If you're not on insulin, you can still benefit from this video, because you may be on insulin at some point, like some people think that insulin is under the road, which is not true. We have patients who have been taking insulin multiple times a day since age one, and they are 81 and they are doing perfectly fine. So if you have type 1 diabetes or type 2 diabetes on insulin, definitely you will need to understand certain things about carbohydrates so that it can be a successful diabetic. Now of course I don't want to use a diabetic word, but it's kind of commonly used so we sometimes use it. But if you are successful with your diabetes, definitely you are not going to have the problems that most other patients with diabetes are having. So education is the key, I always tell my patients understand this, once you get the hang of it, then you're going to be good to go. It's like driving, once it may be intimidating at first, or riding a bike, if you have never done it before, it may be intimidating. Counting carbs may be intimidating, using insulin may be intimidating, but once you get the hang of it, then you're good to go. So let's talk about this. Now there are two ways of taking multiple daily injections of insulin. Now most of the time we give patients basal insulin, that has nothing to do with carbs. So the common misconception is that people end up using more basal insulin, such as basal insulins are terceba, tugeo, lontislevamir, or novoline N, humulin N, etc. So they end up using more long-acting insulin to try to bring their blood sugars down. Some people will say, oh I just had a cake, so I decided to take 10 more units of terceba. Now that approach will not work because the long-acting insulins are long-acting, they are slow, they're like a truck, 18-wheelers. So they're not going to be able to just go fast enough to catch another car, right? So when you eat something, especially a cake or something like that, your blood sugar will spike so high that your long-acting insulin is so slow, it's not going to be able to catch up. Or maybe it will, but it's going to be like 10 hours from now. So unless you want to run 300, 400 blood sugar for another 10 hours, yeah when you wake up in the morning it may come down, but that's too long of a time to correct the blood sugars. Now let's get to the carbohydrates. So there are two ways of doing that. There is a fixed ratio where, for example, I will tell a patient take 10 units per meal of novelog or hemolog, or novoline R, humulin R, or fiasp, whatever that could be, maybe. So basically we tell them to take that much of an insulin. Now we are assuming something here, right? What do we assume? We assume that they eat the same thing every day. Well, we are humans. We like the variety and our hunger level changes, you know. Today at lunch I may be very hungry because I didn't have a good breakfast, but tomorrow I may not want to do anything because I had a big breakfast, so. But the problem is with that, when we assume that people eat the similar ways, the same things, that will work great. And there are some people like that. They eat cereal every morning, which we don't recommend, but let's say oatmeal, something better, right? So if they eat the same amount of oatmeal and I give 10 units and if that works for that 10, for that oatmeal, that's great. They can keep taking that. And some people are very successful with that approach just because they're, you know, they're habitual. They eat similar things. It works for them. Another way to make this fixed ratio work is to understand the carbohydrate rates a little bit better. So if you understand, for example, a slice of bread is 10 to 15 grams, of course, you have to look at the label when you buy the bread. Or, you know, let's say a large potato is 60 grams or one third of a cup of rice is 15 grams. So if you understand how much carbs you are eating at a time, although you're eating different things, you can still have a rough idea of how much carbs you're eating. So you can replace rice with bread, bread with pasta, pasta with potato. So as long as you know how much of a pasta is how much of a potato, then then you're good. Then you can still take 10 units, but you have to limit yourself in terms of how much you can eat. Let's say you have a great pasta dish. If you're taking 10 units of insulin, and if that works for, let's say, 50 grams of carbohydrates, you can not just say, oh, I'll have another plate or I'll have double portion. Then you just basically need double the insulin. So the problem is what most people end up doing, they start estimating. And they start just shooting numbers. They say, oh, well, I normally take 10 units, but guess what? I want to have a little bit extra. I'll just give 12 units. I'll just give 13 units. And then it turns into a guessing game. When there's a guessing game, it's worse than guessing stocks. Okay, so you never know really what's going to happen unless a devastating event like the coronavirus or COVID-19 situation. But most of the time, if you're just on a day-to-day, you know, you're doing day trading, it's really, most people screw it up and they end up losing much of money just because estimating like that is hard. And then your body is very particular. If you give, you know, 12 units of