I welcome the American Diabetes Association's Safe at School Program and Johns Hopkins Division of Pediatric Endocrinology welcome you to this evening to part three of the seven-part series of the webinar Designed for School Nurses. My name is Merith T. Bierge, and I'll be presenting tonight's program entitled Diabetes and Nutrition in the School Setting. I've been a registered dietitian for the past 15 years and a certified diabetes care and education specialist for the past 12 years. I'm currently a diabetes educator at the University of Maryland Medical Center in their outpatient setting. I work mostly with children, but also get the opportunity to work with adults too. Over the years, I've learned how important it is to provide education and support to not only the patients and family, but also to the school staff as children spend much of their time and care in the school setting. The ADA's Safe at School Program is devoted to protecting the legal rights of students with diabetes. So these students may learn and thrive in a safe and healthy environment and be treated fairly. School nurses play a critical role in making sure the needs of children with diabetes are met in the school setting. Our hope in tonight's program is that we will provide school nurses increased knowledge, skill, and confidence to best support students with diabetes to optimize their education and have the ability to safely participate in all school-sponsored opportunities. The school nurse is the student's advocate and the key provider and coordinator of diabetes care in the school setting. School nurses, parents, providers, and students working together can make sure that these children with diabetes are indeed safe at school. For a couple housekeeping tips, please type in your questions that you might have in the chat box and I'll do my best to answer the questions at the end of my presentation. Soon after the program concludes, attendees will receive an email containing a link to the evaluation and post-test. Free continuing education credits will be awarded upon the completion of the evaluation and post-test. Also, be aware that this session is being recorded and will be soon available on the ADA's professional member website. Also, be aware that while the American Diabetes Association attempts to ensure that all information is accurate and current, this general information about potential legal protection and medical best practices is not a substitute for individualized legal or other expert advice and assistance. The American Diabetes Association, its staff, and volunteers do not provide legal or medical advice or represent you. For detailed legal advice or representation, contact and consult an independent attorney, and for healthcare consultation and advice, consult with your professional healthcare provider. Thank you so much for joining us tonight, and again, be sure to type your questions in the chat box. So tonight, our objectives are going to be discussing the nutrition concepts related to the management of diabetes during the school day, review components of school forms that may relate to nutrition, review carbohydrate counting with and without nutrition labels, review appropriate portion estimations when measuring tools are unavailable, discuss management for fixed insulin dosing and management for type 2 diabetes, and practice some common school-day case scenarios. So, what does nutrition management look like in the school setting? So, checking blood sugars before meals, checking blood glucose before exercise to determine if they need carbohydrates to raise blood glucose to a safe target, some of these exercises may include things like gym, but also include things like recess, or if the student may have a field day. Also, possibly checking blood glucose before dismissal to determine if they need carbohydrates to raise a blood glucose to a safe target, carbohydrate counting foods the child will eat to determine the insulin dose or insulin dosing based on the food already consumed, and treating hypoglycemia with fast-acting carbohydrates. So, the school forms, items on the school form that may involve nutrition. The first part is meals. So, what things you may want to consider is, do they eat breakfast at home or at school? Will their lunch be packed from home, or will school provide the meal? And do they receive snacks during the day in the classroom? One thing to think about for breakfast is that if they are receiving breakfast at school, what time does school breakfast start and end to help plan what time do they need to have a blood sugar check? Do they need to have their blood sugar checked at 7 so that they can have breakfast between 7 and 7.30? So, timing and dosing would need to be considered for these meals. Also, the next thing to consider is physical activity. Do they have gym class? Is this gym class going to be daily, or will it depend on the schedule? Maybe they have alternating days, such as A day and B day. What time of day is gym class? Timing can definitely play a role in how blood sugar will be managed. Often if gym class is before lunch, they're more likely to need a snack, especially if they ate breakfast many hours ago, or if gym class is after lunch, they may be fine and not need any adjustments, or some may need an adjustment to the insulin that they're given at lunch to help keep their blood sugar stable during exercise. So, it is important to think about the timing of this, and this would also include for recess kind of similar thing as gym class. When is recess? Is it before or after lunch? Is it the middle of the day? To help kind of figure out what are kind of where the blood sugar may be lying with that activity. Also, do they participate in school sports after the school day lets out? So, is it something where they're on a sports team, and what will their blood sugar look like at the end of the day going into the sport? It's important to follow the DMMP. You can look in section seven, which talks about low glucose prevention, where you can kind of look at how to manage exercise. Often on the form it may talk about blood sugar goals being between 120 and 150, but this will of course depend on the medical team and their family, but if blood sugar is below target, often things that you would consider are what kind of snack will they be having? Will it have carbs and protein together? Next is travel. So, how do they commute to and from school? Do they ride the bus? Do they walk? Are they picked up? Do they bike? And how long is this commute? Is it a five-minute ride home, or could it be 30 minutes? What is their blood sugar goal before leaving school? What happens if the blood glucose is not at that goal target? And when do you check? So, thinking about your timing will be really important. If school lets out at three o'clock and they have to ride the bus, you do not want to wait until three o'clock to check their blood glucose. You may want to check 20 minutes before, so that way it allows time if blood sugar is not at target to have time to provide carbohydrates to bring that blood sugar up to target. Also do they go, another thing to consider is do they go to aftercare? Is the aftercare in school, or is it at home? I mean, is it outside of school? So, like going to an outside daycare? So, thinking about that too will be important of how will that care look at the end of the day and blood glucose goals. Next, we're going to talk about carbohydrate counting. So, how do we carbohydrate count? Step one, we want to find out which foods have carbohydrates. Things like starches, grains, beans, fruit, milk, yogurt, sweet treats, sugary drinks, and vegetables have carbohydrates. Your non-starchy veggies have more of a small amount versus your starchy ones will have more. Step two, after you figure out, once you figure out which foods have carbohydrates, step two will be figuring out how many carbohydrates are in each food and then adding it up. In order to figure out how many carbs, you would look at food labels. You may look at, you may look online. This may give you a note listing the foods with their carbohydrates, or you may have reference sheets. Step three will be once you figure out the total amount of carbohydrates they are eating, then you will divide by their insulin to carbohydrate ratio. So, this will look like total carbohydrates divided by insulin to carb ratio to give you the units of insulin