Webinar on Insulin Dose Adjustments for Dietitians

Posted: June 1, 2022

Publié le 1 June 2022

A summary of the Reg Talks on Insulin Dose Adjustments. 

The College's Practice Advisory Service held two one-hour regulatory ("Reg Talks") webinars explaining the Position and Practice Guidelines. Thank you to all the participants who joined us for the sessions! Overall, 270 dietitians participated.

During the session, we discussed:
  • Regulatory and professional obligations when practicing through delegation of controlled acts
  • The Position Statement (College's interpretation of insulin dose adjustments in dietetic practice) and practice Guidelines (Practice guidelines to assist dietitians, their clients, colleagues, and employers with suggested best practices for insulin dose adjustments from a regulatory perspective)
  • Practice scenarios informed by your calls and emails to the Practice Advisory Service

Summary of FAQs

1. Could you please clarify if a delegation is required if you are a dietitian with a Certified Diabetes Educator (CDE®) certification?
A certified diabetes educator (CDE) certification is additional training that adds to a dietitian's knowledge and skill to practice with clients living with diabetes. Some employers may require it, so the answer is - it depends. It depends primarily on whether a dietitian provides instructions/recommendations to alter the insulin dose. If this is the case, then modifying the units or frequency of insulin amounts to prescribing or modifying a prescription for insulin. This would require a delegation from a healthcare professional authorized to perform the controlled act of prescribing, commonly a physician. The delegation can be conferred to the dietitian via direct order or medical directive. Please see the Standard Practising Through Delegation of Controlled Acts for the minimum expectations when practising under a delegation. 

Providing self-management education where a client is mainly responsible for adjusting their insulin doses can involve education. This education includes information about the nature and causes of diabetes, how activities such as eating, exercise and administering insulin affect the disease, the consequences of improper management, and indicators of when insulin dosages should be adjusted. However, telling a client to increase/decrease a unit dose specifically (e.g., "My suggestion is that you increase your insulin two units to get to a blood sugar of 5-7 mmol/L.”) would be considered prescribing. If a dietitian is adjusting insulin doses, thus performing the controlled act of prescribing, they must do so under a delegation of the controlled act, conferred by direct order or medical directive – this is the case regardless of CDE certification.

2. Does our authority to perform capillary skin pricks include helping clients with the application of continuous glucose monitoring devices (e.g. Freestyle Libre)? In the course of engaging in the practice of dietetics, a member is authorized, subject to the terms, conditions and limitations imposed on their certificate of registration, to take blood samples by skin pricking for the purpose of monitoring capillary blood readings (Dietetics Act, 2009, c. 26, s. 7​). As continuous glucose monitoring devices/flash glucose monitors are newer technologies, we would advise dietitians to consult with their organization's risk management/legal department for further guidance. For example, dietitians could inquire if the situation described would fall under the controlled act of performing a procedure on tissue below the dermis. Dietitians could also ask if the situation would be considered assisting a person with their routine activities of living (if so, this is also provided a dietitian has the competence to assist a client).

If it is deemed a controlled act by your organization, dietitians could obtain a delegation conferred by direct order or medical directive. Please see the Standard Practising Through Delegation of Controlled Acts for the minimum expectations when practising under a delegation. If a dietitian is teaching a client how to insert their own device and is not inserting the device into the client or assisting with the insertion, this would be teaching, which is not considered a controlled act.

3. Does this Position and Practice Guideline apply to non-insulin injectables (e.g., Semaglutide/Ozempic)?
The Position Statement and Practice Guidelines apply to insulin. However, dietitians can use the same concepts for other medications. Dietitians should consult the National Association of Pharmacy Regulatory Authorities (NAPRA) database to determine if the product is listed under one of the NAPRA drug schedules. In the case of Semaglutide, it is a Schedule I drug. Under NAPRA, schedule I drugs require a prescription for sale, whereas unscheduled drugs can be sold without professional supervision from any retail outlet. 

The Regulated Health Professions Act, 1991 (RHPA), Section 27, states that no person may perform a controlled act while providing health care services unless authorized by a health profession Act or have a delegation to do so. This law states that the following is a controlled act (paragraph 8), "Prescribing, dispensing, selling or compounding a drug as defined in the Drug and Pharmacies Regulation Act, or supervising the part of a pharmacy where such drugs are kept." Prescribing, in the context of Controlled Act 8, refers to orders (oral or written), which authorize the dispensing of a drug that requires a prescription. Even if a drug (i.e., Schedule II or III) does not require a prescription, it may still be prescribed. For example, a pharmacist must conduct a client assessment before selling Schedule II drugs to ensure that the drug is safe and appropriate for the client. This action is not currently within the dietetic scope of practice.