insulin, but you need 14 units, your blood sugar can be 100 or 200 more than what you want to be. And that's surprised people. They say, oh, my body is never the same. Well, that's true. Your body is never the same. But also what you're eating, the way you're processing the fiber content in the food, if you're not good at that, counting carbs, then it will never be the same. Okay, so let's talk about counting carbs and being very precise. If you want to be free, and if you want to be precise about how you're controlling your blood sugars with carbs that you're eating, then the best thing to do is counting carbs. So your doctor will decide, in this case, if you're my patient with me, I'll tell you, based on what you have been doing or your body size or how much you're taking, etc. We come up with an estimated number of insulin to carb ratio. What does insulin carb ratio mean? It means that everybody has a certain ratio that one unit of insulin will cover. So let's say one unit of insulin covers 10 grams of carbs for me, then my insulin to carb ratio is one to 10. Somebody else may be more sensitive to insulin. So they may use that one unit for 15 grams of carbs, so they're gonna need less insulin. So the higher the carb ratio, the less insulin you will need. So if you are very insulin resistant, and you need a lot of insulin, your carb ratio could be as low as one to one or one to two. That means that you're pretty much taking one unit of insulin for every grams of carbs you eat. So in this case, for even for a sandwich, for example, let's say turkey sandwich with two slices of bread, that's let's say 30 grams of carbs, some people will take as much as 30 units of insulin, and some people will take as little as two or three units of insulin. So that shows you the variability of insulin resistance from patient to patient. Most type one diabetes patients are very insulin resistant, type two diabetic patients are somewhat more resistant. And you know, in time as they get as they gain more weight and become more sedentary, their insulin resistance becomes higher and higher. But regardless of the case, you will be able to, you should be able to know your carbohydrate ratio. And if you do, you will be able to control it. So somebody who will take three units for the sandwich versus 30 units for the same sandwich, they can still control their blood sugars as long as they know their insulin to carb ratio. So as I said, we start with a certain number and estimated number and based on your blood sugars, we basically adjust that to find the correct ratio for you. Now, if you're using our app, you can even take a picture of it, you can write down your carbs, it allows you to choose how much carbs you're actually eating from a database, you can enter your blood sugars, you can enter how much insulin you're taking. And on my end, since we are doing remote diabetes monitoring and treatment, I can see everything that's happening. So basically you can eat pasta outside somewhere, you can write down your blood sugars and how much carb you have eaten. And then if your blood sugars shoot up too high, I will see on my screen and if you text me, hey dog, I'm in trouble, then I know exactly what happened so I can help you. Or if you see the trend like every time you do something and you get a high number, then you will identify what the problem is by looking at your trends. So that is the beauty of our practice. So at sugar MDs, that's what we do. And I think that's helping our patients tremendously. Now, so this is insulin to carb ratio. Again, we will determine that and we will adjust that. Now, also, there's something called correction factor. Correction factor determines basically how much insulin you need to correct your blood sugar. So I'll give you an example. If your insulin to carb ratio is 35, in this case, you need to know your target blood sugar as well to correct. So what are you correcting to your target? So let's say I want to be 120 or I want to correct my blood sugar down to 120. If I'm 190 right now, and if I want to correct to 120, then basically I have 70 milligram per deciliter higher blood sugar than I want to be. So 190 minus 120, right? So that's 70. And then if my correction ratio is 35, again, I come up with that based on your history, what you're doing, what your weight is. So you divide that 70 by 35, and then you end up with number two. So that number two units tells you that you need two units to cover your high sugar. Now, so what ends up happening here? So you're covering two things. Number one, you're covering your carbohydrates, and then you're covering your high blood sugars. So to do that, so think about this. So if I have an insulin carb ratio of 15, let's make another example, right? And if I am eating 45 grams of carbs, how much insulin do I need? Three, right? So you're dividing your total carbs by that number, your carb ratio, which is 15. So I'm eating 45 grams. I know my carb ratio is 15 because my doctor told me so. So then I can decide how much insulin to take. 45 divided by 15, that is three units. Now, that's great. I'm going to cover my carbs with the three units. But how about my blood sugar? What is it right now? Is it 120 or is it more than that? Is it the 220, 320? We don't know, right? So we need to