needed for food. The units of insulin needed are going to be for the carbs they consume. This would not include their correction dose. They may need additional insulin for that blood sugar. Here is just to show you a chart of common food sources of carbohydrates and their serving size. So, things like this could be a possible resource that someone may use. So, if you're looking, it shows that one bagel is about 56 grams of carbohydrates, or things like a half a cup of baked beans is 29 grams of carbs, or when you're drinking a cup of chocolate milk, that'll equal 26 grams. So, this is just to show this is a chart of commonly consumed carbohydrates and their serving size. Next, the other carbohydrate chart lists out carbohydrates that may not fall into those previous categories. Things like burritos or casseroles may be listed for there. And then to the right, you may see meats on there. Meats don't typically contain carbohydrates. However, if they're breaded or floured, they may contain carbohydrates. So, I use the example that chicken tenders are breaded, so they will contain carbohydrates. But if you had a grilled piece of chicken, that would not contain carbohydrates. Or popcorn shrimp will have carbohydrates because it's breaded, but using like a steamed shrimp will not. Be aware meat substitutes may be carbohydrate-free or may also contain carbs, depending on how they're made. So, things like a black bean burger will contain carbohydrates. So, carb counting. One of the biggest ways to carb count is using the nutrition label. There are two main things to look at on that nutrition label for carbohydrate counting. You would look at serving size and total carbohydrate to figure out those carbs. So, serving size, for this example, if they ate a half a cup, let's say it's yogurt, then they would have consumed 16 grams of carbohydrates. But if they ate two servings or one full cup, then you would do 16 plus 16, which would then tell you that it's 32 grams of carbohydrates. It's important to note that sugar-free products doesn't mean carbohydrate-free. So, it's always important, even if something says sugar-free, to check that label because carbohydrates come from more than just sugar. They can come from other sources such as flour. And for an example, sugar-free pudding, a pudding cup is about nine grams of carbohydrates, so it still contains carbohydrates less than the regular, which contains 19, but you can't assume that a sugar-free pudding cup is that it's carbohydrate-free. So, always check that label, even when it says sugar-free. So, when there is no label, there are apps out there that can help assist with carbohydrate counting. One app that is often can be used is Calorie King, and that's actually in the kind of that apple towards the bottom of the slide, that's Calorie King. So, Calorie King is a database that you can search engine, so you could type in something like apple, and it'll pull it up. And the Calorie King app or website, what it'll do is it'll allow you to change the serving size. So, you could say it's a medium or a small apple, and it may change then the carbohydrate amount, or you can change the quantity. So, if a student said, I ate two apples, you could click and change quantity to two, and it'll change the carbohydrate amount for you. Next, there's MyFitnessPal, which is also a search engine that can also be used. Sometimes you need to use this with caution, because if the foods have not been verified, then the source may not be as reliable. So, just always looking to make sure that when using that as a search engine, that it's a verified food. Next, you have FigWheat, and this is the visual picture to the right with the pretzel sticks. So, FigWheat is a visual portion estimator app. So, what this will allow is it shows you a picture of the food, and you can increase and decrease how much is seen on the plate, and it'll give you an estimate of how many parts. Also, it will tell you the estimate of the size of it or how much it weighs. So, on the left, that's a half an ounce of pretzel sticks, and then on the right, that is 1.25 ounces of pretzel sticks, so another resource. And then you may also use the USDA has a food database. I do always like to note Google or Siri may not always be reliable, but it's often used that often individuals might just ask, hey, Google, how many carbs are in a half an ounce of pretzel sticks? But just be aware that with Google, it's showing you multiple options, so it's always good to double check what Google finds. So, an important thing to note with carbohydrate counting is keto or diabetic foods that you may see from the food industry. So, with these foods, you often see the packaging will say net carbs, and what are net carbs? So, with net carbs, the food industry subtracts all of the fiber and sugar alcohol from the total carbohydrate amount that you see from the label. And so, one thing to note is that so they determine that carbs, they subtract all the fiber and sugar alcohol on the label, and they assume that the fiber and sugar alcohols are not absorbed at all or metabolized, but this is not always accurate, and some are partially digested and still can provide an impact on blood sugar. So, we usually say that you only subtract half of the fiber and half of the sugar alcohol from the total carbohydrate. So, in this example, with this food label, they're saying that you would, for their net carbs, they would say 21 grams of carbohydrates minus the 12 from the fiber and the five from the sugar alcohol would give you four grams. However, that I would not recommend that I would recommend doing half. So, 21 grams of carbs minus six grams of fiber and 2.5 grams of sugar alcohol to now give you 12.5 grams of total carbs. So, something to think about when carb counting is not always just looking at that net carbs, but still always looking at that label to get the most accurate carbohydrate count. So, when putting it all together, so here would be an example of a note that might be given to, that might be packed in a student's lunch that you may see. So, this student's lunch has one turkey and cheese sandwich on wheat bread, which provides 30 grams of carbs. They have one clementine, which is eight grams of carbs, one tube yogurt, which is eight grams, one mini bag of pretzels, which is 15, and a flavored water, which is zero grams. This student has an insulin to carb ratio of one unit of insulin for every 12 grams of carbohydrates. So, with this, you would take the total grams of carbohydrates, which is 61 grams, divide by 12, which would then give us five units, 5.08 units of insulin. So, you would deliver five units of insulin for the food consumed. Once more, this would be, five units would be given for the food. We would also need to take into account, do they need any additional insulin for their blood sugar? So, next is tips and tricks. So, big thing is estimating portion sizes. You may not have measuring cups and spoons with you, or the student won't either. So, being able to estimate portions can be very important. So, for visual thing, a golf ball is usually about the size of two tablespoons. Often people, you might see tablespoons used for things like peanut butter, jelly, syrup, ketchup or barbecue sauce, or other types of sweet dipping sauces. Or if it's for a smaller portion, you could use about the size of your thumbnail as a teaspoon. So, once more, condiments, honey, sugar, butter can be a good way. So, using that thumb to kind of estimate, this is about a teaspoon. For an ounce, you would do a handful for kind of, I would say a cupped handful would be used for a heavier piece of food like nuts or small candies. And then if it's kind of a lighter food like pretzels or chips, it would end up actually being two handful, cupped handfuls that would be about one ounce. So, one ounce is usually those mini bags of chips. So, if you could kind of say about that mini bag of chips would fit in about two cupped handfuls. And your palm is about three ounces, and that often is used for cooked protein. Your fist is usually about one cup. Now, granted, everybody's fists are different sizes. So, I usually tell people, get your measuring cup at home, see how your fist fits into the measuring cup to kind of gauge, is your fist bigger or smaller or about the size of one cup. But often one cup can be used for cereal, pasta, rice, fruit, veggies. Another option too is