POSITION STATEMENT AND PRACTICE GUIDELINES - Insulin Dose Adjustments 

The College of Dietitians of Ontario regulates dietitians for public protection. As per the College's Framework for Standards of Professional Practice, this position statement is intended to inform and clarify the College's interpretation of insulin dose adjustments in dietetic practice.

In addition, the practice guidelines provided here are to assist dietitians, their clients, colleagues, and employers with suggested best practices for insulin dose adjustments from a regulatory perspective. The practice guidelines are not intended to replace or be a substitute for clinical practice guidelines.

Position Statement and Practice Guidelines: Scope of Practice – Insulin Dose Adjustments for Registered Dietitians in Ontario


Approved by Council on xx. 
 
It is the position of the College of Dietitians of Ontario that a dietitian with the required knowledge and competence can provide education to clients living with diabetes who are self-adjusting their insulin dosage. However, where the education becomes instructions with specific recommendation to alter the dose of the insulin, that advice amounts to prescribing or modifying a prescription for insulin and requires a delegation from a healthcare professional authorized to perform the controlled act of prescribing (e.g. a physician).

Principles


1. The scope of dietetics practice is defined in the Dietetics Act,1991 as "the assessment of nutrition and nutritional conditions and the treatment and prevention of nutrition-related disorders by nutritional means." Nutritional means may include nutritional therapy and counselling, which includes providing education to a client who is adjusting their insulin dosage for previously prescribed insulin. Providing education to clients to adjust their insulin dosage for insulin that has already been prescribed is within the scope of practice of dietitians in Ontario. However, there is a distinction between providing education and prescribing. Providing the client with specific instructions about dosage modifications is considered prescribing. Dietitians can give client-specific dose adjustments instructions under delegation, which is conferred by an order - either through a direct order (written or verbal) or via a medical directive.

2. Dietitians must be competent to provide education to a client adjusting their insulin dose safely and effectively. In addition, they must comply with the College of Dietitians of Ontario Standards of Practice, the Code of Ethics, current evidence-informed clinical practice guidelines, and, if applicable, employer policies. The Position Statement: Scope of Practice – Insulin Dose Adjustments for Registered Dietitians in Ontario should not be read or applied on its own; this document should be considered together with relevant legislation, the Code of Ethics and other College Standards and Guidelines.

3. A dietitian's role in insulin dose adjustments is defined by the needs of the client, the interprofessional resources, and the healthcare settings in which the dietetic services are provided.

4. While providing education on insulin adjustments and management of blood glucose, dietitians have the same professional responsibilities as in other areas of practice: to provide safe, competent, and ethical care. This includes identifying the boundary between general client education and the controlled act of prescribing insulin for a client.

Purpose

 
The purpose of this position statement and practice guidelines are to clarify:

1. The scope of practice of dietitians in Ontario who care for clients with diabetes requiring insulin adjustments;

2. The difference between providing self-management education and prescribing;

3. The College's expectations regarding managing risks and identifying and implementing the best protective solutions for safe, client-centred services when dietitians provide education to adjust insulin doses; and

4. The full role of a dietitian within the interprofessional diabetes care team.

practice guidelines: iNSULIN DOSE ADJUSTMENTS FOR REGISTERED DIETITIANS IN ONTARIO

 

Background - Risk Management

Identifying and addressing the areas of high-risk dietetic practice is essential to help the College fulfill its public protection mandate by developing resources and standards for dietitians to practise safely, ethically, and competently in their changing practice environments. Adjusting insulin was identified as a high-risk activity in the College's Risk Research.
 
Risk management is the analysis and control of risks. It is a systematic approach to recognizing the likelihood of risk (how often; the probability of adverse outcomes); analyzing the impact of the potential harm (how bad; the severity of adverse outcomes) to the client, and implementing strategies and processes informed by data to identify and respond to circumstances that put clients at risk of harm. A Framework for Managing Risk in Dietetic Practice is available to guide members.

i. What are Insulin Dose Adjustments?

