Diabetes Q&A: Diet, Insulin Types and Pumps, and Continuous Glucose Monitors (CGM)

Dr. Bill Quick's series of diabetes related Q&A continues here with seven more questions.

1.) My doctor has given me the opportunity to use diet management before he prescribes medication to treat my diabetes - I have six weeks to lose 5-10 pounds. What is a good guideline to use for carbs when trying to manage diabetes through diet only?

Traditionally, guidelines for treatment of newly-diagnosed diabetes recommended lifestyle modification as the first step in intervention to reduce blood glucose levels, but guidelines that have been published in the past few years now advise that metformin be started at time of diagnosis or soon afterwards unless there is evidence or risk of kidney disease. If you didn't get an appointment yet to talk to a dietitian, I'd strongly suggest that you (and the cook in the family, if someone else prepares the meals) set an appointment with a diabetes dietitian, preferably one who has earned the credentials "CDE" (Certified Diabetes Educator). BTW, you can't plan to "try" diet management then go off it when you start diabetes medications -- you will need to make a lifetime commitment.

2.) My meter always reads “E-9” whenever I try to use it - is that normal?

Nope. It's an error message. According to a YouTube video from the manufacturer, it means it's time to change the battery.

3.) I use Humalog insulin in my pump - is there something better?

Nope. Although some people think they can spot a difference, all three brands of insulin (Humalog, Novolog, and Apidra) will work equally well.

4.) I am currently using an old [brand and model number deleted] insulin pump, and am in need of a new pump. What is the best one to get next?

Over the years, the FDA has approved numerous insulin pumps. They vary in complexity, size, and features. As you probably know, you can buy them (with a prescription) from several sources including the manufacturers and DMEs (durable medical equipment suppliers). If your insurance will be providing part of the payment, they may have a preference on where you purchase the device (and they will probably demand that your physician write a "Letter of Medical Necessity" to justify your need).

I'd strongly suggest that you discuss with your diabetes nurse educator the pro's and con's of the various pumps that are available before choosing which to get.

And if you are searching the Internet, only read commentaries that are written in the last year or so, as the technology (and hence, people's opinions) are changing rapidly.

5.) What is bolus-insulin?

"Bolus" is a fancy word for a one-time injection. The word is frequently used as

part of a two-part program of insulin administration: the other part of the program is "Basal," and the program is called a "basal-bolus insulin program." Such a program includes an injection of insulin at each meal that contains carb, and a long-lasting insulin that provides round-the-clock insulin coverage. The program attempts to roughly mimic how a non-diabetic person’s pancreas delivers insulin.

Incidentally, an insulin pump delivers boluses of insulin whenever the pumper decides to push a few buttons.

A basal-bolus program can be used by people with either type 1 or type 2 diabetes. Another term for basal-bolus insulin is "MDI" (multiple daily injections).

6.) Where can you buy a Continuous Glucose Monitor (CGM)?

CGM (continuous glucose monitoring) has become a well-accepted, although expensive, component of diabetes care. It's particularly helpful for people on insulin, who risk hypoglycemia or hyperglycemia if there's a mismatch between their insulin dose and food or activity levels. Commercially-available CGM devices consist of an embedded sensor that measures subcutaneous glucose levels (scGLs) (which correlate nicely with blood glucose levels (BGLs)), and a transmitter that sends the scG information wirelessly to a third component, a receiver that displays the information. (See my previous essay about CGM, CGM and Medicare.)

The FDA has approved CGM systems made by Abbott, DexCom, and Medtronic. Currently, only DexCom and Medtronic are selling CGM devices and supplies in the US. You can buy them (with a prescription) from several sources including the manufacturers and DMEs (durable medical equipment suppliers). If your insurance will be providing part of the payment, they may have a preference on where you purchase the device (and they will probably demand that your physician write a "Letter of Medical Necessity" to justify your need).

I'd strongly suggest that you discuss with your diabetes nurse educator the pro's and con's of the various products that are available before choosing which to get. And if you are searching the Internet, only read commentaries that are written in the last year or so, as the technology (and hence, people's opinions) are changing rapidly.

7.) Protein/Carbs/Fats Ratio - A pre-diabetic cookbook lists the protein/carbs/fats ratio at 13-49-37. Is this a good ratio per meal for those with diabetes?

A pre-diabetic cookbook! Wow! What will someone think of to write next? Anyway, I'd think that the concepts of diabetic meal planning would apply just as much to folks with pre-diabetes as to those with diabetes -- emphasis would be on portion control (which translates to weight loss for many folks) and healthy eating, with a mix of foodstuffs that include veggies, fruits, and nutrients such as minerals, vitamins, and all the other good stuff that dietitians encourage everyone to eat.

You asked about the ratio of protein to carbohydrates to fat: obviously, these three nutrients contain calories that your body uses for energy and growth, as well as the bad guys like LDL cholesterol. What percentage of your calories should come from protein vs. carb vs. fat has been hotly argued in the past (and still is!), and I'd strongly suggest that you (and the cook in the family, if someone else prepares the meals) should discuss meal planning with a diabetes dietitian, preferably one who has earned the credentials "CDE" (Certified Diabetes Educator).

As the American Diabetes Association advises, "The right meal plan will help you improve your blood glucose, blood pressure, and cholesterol numbers and also help keep your weight on track. Whether you need to lose weight or stay where you are, your meal plan can help."

In the meantime, especially since you imply that you have diabetes, please review Diabetes Meal Plans and a Healthy Diet at the ADA website.