using kind of the front part of your fist, like your knuckles, and that would be for a smaller size, for about a half a cup as an estimator. And then the final thing is for pieces of fruit, a medium size, a medium piece of fruit is about the size of a tennis ball. Next, for tips and tricks for mealtime dosing for that packed lunch, I usually would encourage both the nurse and the families to plan ahead. Which days are the students going to be packing their lunch versus getting school lunch? Ask the families to put in a note card with the foods that they're eating and listing the carbs in the total for the whole lunch. So to the right, you can see a parent note example would be them including a peanut butter and jelly sandwich, which is 38 grams of carbs, a fruit cup, which is 15, a bag of chips is 15, their cheese stick is zero, and their Capri Sun roaring water is nine grams for a total of 77 carbs. And it's important not to just put the total grams of carbs in the note, because if they don't eat everything, or they didn't decide they don't want something, this allows for you to more easily subtract and figure out the new total carbs. It's important to note that carbohydrate restricting is not recommended for type 1 diabetes. However, we do want to encourage when they're eating carbohydrates to have protein and fiber with it. Protein examples could be things like cheese sticks, nuts, if your school allows, seeds, Greek style yogurt, milk, and so forth. And then for fiber rich things, fruits, veggies, possibly dip, whole grains, such as whole grains like popcorn, whole wheat crackers, whole wheat bread, could be good ways to encourage fiber. However, if you do notice that your students are choosing foods that are that lack a lot of protein and fiber or just carbohydrates, you could encourage parents to find options that will help their kids feel more full and satisfied throughout the day. Protein and fiber can help that, and kind of talk with them about how protein and fiber not only keeps them full, but can help keep their blood sugars a little bit more stable, which could help decrease chances of missed time if they're having more erratic blood sugars. So what do you do when there are no labels? So one thing is, is if they have containers with them, you look at the containers, do the containers list the size on them? So in the picture to the right, and you can kind of see, but it actually says at the bottom that this container fills two thirds of a cup, or does it list it on the sides? So the other picture shows on the side that if it's filled to that line, is it one cup? So can you, do their containers actually list the servings, so you can better gauge, is the container filled? Is it halfway filled? And how much does that container hold if you fill it all the way? Can you, can you count the food items? So things like crackers or grapes or things that are pieces, could you easily count it and then use something like calorie king where you say, okay, they ate 10 grapes. I can look that up, or there's 10 grapes in the container, so I know how many carbohydrates are in them. Could you use the estimates using your hand or the object? So they, if they have something like a container that has pasta in it, and you'd say that container looks like it's holding about a fistful, it's about one cup. Using your apps, definitely. So maybe you use big week to help you visually look at how much pasta do you think it could be by using that. One thing to note is, do you have a previous food law? So was Tuesday and Wednesday's lunch the same, or they had, they had that same pasta, but the day before the pasta was listed on a card. So maybe you could look back at a food item. And if not, you could call the parents. The parents will likely know they packed the lunch or they may, well, they're more likely to know. So call them and see. They might have just forgotten it, but they know what's in the lunch and can help you figure it out. The next is for planning is when we talk about packing versus getting school lunch, looking at that school menu, can, can the student or you print out the school menu and maybe circle and look ahead at what they're going to be getting for school lunch to plan? One thing is, is to, if you, a lot of schools will have the menus online and they, where you can click on the foods online and it'll give you the nutrition information. So you can look ahead, talking with, always talk about to the food service about possible menu changes. And if you're not sure if your school has nutrition information, make sure you're talking to the food service and administration to see if you can get the nutrition information for those menus. So the kids with diabetes can still enjoy school lunch, just like their peers. So the next thing is figuring out a carb count when there's no carb and you're cutting this, you're presented with a picture like this. So in this picture, you can see the student has a piece of pizza, a protein bar, an apple and a diet drink. So there's no carb included, and this is what you see. So once more, if either any of these foods have labels, look at it. So for the protein bar, you could turn it around and it will tell you. And if it didn't have the label, you can see the brand and you could easily look it up. So using the label when possible, and then using calorie king. So for this example, for this is a slice of pizza. You don't even need to know where it's from. If it's from something like Domino's or Papa John's, but on calorie king, you can type in pizza and it'll actually give you the average amount, average slice of pizza, how many carbs. So you could use that. Average slice of pizza, 27 grams. That apple looks to be about the size of a tennis ball. So you could say, okay, that's a medium size apple. So maybe it's about 20 grams of carbs. You've turned that label over on that protein bar and that's 15 grams of carbs and the diet soda is zero. So this lunch right here for estimating is 62 grams of carbs. So definitely, you know, piecing together and using the different resources will help you best guess and estimate the carbohydrates when you aren't given a card or there's not, everything is not labeled. So another example of, let's say that your student came with this bento box lunch and without a note, and you're unsure, this is again, where you could try estimating. So if you look at that far left compartment, that looks, you could say to be about a fistful of pasta, depending on once more your fist size. So, okay. So you're saying, okay, that compartment of pasta is about one cup. We're going to estimate. Then that far right compartment that has the fruit in it looks to be about half the size of that, that last one. So you could say that fruit compartment is about a half a cup for it. And then when you look at that bottom center, that where the yogurt is, that looks to be about one fourth of the largest compartment or half the size of that one on the right. So you could say, okay, that yogurt compartment looks, it's probably about one fourth cup. And then the center, you could say it looks the smallest. So maybe that holds two tablespoons because two tablespoons would be half of that one fourth cup size. And I know that kind of sounds a little bit confusing, but kind of just start thinking about when you're trying to estimate your sizes, also counting pieces or eyeballing whenever possible. So things like the almonds in the center, you could count them, the fruit, the raspberries and grapes you could count. And then the cheddar bunnies could also be counted. So for this example, let's say you count and it is about seven grapes and you count four raspberries and you figure out with that, then that it's about 11 grams of carbohydrates for that. And then you count the cheddar bunnies and it turns out that there is 35 cheddar bunnies. So that equals 13 grams of carbohydrates. And you're going with that. That yogurt size is about one fourth cup. So one fourth cup of a vanilla Greek yogurt, six grams of carbs. Next up, you say you count those almonds. There are 10 almonds. So it's about two and a half to three grams of carbohydrates. And then the pasta is one cup. And we say that's about 40 grams of carbs. So you add it up and the lunch is 70 grams of carbs. Once more, this won't be perfect, but this kind of is way. So thinking about where can you count pieces? What do we think the measurement possibly