 Clients with diabetes who require insulin to manage their blood sugar levels are typically prescribed an injectable insulin regimen by their primary care provider or medical specialist (e.g. family physician, nurse practitioner, or endocrinologist). Providing self-management education to clients on how to best adjust their insulin doses adjustments by dietitians involves guiding a client to altering the pre-established insulin dose(s) in response to a range of blood glucose readings as it relates to the assessment of a client's food and beverage intake, physical activity, and other health factors to normalize glycemia.2

ii. Insulin is a Schedule II Drug

 Health Canada determines whether a drug requires a prescription for sale in Canada. If a drug has been given a non-prescription status by Health Canada, it is up to the provinces and territories to determine the appropriate conditions of sale for that drug. Ontario has adopted the National Association of Pharmacy Regulatory Authorities (NAPRA) National Drug Schedule, which determines where drugs may be sold.[1][2]
 
Under NAPRA, insulin is classified as a Schedule II drug, which does not require a prescription. While insulin does not require a prescription, it is still often prescribed. Schedule II drugs are only available from a pharmacist and must be retained within an area of the pharmacy where there is no public access and no opportunity for client self-selection (often termed 'behind the 'counter'). A pharmacist must conduct a client assessment prior to the sale of insulin to ensure that the drug is safe and appropriate for the client[3].
 
If insulin is prescribed, it is prescribed by someone who is authorized to perform the controlled act of prescribing a drug. Dietitians in Ontario are not authorized, absent delegation, to prescribe a drug. However, as a Schedule II drug, insulin doses can be self-determined.
 
While healthcare providers play an essential role in delivering self-management education, clients are primarily responsible for their diabetes management. Improvements in glycated hemoglobin (A1C), blood glucose and quality of life, as well as a decreased requirement for insulin, can be achieved when individuals with Type 1 or Type 2 diabetes receive education on matching insulin to the carbohydrate content of meals and snacks and to interpret their blood glucose levels to make appropriate insulin dose changes. The controlled act of prescribing is a higher-risk procedure, and no one, including dietitians, is permitted to perform them without legal authority.

What is a delegation?

As noted in the Standard for Dietitians Practising Through Delegation of Controlled Acts, if a procedure involves controlled acts that are not authorized for dietitians, then the Regulated Health Professions Act, 1991 generally permits delegations to transfer the authority to dietitians to perform a controlled act in some situations. Delegation is not specifically defined in the RHPA, but it is described as a process whereby a regulated health professional who is authorized to perform a controlled act confers the authority to someone (regulated or unregulated) who is not authorized to perform a controlled act.

How is a delegation conferred?

For dietitians, delegations may be conferred by an order – direct order or directive.

Orders
An order is a direction from a regulated health professional with legislative ordering authority that permits the performance of the direction by another healthcare provider. Orders can apply to controlled acts where a dietitian is authorized to perform only with an order. There are two types of orders:

1. Direct Order
A direct order provides instructions for an intervention or treatment to be delivered at a specific time and relates to only one client/patient. Direct orders may be oral (e.g. over the telephone, via videoconferencing, or in person) or written.
2. Directives
Directives (also called medical directives) are written orders by an authorized health care professional (often more than one) to other health care professionals that pertain to any client/patient who meets the criteria set out in the directive.
 
More information on delegations can be found in Practising Through Delegation of Controlled Acts.

Practice Guideline: Providing Education on Insulin Dose Adjustments and the Dietetic Scope of Practice

 
The dietetic scope of practice statement in Section 3 of the Dietetics Act, 1991 states:
 
The practise of dietetics is the assessment of nutrition and nutritional conditions and the treatment and prevention of nutrition-related disorders by nutritional means.
 