know. So as a result, we always recommend to check the blood sugar before you eat. So if it is high, you can also cover the high blood sugar. So how do you do that? Let's say, again, same example, if your blood sugar is 190 and your target is 120, here you have 70 milligram per deciliter high blood sugars. So if your correction ratio is 35, because your doctor told you so, right? Then divide the 70 by 35 and you end up with the number two. So the two units is to cover the high blood sugars. Now, a lot of times people sometimes have trouble understanding these two numbers because they need to add it together. So you're covering your carbs and you're covering your high sugars. So there are two different things. As a result, you have to add them up. So that's three units for carbs we came up with and two units for the high blood sugar. So you end up taking five units at that moment for that high blood sugar and then for the carbs that you're about to eat. I hope that's clear. Now, sometimes, especially our older patients may not be willing to do all this math. And we kind of make want to make things easier for them. So we sometimes give them a fixed ratio. And they say, for example, oh, you know, my log is not that complicated. I don't go out too much. So I don't have to make too much decisions. So I can understand the carbs. I'll just figure it out. Like a like a ballpark figure out how much carbs I'm eating, I'm going to stick to, let's say 45 grams of carbs per meal. So we'll give them let's say three units, okay, take three units per meal, just eat 45 grams of carbs. And that works for a lot of people. Now, sometimes they don't want to do the correction calculation, you know, your target minus divided, etc. So we give them a sliding scale, right? So sliding scale will tell them how much extra insulin to take to cover the high blood sugar. Now, a lot of times people come back and they're totally confused. They'll they'll start they'll either do sliding scale or they'll just do the prescribed insulin. So I always tell them, look, you're taking three units for your carbohydrates. Okay, so if you're eating 45 grams every meal, that's great. You're taking three units, that's great. We look at their blood sugars, for example, when they are 100 blood sugar, and they take this three units, right, for 45 grams of carbs. And then next meal, they are, you know, around the same number, that means that that three units worked, because if you didn't take your blood sugar could have been higher. So but if their blood sugar was high to begin with, so let's say 220, they still take three units, but they don't take anything to cover, which is the sliding scale, sometimes in this case. So I tell them, look, it's different things. So three units for your carbs, and then you have to look at the sliding scale and combine them together so that you can actually know because we do we do this sliding scale separately because you can actually correct your blood sugar independent of eating. Let's say you're sick and you don't even feel like eating, but your blood sugars are running high. And, you know, of course, you cannot take this three units because you're not eating any meals or anything like that. But your blood sugar is running high due to stress or steroids they have given you. In this case, you can use your sliding scale without eating because sliding scale, the purpose of sliding scale is basically just to correct your high blood sugars to bring it to normal. So you don't have to necessarily eat to be able to use the sliding scale. So that is that is very important to understand. So I hope that video helps you in that regard. So if you have an insulin pump, all these things, all these calculations, carb ratios are programmed into the insulin pumps. As a result, if you have an Omnipod, Metronic or tandem insulin pump, whatever it may be, you will be able to get automatic decision based on the calculations that the pump does for you. All you have to say how much carbs you're eating and what your blood sugar is. And some pumps like tandem control IQ will be connected to DEXCOM and you don't even have to enter any numbers. You know, everything is already there calculated for you. You just have to enter how much carbs you're eating. So entering the carbs, understanding the carbs is very, very extremely important, guys. So if you have any questions, concerns, please let us know. Again, we will treat you remotely. You can see us from your car. You can see us from your balcony. If you're appropriately dressed from your bed, you know, you don't have to really go anywhere to see the doctor. So we are going to be there for you. And we will work with you, get your diabetes under control perfectly without stepping into the doctor's office. So the app that we have built is perfect for patients with diabetes to collect data and share it with the physician in the moment. Chat with the physician, chat with the educator. That way you're always on your game. Once you get the hang of it, you're going to be a pro in diabetes care. And I think you will be able to do that. I believe in you. And we will do this together. Have a wonderful day. Now, if you like the video, please give it a thumbs up and subscribe for future videos. I believe you will be getting some benefit from