Effectiveness of Using Patient-Defined Meal Sizes to Determine Bolus Doses of Insulin

Some individuals with diabetes requiring bolus insulin doses do not have access to dietitians to teach advanced carbohydrate counting. In this situation, meal sizes defined by individuals taking bolus insulin have been used to determine doses. This observational study evaluated the effectiveness of this approach.

In a diabetes program serving a minority population with low socioeconomic status (SES), primary care nurse practitioners (NPs) trained in diabetes care spent one-third of their time managing referred participants with diabetes who had A1C levels ≥9.0% for ≥6 months. They interacted with participants taking bolus insulin (telephonically or in person) every 3-4 weeks until there were no dose adjustments made based on glucose patterns and then every 6 weeks. NPs followed these participants for up to 1 year before referring them back to their primary care clinicians, either when they achieved target A1C levels (measured every 3 months) of ≤7.5% or at 1 year. The primary outcome of changes in baseline A1C levels evaluates the effectiveness of NPs using patient-defined meal sizes.

NPs managed 149 participants requiring bolus doses. Baseline A1C levels had significantly decreased (P < 0.001) by 3.2%, from 10.3% to 7.1%, at the time of referral of participants back to their primary care clinicians. Ninety-five percent of participants achieved target A1C levels of ≤7.5% after a mean of 6.1 months.

Experienced clinicians using patient-defined meal sizes to determine bolus insulin doses who frequently interact with patients can optimize glycemia in those with high A1C levels from minority populations with low SES.