The College of Dietitians of Ontario defines dietetic practice as including activities for which dietitians use their food and nutrition-specific knowledge, skill and judgment while engaging in:

  • The assessment of nutrition-related to health status and conditions for individuals and populations;

  • The management and delivery of nutrition therapy to treat disease;

  • The management of food services systems; building the capacity of individuals and populations to promote, maintain or restore health and prevent disease through nutrition and related means;

  • and the management, education or leadership that contributes to the enhancement and quality of dietetic and health services.

For greater clarity, the dietetic practice includes the following activities:

As a component of diabetes care, in the context of a complete assessment of nutrition and related health needs, dietitians may provide education to clients to self-adjust insulin, assess the carbohydrate content of food and beverage intake, and work with clients to adjust the amounts consumed to achieve the client's blood glucose goals. Physical activity, lifestyle, health, and wellness factors are also considered when adjusting insulin doses.[4] Dietitians must adhere to provider/organization policies and comply with the College of Dietitians of Ontario Standards of Practice. 

i. Impact on Nutritional Status
Diabetes Canada Clinical Practice Guidelines Expert Committee (2020) states that "people with diabetes should receive nutrition counselling by a registered dietitian. " In addition, nutrition therapy can reduce glycated hemoglobin (A1C) by 1.0% to 2.0%. When used with other components of diabetes care (including education on how to adjust insulin), it can further improve clinical and metabolic outcomes.[5]

Clarifying education versus prescribing

Insulin dose adjustments are recommended as part of diabetes self-management. It has been shown to improve quality of life and diabetes control by empowering clients to make informed choices.1  Most often, self-management education is provided by dietitians in a diabetes-focused setting. Care should be provided in the timeliest manner by the most appropriate professional in the best setting for any given client. The dietitian is often suited to provide care based on the client's needs with diabetes.

Dietitians with the competence to provide the education to adjust insulin dosages and timing may teach clients to self-adjust; if self-management is indicated based on the dietitian's assessment, and whether the physician/initial prescriber has recommended self-management to the client, along with any instructions or advice given by the prescriber regarding self-management. In addition, the dietitian must consider if the client has the ability and interest to self-manage. Overall, dietitians aim to provide collaborative care with the client, their caregivers and healthcare providers, ensuring they receive informed client consent for self-management education.

It is broadly accepted that providing general education to clients about diabetes and its management, including self-management, is not a controlled act. This would include education on the nature and causes of diabetes, how activities such as eating, exercise and administering insulin affect the disease and the consequences of improper management. In addition, this education can include indicators of when insulin dosages should be adjusted.

When does a dietitian need delegation? 

Even where activity is within the scope of dietetics practice, dietitians still require an authority to perform a controlled act.
 
Prescribing or dispensing a drug is a controlled act not generally authorized by dietitians. Thus, dietitians prescribing drugs would have to obtain authorization, usually 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., for an identified client) or general (e.g. can pertain to any client who meets the criteria set out in a medical directive). More information on delegations can be found in Practising Through Delegation of Controlled Acts.

How specific can educational guidance be before it becomes the task of prescribing?

It may be best to consider adjusting insulin dosages as a spectrum (See Figure 1 – Adjusting Insulin Doses below). For example, providing generic education about diabetes and how insulin works would be at the lowest end of the spectrum. While giving specific dosage instructions to an individual client within a particular situation would be at the upper end of the spectrum. The middle of the range would include statements by a dietitian about generic indicators of when a client should consider adjusting dosages when an authorized prescriber has instructed clients to modify their dosages.

For example, the middle (but moving towards the upper end of the spectrum) would include more specific education but not an outright, specific, individualized direction (e.g. "Given that x, y, and z are present, generally the dose of insulin is increased by an appropriate amount unless there are reasons that you have not mentioned to me."). This would include providing self-management education and making recommendations without specifically telling a client to adjust their dose. The upper end of the spectrum would include specific, individualized direction (e.g. "Increase your insulin by two units to get your fasting blood sugar between 5-7 mmol/L.").