is? So using kind of those eyeball estimates. And then once more, you could use your different apps if possible. So what do you do with only partially a lunch? How do you count a partially consumed lunch? So for this picture, what's packed is a turkey and cheese sandwich, a cheese wheel, which you don't see in the picture, but that has zero grams of carbs, a one ounce bag of chips, 20 grapes, and a water bottle. And this meal, if they eat everything, it's 65 grams of carbohydrates. However, they come back to you after lunch and say, well, this is what is left in my lunch. I couldn't eat it all. So how do we estimate? So I usually tell people kind of look at that looks like to be about half of the sandwich was eaten. So then that's 15 grams of carbs. And if you count those grapes on the picture, there's seven left out of the 20. So they ate 13, 13 grapes. So that's about, they consumed about 13 grams of carbohydrates. And then that bag of chips is empty. They made sure to eat all their chips. So they ate all 15 grams. So now they consumed 38 grams of carbs instead of the 65. Will they need to make up the carbs? Yes. They're going to need to have additional food because they were, if they were dosed for 65 grams of carbs and they only ate 38. And we'll talk about what to do in a few slides, if don't consume all the lunch, but they've been given insulin. So other management that I wanted to talk about is type two diabetes and the use of fixed insulin doses that you may. So these are things that you may see also in school. So fixed insulin doses. So some individuals with diabetes may manage their blood glucose with fixed or set insulin doses at meals. So often this can include a sliding scale insulin for blood glucose in addition to a set meal dose. So on the right is a chart. That's just an example. So it shows that where their blood sugar is running and how much insulin they'll need for their blood glucose. And then plus the set amount of insulin they may need at a meal. So for example, if a patient came to you and had a blood sugar 220, they would receive two units for their blood sugar and then 10 units for that meal. So a total of 12, or if they came to you and their blood sugar was one 20, they wouldn't get any additional units of insulin for their blood glucose, but still would receive 10 units for that meal. So the meal dose doesn't change. They get the same 10 units, but then the blood glucose, the amount of insulin they need for their blood glucose will vary depending on where their blood glucose is. With this method, it's important to that individuals try to eat consistent amounts of carbohydrates to match that insulin dose. That insulin meal dose is often based on the average carbohydrate intake from that individual. Often the endocrine team or the dietician in that team may help to calculate how much on average they eat for their meal at school, whether it be a packed lunch or school lunch, they try to come up with an average amount to set that units of insulin. So if they don't eat much of their meal, or they have more of a snack instead of that full meal, then they're going to be at greater risk for hypoglycemia. And it's important that their blood sugars are going to be monitored closely. So tips with fixed insulin doses. So, like I said, we want to try to have them eat similar amounts of carbs as the previous day, or think about a day where their blood glucose was more stable. So if they're not eating lunch, then that fixed meal dose would not be given. They may still need insulin for that blood glucose correction. So it's important that you talk with the diabetes team or parents if the DMMP does not state how to dose when eating versus when they aren't eating food. Things to consider are, are they taking other medications that could impact their appetite? So GLP1s and stimulant medications can decrease appetite, but this may impact them being having an appetite to eat a full meal. And then if you're noticing they tend to eat more of a snack during meal time, then talk with the parents or diabetes team about adjusting that meal dose or including a fixed insulin dose for not only a meal, but a snack size or thinking about it as a large versus small meal. And if that was the case, that would then need to be put on the DMMP to be included. Next up is type 2 diabetes management. So one thing to remember is type 2 diabetes in youth results from genetic, environmental, and metabolic causes. It's not related to autoimmune disease like type 1 diabetes. So there is insulin resistance with relative insulin deficiency due to beta cell impairment and impaired and prevent effect. So possible medications that you may see someone with type 2 diabetes using is insulin, metformin, GLP1 receptor agonist, and SGLT2 inhibitors. So with this for insulin, there's different combinations that they may use to manage their type 2. So using rapid acting insulin with an insulin to carb ratio and a blood glucose correction scale, or they may use the rapid acting insulin with a fixed insulin dosing. They may use the rapid acting insulin with a sliding scale only, or you may also see long acting insulin. Often long acting insulin is given at home, but some students may end up taking their long acting in school if talk with the diabetes care team and school about what works best for that student. GLP1 receptor agonist, they stimulate insulin secretion after eating, delay gastric emptying, and inhibit production of buprenorphine if blood glucose is high. So with these medications, it's important to be aware that hypoglycemia can happen if they're also using insulin therapy. Side effects are often decreased appetite. So with decreased appetite and on insulin, they may need to make adjustments to their insulin regimen if they're noticing that their decreased appetite impacts their carbohydrate intake. Next, those with type 2 may be taking metformin, and this is an insulin sensitizer. The important thing to note is that it can have GI side effects such as nausea and diarrhea. It doesn't typically pause hypoglycemia, but it may impact them wanting to eat if they're having some of those GI side effects. And then finally, your SGLT2 inhibitors decreases glucose reabsorption in the kidneys and promotes glucose excretion through the urine. So this could cause hypoglycemia if they're also using insulin therapy. Big side effects can be decreased appetite and increased urination. So guidance for type 2, our goal is to improve insulin sensitivity and blood glucose. So this is typically achieved through eating healthy meals and snacks, exercise and physical activity, losing weight if needed, and taking those prescribed diabetes medications. So nutrition recommendations for type 2 diabetes. Individuals with type 2 diabetes often require diet modification, but it's important they can still also consume carbs. They also don't have to go on a low carb diet. But it's important that they cut out sugar sweetened beverages. So they want to avoid regular soda, juice, sweetened iced tea, lemonade, sports drinks, and swap out instead focusing on water, milk, or low calorie drink. They want to decrease refined sugars and processed foods, increase fruits and vegetables. And with increasing fruits and vegetables, it's important to note it's okay for it to be fresh, frozen, or canned. With those, you just want to make sure for canned or frozen that there's not added salt, fat, or sugar. These fruits and vegetables tend to be lower in calories and higher in fiber. And we want to increase whole grains and whole wheat products. So whole wheat bread, whole wheat crackers, popcorn is a great actually fiber source that can be part of the whole grain. Fiber can help lessen how the blood glucose spikes and help with fullness and satiety. And then thinking about portion control. So when thinking about portion control, we want to include protein to help them with how feeling full and how that blood sugar, the blood sugar rises. So right here on the right, you can see an example of kind of a balanced plate with portion control where half that plate is non-starchy vegetables, a quarter of it is protein, and then a quarter of it is carbohydrates. So thinking about those non-starchy veggies are full of fiber, then you have your protein, which also will kind of help with satiety. And then that's still enjoying the carbohydrates, but thinking about that carbohydrate in a portion controlled