Therefore, if this is a scheduled drug, and a dietitian is providing a specific recommendation, the College advises dietitians to obtain authorization in the form of a delegation from a practitioner who is authorized to perform the activity (e.g., a physician). A delegation can be specific (i.e., direct order for an identified client) or general (e.g., a medical directive which can pertain to any client who meets the criteria set out in the medical directive). More information on delegations can be found in Standard Practising Through Delegation of Controlled Acts.
4. Should a specific instruction/recommendation such as changing the timing of insulin be done under delegation (even if the dose remains the same?) For example: In the case of a client who is doing shift work - if a client is taking 20 units of Lantus qHS, could we recommend they take it in qAM instead? 
Is a dietitian is providing instructions/recommendations to alter the dose or frequency of the insulin? If so, the College would advise dietitians to do so under delegation. In this example, the prescription frequency is being modified (from q HS to q AM). Modifying the dose or frequency amounts to prescribing or modifying a prescription for insulin would require a delegation from a healthcare professional authorized to perform the controlled act of prescribing. The delegation can be conferred to the dietitian via direct order or medical directive. Please see the Standard Practising Through Delegation of Controlled Acts for the minimum expectations when practising under a delegation. 

5. Can a dietitian remind patients of how they are supposed to be taking their insulin?  For example, if the client has received instructions by the physician to increase their insulin dose if their fasting blood glucose is above 7 mmol/L and the client tells you their blood sugar is regularly above 7 mmol/L, can you advise them that they should be following the physician's instructions? 
Dietitians may provide clients with general education, such as clarifying or reinforcing self-management education that other healthcare providers have provided.

6. Can dietitians provide education on insulin starts? This refers to educating/teaching a client and not administering insulin. 
Yes, dietitians may provide clients with general education, such as teaching a client who is starting an insulin regimen (e.g., benefits, insulin injection techniques, hypoglycemia management, daily management such as self-monitoring blood glucose, blood glucose targets, reinforcing when and how much to take as previously prescribed etc.). However,

7. Can a dietitian recommend insulin dose adjustments to the client's physician?  
Dietitians should collaborate with other healthcare providers, working in the client's best interest and providing client-centred services. In this case, is the dietitian requesting a delegation (direct order) to adjust the client's insulin? Or is the dietitian providing a suggestion which may inform/contribute to decision-making exercised by another healthcare provider (i.e., the physician determines that it is clinically appropriate and prescribes the drug)? Nothing would prevent a dietitian from collaborating with other healthcare professionals, and providing information based on the client's nutrition assessment. Collaborating and sharing in decision-making with the client and their healthcare providers is within a dietitian's scope of practice. Please refer to the section "Interprofessional Resources and Overlapping Scopes of Practice" in the Position Statement and Practice Guidelines.

8. Sick day management instructions are provided in the Diabetes Canada Practice Guidelines, including specific directions to stop medications. Would this be considered providing a specific dose instruction which should be done under delegation?  
Providing clients with general instructions such as increasing the frequency of self-blood glucose monitoring and that adjustment to their medications/insulin may be necessary during periods of illness is not a controlled act. Providing a specific dose adjustment, including modifying the dose (i.e., decrease 2 units) or frequency (i.e., stop taking your insulin) is considered prescribing and client-specific adjustments should be given under delegation conferred by direct order or medical directive.

9. Can a dietitian in private practice with a CDE get a delegation (direct order or medical directive) from another healthcare provider to adjust insulin? 
Dietitians should be aware of the minimum level of performance expectations when practising through the delegation of controlled acts. Practice setting is not a factor that eliminates the need for a delegation; however, dietitians should be aware of accountability, quality assurance and delegation processes in their practice setting. For example, a dietitian should be aware of establishing a shared understanding of the roles and responsibilities for coordinating the delivery of optimal care to enable respect, trust, and shared decision-making. In addition, ensuring processes for ongoing communication, monitoring and evaluating the act being performed. Please see the Standard Practising Through Delegation of Controlled Acts for complete details.

10. If I receive a direct order verbally for a delegation of a controlled act, what is the expectation for documentation?  Dietitians should implement the documentation method that makes practical sense for their practice setting and, as applicable, to ensure they are meeting the College's Professional Practice Standards for Record Keeping (i.e. the minimum expectations dietitians must meet). See Standard 3 for complete details.

When practising through a delegation of a controlled act:
  • Follow organizational policies regarding documentation
  • If the authorizing health care provider was required to document the intervention, then document in the same way
  • If you are unclear – ask your organization

Any questions?
Please contact