Providing the client-specific instructions about dosage modifications is considered prescribing, regardless of how the dose adjustment occurs (e.g. via changes in pump settings or via sick day management calculations, or percentage of the total daily dose, etc.). Dietitians can give client-specific dose adjustment instructions under delegation, which is conferred by an order - either through a direct order (written or verbal) or via a medical directive. Please see the Standard Practising Through Delegation of Controlled Acts for the minimum expectations when practising under a delegation.  

When in doubt about whether advice constitutes educating or prescribing, making any recommendations for dose adjustments under delegation would be prudent. 

Practice Guideline: Competent dietitians must be confident in their ability to practise competently at every phase of the practice, whether at entry or in highly developed areas of practice

 

Dietitians must assess whether they have the required knowledge, skills, and competence to provide education on insulin dose adjustments safely and effectively. This may include assessing their academic and practical experience, consulting with others, seeking supervision or mentorship, and reviewing research literature.

Dietitians are encouraged to develop their expertise and increase their knowledge and skills in providing education for insulin dose adjustments through cross-training with and mentorship from other dietitians and health care providers; attending workshops, conferences, seminars, and courses; learning from day-to-day work on diabetes care teams; and/or completing formal training (e.g. Certified Diabetes Educator (CDE®)  Certification, Intensive Insulin Management Course, etc.).

Dietitians are trained to perform in a manner consistent with generally accepted standards in the profession. Dietitians anticipate the outcomes in each situation and respond appropriately. However, dietitians may also be faced with unusual, difficult-to-resolve and complex situations which may be beyond their capacity. In these circumstances, dietitians take appropriate and ethical steps to address these situations, which may include seeking consultation, supervision, or mentorship, reviewing research literature, and/or making a referral to the appropriate health care professional. 

Practice Guideline: The Registered Dietitian's role is defined by clients' needs and context

A Registered Dietitian has an important role in diabetes management. This role is defined by the needs of their clients, the interprofessional resources and the healthcare setting in which dietetic services are provided.

Clients' Needs, Interprofessional Resources and Healthcare Settings

 

Clients' Needs

Dietitians are expected to provide client-centred, evidence-based, interprofessional, safe, competent, and ethical services. A dietitian's role is defined by facilitating client-centred service and informed decision-making based on client needs and goals. When clients understand the options presented, they engage and share their own perspectives and values when making decisions. A dietitian is uniquely trained to consider all client factors in the assessment of their nutritional status and determination of their insulin dose adjustment.
 
Dietitians should ensure that they obtain informed consent when initiating an intervention, including describing the reason, nature and prospects of any proposed treatment, who will be providing the treatment, its expected benefits, its material effects, risks and side-effects of the treatment, alternatives to the treatment and the consequences of not having the treatment, including the right to refuse or withdraw consent at any time as per the Professional Practice Standard Consent to Treatment.

Interprofessional Resources and Overlapping Scopes of Practice

The Regulated Health Professions Act, 1991 recognizes overlapping scopes of practise for health professions. Insulin dose adjustment is an example where overlap occurs. In particular, the scopes of practice of physicians, nurse practitioners, nurses, and pharmacists concerning insulin dose adjustment are recognized and valued, providing for some role overlap, shared skills, and complementary roles. The individual expertise within healthcare teams and institutional policies typically contribute to decisions regarding role delineation and the scope of practice exercised by professionals in each practice setting.
 
The College recognizes that other professionals have an overlapping scope of practice and knowledge in insulin dose adjustments. When multiple professionals are readily accessible, dietitians must work collaboratively in the interest of client-centred services. Collaboration ensures that each healthcare provider provides unique and valuable contributions based on their knowledge and training.
 
In addition to the unique skills and perspectives each professional brings, team members may share similar knowledge and skills. For example, dietitians may have expertise in food composition and insulin dose adjustment yet recognize that other disciplines have overlapping scopes of practice. Communication and collaboration enable an interprofessional team to recognize and best utilize overlapping scopes of practice so that clients receive optimal care in a timely manner.
 