manner. So guidance in this food for type 2 diabetes. So it's one thing I like to, it's really important that kids still eat and don't skip meals. So food insecurity can be a very big factor. So they may rely on the meals in school to provide much of their calories and nutrition. So skipping the meal would not be encouraged. And a grumbling stomach can make it really hard to focus in school and more likely to overeat once out of school. So if they skip breakfast and lunch at school, once they're good home, they're going to be very hungry and not be able to likely make good choices. They're going to be grabbing whatever is quick and easy because they're so hungry. And that tends to be convenience foods, which tend to be higher in fat and salt and process. We want to try to avoid saying things like you can't have that food because you have diabetes. Instead, try to make it a teaching moment with these kids. We want to try to build trust with them and make this teaching moment, try to come to them without judgment. It can be really hard to be different from your peers who may be eating different things. So I usually tell people approach it as, well, when you choose juice, this really makes your blood glucose rise. What about trying to choose milk or water, which tend to let have less of an impact on your blood sugar and then guiding them on how other options can help their blood glucose. So making it a point to say, well, when you choose popcorn instead of chips, that popcorn has more fiber, fiber can help keep you full and tends to make your blood sugar rise less going through options for the school meal, letting them kind of going through that menu. Is there a fruit or vegetable option that they could choose? Are there whole wheat options like bread? So if they were getting a sandwich, could they ask for wheat bread instead of white bread? And where can nutrient dense foods be added in? So if they're having a, let's say a fried chicken patty sandwich, okay, maybe, and it's all in white bread, but where could they add a nutrient dense food? Okay, well, they could get an apple and some carrot sticks on the side. That could be a great way to add in those fiber rich foods and then encouraging to avoid vending machine items. Those vending machine items tend to be high in saturated fat, salt, and they tend to be more processed carbs. So I wanted to then now practice the practice in different scenarios. So first step is going to be gym class. So let's say your student had breakfast and took insulin at 645 at home. Their gym class is at 1030 in the morning, and then they'll have lunch at 1230. They come to you at 1020 and you see that their blood sugar is 100. What would you do? So with their blood sugar being at a hundred, they're at risk for hypoglycemia with exercise. If they don't have a snack prior to that activity, they've gone on, you know, it's been four hours since they last ate and they still will have some time after gym before they had to lunch. So they likely would benefit from having a snack, which would contain carbs and protein. An example could be something like a kid's protein bar, or you could use something like an applesauce pouch and a cheese stick. And then things, if they're on an insulin pump, you would follow the orders for pump management, such as using a temporary basal rate or putting on their exercise or activity mode. The big thing is you want to follow the DMMP. So you could go to the section where it kind of talks about managing blood glucose with exercise and what is the blood glucose target. The next up for an example is before lunch, they come to you and their blood sugar before lunch is 75. So with this, you would definitely want to dose insulin immediately before eating. And you may even consider dosing that insulin right after the meal due to the hypoglycemia risk. So the risk of hypoglycemia would increase if they had to, let's say, buy their lunch. So if they needed to get their set, they come to you at 75, you give them insulin, but then they have to wait in line for 10 to 15 months to get their school lunch. Their blood glucose will continue to drop. So they are at greater risk for hypoglycemia. So things to consider. Next, what happens if they came to you and instead of it being low, their blood glucose is elevated at 287. So with this, you would give insulin dose for correcting the blood glucose and carbs. You don't have to avoid carbs because the blood glucose is elevated. They can still eat carbohydrates. But it would be important to talk about why, what are the possible causes of it? Did they forget to take insulin at breakfast, or maybe they didn't calculate correctly, or if there's no reason to kind of just noting, if there's a pattern to see, maybe they need an adjustment in their insulin. So one thing to note is at 287, depending on if their sheet is listed, they may need to check for ketones. So if there's not kind of a clear explanation for the high blood sugar, definitely you may need to check for ketones. However, you would look at your DMMP, which will state when to check for ketones at what blood glucose threshold would you check? Because if they were, if they, and this can be found in section six, but if they had ketones, it would help, you would then possibly need to give additional insulin, but this is where you would check your sheet. So at a higher blood glucose level, they still can eat carbohydrates, but you would just need to for the correction. And then just talk about possible reasons that they were elevated. After lunch. So the student was both before lunch, but returns to the health room and reports that they didn't want to eat all of their food. So the big thing is to find out how much of their lunch did they eat because you both them for eating all of it. So I usually tell if possible, and they have their lunch, ask them to finish their lunch. So if they were like, well, I didn't want to eat all of it, but okay, I'll finish my sandwich. That would be great. It's not always going to happen that way. And then think about the food that they consumed in kind of quarters. So you can kind of figure out how much of it did they eat? A fourth of their sandwich, half of their sandwich, three fourths of their sandwich. So you can kind of figure out how many carbohydrates they actually did consume and then having backup food and drink to cover for them to use, to eat, to cover those uneaten carbs. So let's say they only ate half of their sandwich. So now they need about 15 grams of carbohydrates. So something like you could give them a granola bar to make up for that, the carbs they did not consume. So that would be very important that they have food items that they can consume to make up their carbs so they don't go low. Next up is a class party. So let's say the class party could be anywhere from one and a half hours before, after lunch. Basically this class party is happening not near lunchtime. So it can't easily just be dosed. So students can partake, students with diabetes can still be a part of the classroom party, but they'll need insulin. So for individuals who are on insulin injections, if it's been less than three hours since their last insulin dose, then you would count up the carbs and give insulin for the carbohydrates only. You wouldn't do a blood sugar correction. However, if they're on an insulin pump, then you would plug into the pump the carbs that they're eating, the blood glucose, and then let the pump give you the recommended dose. So with classroom parties, if it's store-bought food, then hopefully you can read the nutrition label to figure out that they're eating too many cupcakes. And those too many cupcakes is 40 grams of carbs. If it's homemade, then you would need to estimate or use those websites that we talked about. So one thing I used to say is with classroom parties, you know, talk with the teacher, the teachers, if the teachers kind of, you can get a feel for, oh, when are you guys doing your classroom party for spring? So that you can plan ahead and kind of try to figure out a plan for carbohydrate counting, or if it's, oh, what is the sign up? Oh, the signup is going to include many cupcakes, pretzels, juice boxes. So that way that planning ahead to figure out carbohydrates to more easily and quickly carbohydrate count and dose for that party. Or if I'm talking with the parent, like if they're bringing in a birthday treat, what would