Team members learn from and with each other to practise in the interest of client-centred care. This often involves distributing the tasks associated with client care in the way that best serves the client's needs. Considerations may include clinical appropriateness (what is the most appropriate course of treatment for the client); safety (which providers have the appropriate knowledge, skills, and judgement to perform activities and how best to ensure seamless transition and communication between the members of the team); and efficiency (which provider is best positioned to perform the activity in a timely manner and effectively). As such, insulin dose adjustments should always be made in collaboration with the client and the interprofessional healthcare team.
 
In the interest of public safety and the provision of safe, competent services, the College encourages members to assess personal practice ability and communicate with and establish their role in practice, on the interprofessional team before adopting any new practices. When taking on new tasks, dietitians should also check that their professional liability insurance provides coverage. Dietitians can be guided by the Role and Task Decision Framework when facing new tasks and roles in practice. 

Healthcare Settings and Delegations  

In places where health care is provided, a lack of optimal resources, such as access to an interprofessional team, may exist. This may result in a disparity in the availability of healthcare professionals in specific settings. In rural areas, access issues may be further exacerbated. Access to a dietitian or other healthcare provider who may advise on insulin dose adjustments may require that the client waits for assessment and treatment. This may compromise the client's nutrition and health status. Where there is no access or significantly limited access to an interprofessional team, it is in the client's best interests that the professional or professionals available on-site be trained to work to their full and authorized scope of practice. It may be that dietitians and their employers determine that it is in the best interest of clients for dietitians to increase their knowledge and skills to play a central role in the assessment and management of insulin dose adjustments.
 
The diabetes care setting and presence or absence of other skilled professionals working in this area may impact a dietitian's educational strategy and/or educational content. Dietitians must have the appropriate workplace support. Employers have the right to determine whether a given role is or is not within the dietitian's job description. Members of the interprofessional team often support dietitians' working to the full scope and may assist and promote the dietitian's role in client-centred care.
 
The healthcare setting, the availability of other team members and clinical complexity will determine how dietitians will collaborate with other healthcare providers. Notwithstanding the importance of the professional care team, understanding the integral nature of client and family as active participants across the spectrum of care adds an essential dimension to the continuum of care in diabetes assessment and management.
 
The development of collaborative policies and processes to provide safe, timely and effective care is critical. When dietitians are working alone, or with limited access to other healthcare providers, they should develop collaborative and communication strategies to provide safe diabetes-related care. The practice environment, the client's needs, and the dietitian's knowledge and skills will define the dietitian's role. 

Managing Risk and Quality Assurance  

Dietitians are legally responsible (liable) for their actions and omissions. They must acknowledge and recognize where there is increased risk in their practice. Insulin dose adjustments have inherent risks for both the client and the dietitian. While it is not possible to eliminate all risks in dietetics, dietitians have to protect clients from harm as much as possible. If a dietitian identifies risk in their practice, dietitians can apply a framework for managing risk in practice based on principles of public protection, including safety, client-centred services, communication, accountability and compliance with professional and regulatory obligations.
 
To promote appropriate treatment, dietitians can apply protective factors such as client monitoring and collaborating with other healthcare providers to monitor the accuracy of their insulin dose adjustments. This includes working collaboratively with sufficient interdisciplinary support, supervision, and healthcare provider involvement where necessary in the client's best interest. As per the Standard Practising Through the Delegation of Controlled Acts, dietitians inform the delegating healthcare provider of any adverse event(s) and actions taken by the dietitian to manage the adverse event(s). Providing education on insulin dose adjustment cannot be done without considering risk management strategies for safe, ethical client-centred care.
 


Insulin Dose Adjustment – Frequently Asked Questions


Some content has been adapted from the College of Dietitians of British Columbia.
 
1. Why is this position statement required now? This seems like what we've always been doing.
In the past, dietitians have contacted the Practice Advisory Service to clarify if a delegation would be required to adjust insulin. Given some ambiguity as to whether providing specified dose advice to an individual client in a specific situation constitutes the controlled act of prescribing, the College was reluctant to give definitive guidance until the matter could be clarified. The College did not have a position on this topic and, in the meantime, advised dietitians that it would be prudent to obtain delegation before giving a client advice that could be seen as prescribing. 

Therefore, many dietitians may note that this is how they have been practising all along. The College completed a thorough policy analysis to confirm this position statement and provide these practice guidelines, including environmental scans of Ontario health profession regulators and Canadian dietetic regulators, a focus group with dietitians practising in diabetes and performing insulin dose adjustments and several consultations with colleges most affected by this position, legal counsel, registrant, and system partner consultations. While it may seem we have come full circle, this policy work has allowed the College to provide more definitive guidance on this topic.
 
2. Are Dietitians allowed to initiate an insulin order?
No, dietitians cannot initiate an insulin order without a delegation conferred by a medical directive or direct order. Initiation of an insulin order is equivalent to prescribing insulin. Dietitians are not authorized to prescribe.
 
3. Can dietitians tell clients to increase/decrease their insulin dose?
Providing self-management education where a client is largely responsible for adjusting their own insulin doses can involve education on 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 2 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. More information on delegations can be found in Practising Through Delegation of Controlled Acts.
 
4. My client has experienced low blood sugars over several days. Unfortunately, I do not have a delegation currently. What am I able to do?
A dietitian may provide specific self-management education (e.g. "Given low blood sugars, generally the dosage of insulin is decreased by an appropriate amount unless there are other reasons that you have not mentioned to me)." In the absence of a delegation, dietitians may consider applying the principles of blood glucose pattern management with clients for self-management responses to high or low blood glucose readings. In addition, may consider referring clients to a healthcare provider who is able to assist the client, working collaboratively with their clients, colleagues, and employers to ensure the client receives the care they need. 

In the absence of delegation, dietitians may consider working with employers and colleagues to obtain a delegation conferred by direct order or medical directive.  If providing more specific, individualized direction (dose adjustments) (e.g. "Decrease your insulin by 4 units to get your fasting blood sugar between X-Y mmol/L.”) the advisement is that this should be performed under delegation, which is conferred by an order - either through a direct order (written or verbal) or via medical directive.

When in doubt about whether advice constitutes education or prescribing, making any recommendations for dose adjustments under delegation would be prudent. Please see the Standard Practising Through Delegation of Controlled Acts for the minimum expectations when practising under a delegation.  When providing education, a dietitian should collaborate and communicate with the client's care provider and any other relevant members of the care team and keep records in an organized and systematic way that supports collaborative practice and compliance with applicable legislation.
 
5. As an insulin pump trainer, prior to training a client, the referring physician orders insulin and insulin pump teaching for the client. I then train the client to use the insulin pump. Am I working within the dietetic scope of practice?
Yes. Providing education on how to dose adjust with an insulin pump is within the dietitian scope of practice, regardless of the mechanism used to administer the insulin dose if the dose is self-administered by the client. If the dietitian provides specific, individualized dose adjustments as described above, this should be completed under delegation.
 
6. Can I administer insulin to my clients?
No, dietitians cannot administer insulin in any setting. Administering a substance by injection is a controlled act in Ontario, and dietitians are not authorized to perform this task under the profession's scope of practice. Exception: dietitians may perform a controlled act under a delegation of the controlled act. Another exception permits assisting a person with their routine activities of living (e.g. assisting a client with administering an injection). See Standard for Dietitians Practising through Delegation of Controlled Acts.
 