they be bringing in to help kind of help figure out the carbohydrate? Next up is dismissal. So the end of the day. So the blood sugar before dismissal, 15 minutes before dismissal is 92. So one thing is that you want to consider treatment time to allow the blood glucose to rise before dismissal. So this is where I'm having a plan of when you check blood glucose before dismissal. So I would say don't check right before they're about to leave to get on the bus. You want to allow some time that way, if they happen to not be at target, that you have time to give them something to raise that blood sugar. Also need to consider their mode of transportation. Are they walking? Is someone picking them up? Are they getting on the bus? Treatment is going to be patient dependent. So with this thinking about injections versus having a hybrid closed loop pump, and then wanting to discuss the treatment plan with the parents at the nurse parent meeting, because your, your plan will vary depending on how they get home and how they receive insulin. So for an example, if they're riding the bus, the bus may differ from somebody that's being picked up in the car. So if they were 92 and they're about to get in mom or dad's car, you can let the parent know versus if they're getting on the bus, the bus may take 20, 30 minutes. So you might need to make sure that that blood sugar is higher so that they're not dropping while on the bus. It's important to go to section seven in the DMMP for guidance for early low blood glucose treatment. And this would include things like dismissal. Next, practicing your fixed doses at lunch. So the student comes to the nursing suite before lunch to get their fixed insulin dose. Their blood glucose is 223. So looking at that chart at 223, they would get two units for that blood glucose plus 10 units for the food there for their meal. And so they get a total of 12 units of insulin. So for lunch, they tell you they're going to have a cheeseburger and an apple and drink water. Then they come to you after lunch and they're going to drink water. Then they come to you after lunch and tell you that burger was nasty, so they didn't eat it. They did eat the apple and then they grabbed cookies from the vending machine. So big thing is, is what do you do? They didn't eat what they said they were going to eat, but they've already received insulin. So do you need to give them extra carbs? So you actually probably don't need to give extra carbs to them. The carb amount is similar between the cookies and the burger bun. So a pack of cookies is probably 25, 30 grams of carbohydrates and the burger bun is going to be about 30. However, if they only ate the apple and they didn't eat cookies, then you might want to consider giving them some carbs. Or if they ended up completely not eating, like they thought the whole meal was gross and they didn't go to the vending machine, then you would need to find some similar carbs to try to match that insulin dose. The big thing with fixed dosing is going to be monitoring too, is do you need to then monitor their blood sugar? Maybe they need to come back because you need to see how are those 10 units doing, um, with the cookies and apple versus having a main meal. And if you kind of notice this as a pattern where they're not really eating all of their lunch, then you may have to talk with the parents and the diabetes team, because maybe the insulin dosing that is listed may not be appropriate for them. And they may need adjustments based on, like I said before, are they eating a small meal versus a large meal? Um, or kind of thinking about less units that they often skip meals or think that the school lunch is not so, not so tasty. So next step is a lunch for a type two individual. This type two individual, um, uses an insulin to carb ratio of one unit for every seven grams of carbohydrates, and they get a correction dose of one unit for every 30 blood sugar points over 150. And to the right is the school menu that is being offered that day. They could choose a personal pan cheese pizza, turkey pepperoni personal pan pizza, turkey and ham cheese sandwich, side salad, carrot sticks, an array of fruit, and some assorted milk. So the patient comes to you to receive insulin before lunch. The blood sugar is 130, and they plan to get the cheese pizza, a bag of chips, and a scorched drinks from the vending machine. So things to kind of think about. Talking with them about food choices. So this is where kind of being a teachable moment. Talking to them and saying that turkey and ham sandwich may be more satisfying as it has more protein, and the bread may have some whole grains, some fiber that'll also keep you full and help with blood sugar. And then think, okay, maybe they said, no, I don't want that sandwich, I want that pizza. So where could we add in some nutrition? Could they add in a fruit or a veggie on the side? Could they get that side salad or those carrot sticks? And then could they pick a piece of fruit to go with them? Then thinking about talking with them about the sugary drinks. So that scorched drink may make their blood sugar rise more, it may not be helpful for their diabetes management. So maybe encouraging some milk with flavored water may be a better option. And if they could just do water, I could save them some money from the vending machine. It's really important trying to avoid saying foods are good or bad, really approaching it as foods that may be more helpful for their diabetes management and general health. So now I will take your questions in your chat box. I want to thank you very much for listening to my talk and I welcome questions. Thanks so much, Meredith. We do have quite a few questions. I'm sorry? We do have quite a few questions. Great. To your presentation. So I will read through those and appreciate your response. So the first one is, I had a high school student type one who wanted to eat a jar of peanut butter for lunch. This seemed inappropriate to me as the sugar and fat content is high. The student said, that is what insulin is for. What would be your response? Okay. So the one thing would kind of seem, why do they just want to eat the peanut butter? And kind of talking about, okay. Saying, you know what, I'm glad, you know, the peanut butter is going to provide you some protein and fat, which will help you feel full. However, you may want to include some other things that could help with your blood sugar. So could we have an apple with it? Could we have some whole grain crackers with it? And then thinking about that added sugar is kind of looking at, you know, with that, okay. Saying sometimes with added sugar, when there's foods that have more added sugar, added sugar tends to hit our bloodstream and makes our blood sugar spike more. So where could we kind of add in different items? And this is where it can be really hard. And you can say, you're right. Individuals with type one diabetes can eat whatever they want as long as they're giving insulin. However, it doesn't mean that eating these foods are always going to be the most helpful for our blood sugar. So kind of, I usually say, trying to find a middle road with them. And this could be somebody who I would say, trying to build trust and saying, okay, I see that you want to eat the peanut butter. Would you be willing to try to add in something else to make it a little bit more balanced and see what they say? And then just talking with them. Why only peanut butter? One thing that may not come across too is, is it that they just want peanut butter or is that the only thing they have? And so that's what they're choosing to have. So kind of learning a little bit more about why they're just choosing the peanut butter. Another thing actually to note, which we didn't talk about, is higher fat foods can delay, take longer to digest. So sometimes there can be a delay in how blood sugar rises. So kind of talking about them that this large amount of peanut butter could make it harder on figuring out when your blood sugar is going to rise. So may make it more tricky and may require you then to come back to the nursing suite and miss class or may be disruptive. So maybe we'll consider adding something else. Thank you. The next question is, I heard of a mom who is giving insulin for protein as well as the carbs. I'm not familiar with giving insulin for protein. She says her group of mothers of kids with diabetes is doing this. Have you heard of this? I don't have doctor's orders for it. So exactly. If you don't have doctor's orders, then you have to follow the form. That's for your safety too. So I have heard of dosing insulin for protein. It is not a common practice. It is also, there's not this standard equation per se to use it. So a large amounts of protein can have some impact, some rise on blood sugar. It is nowhere near how you see your blood sugar rise with carbohydrate. So some people who follow a low carbohydrate, high protein diet may still need additional insulin, may need some insulin with that. However, like I said, this is not something where there's the standard equation or standard way to figure out that you as a healthcare provider without those proper orders, you can't be dosing for that. So that would be something, if you had a parent that said, well, I want you to, when he eats this protein food, I want you to give an extra unit of insulin. You can say, I can't do that without the proper documentation and the form. And then she could take that to her endocrine or diabetes team, and then they can decide if they think it's appropriate to put that on the form. Next question. Can you go over the slide again about net carbs? Are you saying that we don't use the listed total carbohydrates for determining insulin coverage? Or is it that only products specifically labeled as keto or diabetic? So I would say any, I'm sorry, I'm just trying to get back to it. So any product, so I use the term keto or diabetic because that's where you often see foods listed as net carbs, but anything that says on their package net carbs, I usually tell people check that label. So what it really is is that when you, for fiber, the rule, why fiber especially is half of, you only take half of it is that fiber is thought to be on average, half of it is insoluble and half is soluble. Insoluble, we don't digest, so it doesn't raise our blood sugar, but the soluble can have an impact on our blood sugar. So we still need to account for that. And then sugar, alcohol, some can be utilized or cause a rise in blood sugar. So it's still significantly less than regular sugar, so we usually say take half of that. One thing I usually tell people is take a look and see. If someone says, well, whenever I use this product and I don't take, I use anything other than the net carbs, then I end up dropping low, then maybe they're more sensitive and they can, but I would say I caution because I think when people only use the net carbs, they may see more of a rise in blood glucose. So any product, whether it says keto or diabetic, but it's using the term net carbs, take a look at that back label and take a look at your fiber and sugar amounts and see how they came up with that net carbs. Did they subtract all the fiber and sugar alcohols to come up with that net carb or did they use something like half? Calorie King shows 24.7 carbs for an apple. We were always informed that an apple was approximately 15 carbs in our school. That's a huge difference. How do we know which one to use? That's a great question. So usually it's a small apple is about 15. And no, you're right. It is not exact. The most exact way of, for fruit, and this would be something that families can do at home that it's not usually done at school or expected is weighing to know because apples do vary in size. It is a, what I think is small and what you think is small could greatly vary. So this is where carb counting is not always going to be a hundred percent accurate, but I would say is kind of taking a look at, okay, does this appear, you know, kind of stay consistent. I'm calling this a small apple and I'm saying, I'm going to say that it's 15. And then you can kind of see, okay, every time I do that, they seem to have higher blood sugars. Maybe I'm going to account for it to be 20, but using calorie, so calorie King is nice because it does give you small, medium, large, where you can change the serving size. That one small apple is 15. Also can come from the days of just using the exchange list where a lot of things were all portioned as 15 to make it easier for figuring out carbohydrates consumed versus this more exact grams of carbohydrates. So I would say, try to use that calorie King so that you can kind of gauge is this a small apple, medium or large. How do artificial sweeteners impact blood glucose? Usually artificial sweeteners do not have much impact on blood glucose. Most of them are not absorbed or digested. Some of the sugar substitutes that are plant-based can have a little bit of a rise on blood sugar, but significantly less than sugar. So typically like if something is using like a Splenda, then you'll see that there's no added sugar. And so like for a diet soda, there'll be no carbs. So really there should be minimal impact on blood sugar. You don't carb count, you don't dose insulin for it. So sugar substitutes or artificial sweeteners can be a tool to be used to cut down on carbs or cut down on how you see a blood glucose rise versus using like a regular white sugar, honey, agave, anything like that. Is it important to have the insulin to carbohydrate ratio information if the student is on an insulin pump? So the pump will have all that information listed, but I still think it's important because if something were to happen where the pump fails or they need to take the pump off or for whatever reason, so it's still having all the proper doses is important. So knowing the insulin to carb ratio or also important to note, if your form says that the insulin to carb ratio is one unit for 10, but now their pump is saying one unit to eight, that means that somewhere something needs to be updated. So verifying is always important. So I do think it's still important to have all the doses. And like I said, if for some reason that like, let's say maybe the pump fails and they need to take their pump off and they need an injection, then it's important for you to have the dose information. Okay. Thoughts on a parent who only sends in Smarties for hypoglycemia treatment? I'm okay with that. So in times of hypoglycemia, I think of any of these treatment options, I think of it like medicine. So I tell people you're using this to help, you wanna bring up a blood glucose quick. So if they're less than 70, I want quick, so candy can work really well. So I'm really open to, I want it to be whatever is that they're willing to take that can bring it up quick. However, you can think about certain foods, certain things may make them spike more, rise more than they need to. Some sometimes individuals after they treat a low rebound high. So maybe they choose different food items that bring them quickly up, but not too high, or they think about using different things where they noticed that they could, that juice tends to make them spike quicker than Smarties or makes them spike higher. So maybe they choose to use the Smarties, but really for treating a low blood sugar, I'm okay with any treatment that allows it to happen quickly so that it doesn't become a severe hypoglycemic event. Can you repeat the part about the classroom party, please? I think I heard that if it's sooner than three hours since they had insulin, you only cover the food. Correct. I'm just going back to the slide real quick. So for classroom part or anytime, so your rapid acting insulin lasts about three hours in the body. So usually we say is if it's been less than three hours since their last insulin dose, you would give insulin just for carbohydrates. You wouldn't do a blood sugar correction. So if you did, if you gave that, if you ended up giving them insulin for their blood sugar, that would be stacking insulin because if insulin lasts about three hours in the body, if that means when you check an hour and a half in that blood glucose may not be at its final destination point. So you wouldn't want to give insulin for that blood sugar that may not be at its final point. It might still be going lower. So then you would just be giving insulin for the carbohydrates they consume. I have a parent who doesn't want her son to eat carbs for lunch if his blood sugar is high around 275 or higher. Any advice? So for this, this can be a hard one. I would say if you feel comfortable or you have access, maybe talking with their diabetes care team because it could be something, an education piece for the parent to understand why it's okay