7. Am I allowed to provide my clients with free insulin samples?
No, dietitians cannot dispense insulin samples to clients in any setting. Dispensing drugs, including Schedule II drugs such as insulin, is a controlled act in Ontario, and dietitians are not authorized to perform this task under the profession's scope of practice absent delegation. 
 
8. I am a Certified Diabetes Educator (CDE®) who has completed competencies in insulin dose adjustments and received training in insulin pumps, insertion of pump devices and continuous glucose monitoring. Am I able to insert a soft flexible cannula for insulin injection into a client with diabetes?
No, dietitians cannot perform a procedure below the dermis, such as insertion of cannulas and insulin injections. This type of procedure is a controlled act and is not currently part of the dietetic scope of practice, absent delegation. Note: finger pricks for the purposes of monitoring capillary blood glucose are a controlled act in Ontario which dietitians are authorized to perform under the profession's scope of practice (See Collecting Capillary Blood Samples through Skin Pricking & Monitoring the Blood Readings (Point of Care Testing)).
 
9. In my new role as a community outpatient dietitian, I am working with a large population of individuals with diabetes. The dietitian who was previously in this role had her Certified Diabetes Educator (CDE®) certification, however, I do not. What is my scope regarding insulin adjustments?
There is no regulatory requirement for specific certifications currently, but dietitians are reminded that they must possess the individual knowledge, skill, and judgment (competence) to provide education and accept a delegation for insulin dose adjustments.  If a dietitian does not feel confident and safe to provide education on insulin dose adjustments, they should collaborate with their employer, inform the client, and refer them to a health professional who can help them. An employer may require the CDE® certification to adjust insulin. Dietitians should consider developing the required knowledge and skills to best meet client needs for the delivery of safe, competent, and ethical dietetic services. Dietitians are encouraged to develop their knowledge, skill, and judgment in a variety of ways, which may include certifications and practice experience hours.

10. I am a Certified Diabetes Educator (CDE®) and a dietitian. Do I need a delegation to adjust insulin?
Yes, if the education provided to the client becomes instructions of a specific recommendation to alter the dose of the insulin. In this case, that advice amounts to prescribing or modifying a prescription for insulin and will require a delegation from a healthcare professional authorized to perform the controlled act of prescribing. The delegation can be conferred 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.  

Acknowledgements: This Position Statement has been adapted from the College of Dietitians of Alberta, Position Statement: Position Statement: Insulin Dose Adjustment and Diabetes Self-Management Education, The College of Dietitians of British Columbia, Position Statement: Dietitians' Scope of Practice for Insulin Dose Adjustment (2017), and from the College of Dietitians of Manitoba Practice Direction 16.19 Diabetes Self-Management Education by RDs (2018).


[1] Ontario College of Pharmacists. (2015). Pharmacy Connection – Keeping Current with Drug Schedule Changes. Retrieved from: http://www.ocpinfo.com/library/practice-related/download/napraschedulingsummer2015.pdf
[2]National Association of Pharmacy Regulatory Authorities. National Drug Schedules. Available from: http://napra.ca/national-drug-schedules
[3] National Association of Pharmacy Regulatory Authorities. (2005). Supplemental Standards of Practice for Schedule II and III drugs. Retrieved from https://napra.ca/sites/default/files/documents/SupplementalStandardsofPracticeIIandIII-June2005_0.pdf
[4] College of Dietitians of Alberta (2020). Position Statement: Insulin Dose Adjustment and Diabetes Self-Management Education. Retrieved from https://collegeofdietitians.ab.ca/wp-content/uploads/2020/12/Insulin-Dose-Adjustment-Position-Statement-2020.pdf
[5] Diabetes Canada Clinical Practice Guidelines Expert Committee (2018). Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2018;42(Suppl 1): S1-S325. Sievenpiper, J.L., Chan, C.B., Dworatzek, P.D., Freeze, C., & Williams, S.L. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Nutrition Therapy. Can J Diabetes 2018;42 (Suppl 1):S64-S79.