to still eat carbs or even talking with them. Okay, what can we do to try to prevent blood triggers from being higher? So being above 250 before lunch, because I think that part can be hard to manage. One thing I would say is that you would, something like that you'd want written down in the form so that you kind of have it that this is what they've wished and this is what's being prescribed. So that would be something where talk, possibly if you can talking with their diabetes team and then seeing maybe the diabetes team can talk with them about that approach. I have an elementary school student who cannot have added sugar as they spike her. What are some options to help with foods that do not have added sugars? Well, my question would be, yes, added sugars will spike you more, but maybe finding ways to enjoy those foods in smaller moderation could be important. However, for foods that have less added sugar, you know, think your fruits. So fruits are sweet, but don't have added sugar. So things like you could use, things like dates are very sweet. So if they're wanting something like a sweet treat, a date may work well. So you could use things like that, milk, and you could use then sugar-free products. So sometimes those kinds of products can be helpful. So if they were wanting, let's say chocolate milk, they would use regular milk and then they could use a sugar-free syrup, which may use like a sugar substitute. So they could try some sugar substitute things. So think products that have been sweetened with things like Stevia. So for example, for juice boxes, there are juice boxes that have no added sugar, but they've used things like monk fruit to sweeten it. So it has no extra added sugar, but it's still a juice box that a kid may enjoy, that they can enjoy like their peers do. So kind of, that's where kind of looking at some of those sugar substitutes as a tool to help that child have things that taste sweet, but aren't having added sugar, especially if the parent is concerned that the added sugar is really making them spike. Couple more, Meredith. Of course. I have a student that is a very inconsistent eater at lunch. She's thankfully on a pump. We tend to dose her for half the carbs at lunch. And when she's done eating more than half, we dose her for the remaining carbs, but not for her blood sugar. The time between the first and second doses is usually 20 minutes or less. Is this correct? So what I would say is, yeah, for those that may do a split dosing, you would, in the beginning, before she starts eating, give her insulin for that blood glucose. So you want to give the correction dose before she starts eating, because if you wait 20 minutes in, that blood sugar is going to be rising, but that's from the food. So you wouldn't want to dose based off of that. So you would dose for the blood sugar and you would dose for the part of the carbs that she's eating, so maybe half of her lunch, and then dose the rest of the carbs at the end. With the pump, the pump will recognize how much insulin is on board and how much you've dosed. So it can make adjustments too. Okay, one last question. How do you approach parents when the student's lunch only has snack items in the lunch, no protein, no fruit, et cetera? So this is where to just kind of finding out, you can always talk to the student, what kind of, do you like fruits and vegetables? So sometimes like when I have patients, I ask them, well, what fruits do you like? And they can kind of list those different items that they may like. And then trying to talk with the parents about, hey, I've noticed that when they eat these foods, their blood sugar really rises. What I've learned is that when you can include things that have some protein and fiber, this can help them with less blood sugar spikes and can help them feel full and satisfied, which may help them focus in class more. And then thinking about things like, oh, your son or daughter said that they like applesauce. What about including an applesauce and maybe thinking about, and I saw that they like sunflower seeds, what about including some sunflower seeds in an applesauce to go with their bag of chips and their cookies? So kind of thinking about, approaching it as, here's what I've learned or I just, I'm hoping to help with blood sugar and then always take into account, if you know their financial stability too. So what are they able to buy? Do they live near places that are, do they have fruits and vegetables? This is where definitely utilizing fruit cups. So peaches, pears, applesauce, ones that are packed in water or have no sugar added, but those can be good ways to add in some fiber that can be less expensive. I would love for everybody to have fresh fruits and veggies, but it can get very expensive and can be hard for families, but things like your fruit cups and stuff may be a little bit more manageable and have a better shelf life where they won't go bad. So just thinking about, approaching it and maybe one thing at a time, but seeing about talking with them and even talking to the student, depending on the age of the student. So if they're a teenager, maybe talking to them a little bit more because then they may feel comfortable too, saying, hey, mom or dad, do you think I could get some cheese sticks to put in my lunch? So those kinds of things. And once more too, sometimes if you feel like there is an education deficit for the family, that could be something too, if you felt comfortable talking with the diabetes team and seeing maybe then the diabetes team could talk to the family too about it. And actually I have one last question if you don't mind, and then we will conclude the program. I don't mind at all. Okay, great. When you say a person with type one diabetes shouldn't be limited on carbs, is it all right for a student to eat a 90 carb lunch? Usually this happens when cake and ice cream is on the lunch menu. So my approach, which could be very different from different people is no, I don't think kids with type one should be restricted. However, I think it's more important to focus on the type of carbs than just the grams of carbs. So when eating, a banana is 30 grams of carbs and a bag of chips is 15. So the banana has more carbs, but it's gonna provide you a lot more nutrition and fiber versus the bag of chips isn't, but is less carbs. Or even take it as far as eating three slices of bacon gives you no carbs versus that banana. However, a bacon has a lot of saturated fat, which is not great for our heart. So it might've been better to eat that banana. Maybe you needed to add a little protein to it. So 90 grams, that's hard to know, is it a lot? What, you know, how active are they? What types of carbohydrates are having? What are they having with it? And when it comes to things like cake and ice cream, I always think about, one thing to think about is, does anybody need a brownie sundae every day? No, no one does. Whether you have diabetes or not, none of us need that. However, I usually say, if everybody else, let's say there's a class party is having a brownie, then I think the kids with diabetes should be able to, we need to figure out how can we manage it? What do we need to do for insulin? How do we best manage those blood sugars? So find it, kind of finding a way that there's moderation with that, but also some inclusion. And kind of figuring out 90 grams could be a lot for some, and it may not be for others. And think 90 grams, is it all the time? Or is this meal happen to be large, but other times they have 30? That's where those that are, you know, using an insulin to carb ratio and correction scale, this allows them to receive different amounts of insulin, depending on what they eat. So they could eat a 30 gram meal, and then the next they could have 90, and figuring out we can calculate the insulin they need for that exact meal. Thanks Meredith, could you close this out? Yep, so the last thing I just want to thank everybody again for attending, especially in the evening, and listening to my presentation. Reminder that you should soon receive an email from the ADA directing you to the evaluation and the post-test. I hope everybody has a great evening, and thank you again for listening.

Diabetes and Nutrition

School Setting

Education and Support

American Diabetes Association

School Nurses

Nutrition Management

Counting Carbohydrates

Insulin Doses

Type 2 Diabetes

Balanced Meals