Wil Dubois

Happy Saturday, DiabetesMine Friends!

With this being our first weekend here at our new Healthline home, we wanted to make sure you knew about our frank and fun diabetes advice column called Ask D'Mine. It's hosted weekly by the esteemed Wil Dubois, who's not only living with type 1 diabetes himself but also a well-established diabetes author and educator at a community clinic in New Mexico. Wil's been at this for a while; he just penned his 200th anniversary column reflecting on highlights dating back to early 2011.

This is a place to send all your lifestyle queries, quirky or potentially embarrassing questions, behindAsk D'Mine-the-scenes curiosities, or even ethical dilemmas related to life with diabetes. Don’t know who else to ask? Ask D’Mine!

Be sure to keep in mind of course that we don't offer any official medical advice here. We aren't doctors and have no pretense of replacing your healthcare professionals (see the standard disclaimer at the end of each Saturday's column, below). But we have a lot to offer on the lifestyle front as seasoned fellow PWDs (people with diabetes).

With that, let's dig into this week's topic...

{Got your own questions? Email us at AskDMine@diabetesmine.com}

Ernie, type 2 from California, writes: I have always counted carbs and I am a type 2 diabetic and on an insulin pump. A friend of mine just started on the pump and the doctor said to use the same amount of insulin at each meal, which is 8 units. After doing this and not counting carbs, her A1C went from 13 to 7. Is this possible, if you aren't eating the same things every day?

Wil@Ask D’Mine answers: My mother’s VCR blinked “12:00” for twenty years because she never programed in the time. But that didn’t stop her from watching movies from Blockbuster Video, which was all she used the machine for. Was she using it “right"?

Well, no, not exactly. At least not to its fullest potential. But it served her purpose, and that’s the key. Using something correctly for you is more important than using it “right.” Actually, I hate the notion of using equipment right, as our gear should serve us, not the other way around.

Waaaaaaaay back before diabetes, I worked in the photo lab biz. The first time I saw the massive digital imaging software program called Photoshop I was overwhelmed by it, so I picked up an instruction book. It was 12 DVDs. I fell into a deep depression and began drinking and swearing a lot.

Oh. Wait. I did that before Photoshop, too.

Anyway, I was bemoaning the difficulty of learning the software to a colleague and he told me, “You don’t have to learn Photoshop, you just need to learn to use the part you need.”Medtronic Time Setting Midnight

In other words, there's nothing wrong with using some insulin pump features and not using others, leaving them untouched and metaphorically blinking 12am.

Can you say light bulb?

My point here is that you don’t need to use every feature of every high-tech tool. Is the same true of medical devices? I think so. Let’s face it; insulin pumps come with a blizzard of features, and not every feature is right for every user. On my Snap pump I use the temp rates, the stop feature, and the infusion set reminder all the time. Oh, and the flashlight. Love the flashlight. Combo bolus, I like to have that, but I don’t deploy it that often, and I never use extended boli. I had forgotten it had a logbook and a missed bolus alarm until I looked at the pump’s menus just now. But I’ll bet someone out there thinks the logbook and the missed bolus alarm features are the greatest things since Saran Wrap, and that the temp rates and the flashlight are a silly waste.

I think you can see where I’m going with this. But first, a quick detour. Let’s talk carb counting. I don’t think anyone would argue that carb counting is the gold standard when it comes to matching insulin needs to meals about to be consumed. Now, for you out-of-the-loopers, the carb content of a meal is a way of expressing the likely blood sugar impact of the food. To carb count, you add up the carbohydrate content of each item, subtract the fiber, and divide by your personalized insulin-to-carb (IC) ratio to get the perfect insulin dose for you, for that meal. Like magic, your blood sugar level will rise to a modest 140 mg/dL two hours after eating, then tamely return to your fasting level in four hours.

Well, that’s the theory, anyway. Of course, it never works.

In the real world there are too many variables to pin down. If you only eat out of boxes and cans, you can, theoretically, read the label to get the carb count of the package and divide by the percentage of the package that you intend to eat. But, sadly, there is as much variation in carb counts on labels as there is in test strip accuracy. And if you’re cooking from scratch, it can take as long to calculate the carbs as it does to actually prepare the meal. You’ll need a kitchen scale, measuring cups, a calculator and a slide rule, a pencil, several sheets of paper, and a bachelor’s degree in calculus. And even if your carb count is right, you still have to figure out what your insulin to carb ratio is for every time of the day.

This is why many alleged carb counters “SWAG” their carb counts instead of carefully calculating them. SWAG stands for Scientific Wild Assed Guess, basically just looking at a plate of spaghetti and saying, “Well that looks like 85 carbs to me.”

By the way, does anyone know (or remember) what we did before carb counting? We had a system called exchanges, which was a quasi-science for recognizing 15 carb portions. Each exchange required one unit to cover, as a common IC ratio for T1Ds is 1:15. The idea was to quickly identify in the field how many units were needed to cover a meal. Oh look, one slice of bread. That’s one exchange. Side of rice. That’s two. Small glass of milk. Three. Grilled chicken breast, zero. OK, I need three units. Let’s eat.

Not entirely precise, but fast. And perhaps more accurate than the SWAG. And exchanges aren’t eMedtronic insulin pump food settingsxtinct either. Medtronic pumps, for instance, can still be programed for either carb or exchange entry.

But what about just taking a flat bolus and picking up a fork? Can that work? First the history: The notion of the flat bolus comes to us from the universe of T2 treatment. Quite incorrectly, for years many diabetes docs assumed that type 2s are some sort of diabetes Neanderthals. Evolutionary throwbacks that aren’t as smart or as motivated as type 1s. Nothing could be farther from the truth. I know plenty of smart, motivated type 2s. I also know some lazy and ignorant caveman type 1s. Still, this misguided belief led some docs to assume that type 2s couldn’t handle carb counting (never minding that the Atkins Diet craze showed us that huge numbers of people can master carb counting), so something called “flat-rate dosing” became the vogue.

The idea is that you, or actually the almighty and all-knowing doctor, chooses a middle-of-the-road dose that will cover most meals. It’s not as crazy as it sounds. The bulk of people tend to eat meals around the same size. All that is required is to choose an insulin dose that doesn’t let the patient get too high or too low.

Sound crazy? Well, in the case of your friend, I think we could argue her doc was pretty wise. Assuming she’s not having any lows, dropping her A1C from 13 to 7 was a job well done. Plus, by just dialing up 8 units at each meal, she’s eating before her food gets cold while you and I are still crunching numbers.

Now some folks would argue that using a pump for flat-rate boli is a waste of money and technology, but I disagree. She still has the advantages of a customized basal pattern, optimized corrections, insulin on board tracking for anti-stacking, and the ability to use temp rates for exercise and the like. And maybe a flashlight.

I have a confession, however: I’ve used this same playbook myself. I have this wonderful little ol’ lady patient who is a type 2 that we put on a pump. She’s plenty smart and no cavewoman, but technology just gets her easily flustered. When I inherited her, she was a mess on MDI. Ambulance visits at night were a regular feature of her life. Along with an A1C in the low 14s.

I tried to set up her pump “properly” and teach her to carb count, but only succeeded in stressing her out. In the end, I decided to let her VCR blink “12:00.” She started using flat-rate boluses with meals, and correcting the few that didn’t work out well. (“Maybe I shouldn’t have had two pieces of that pecan pie,” she told me recently. Perhaps not.) Her A1Cs dropped to the mid-sixes and the nocturnal ambulance visits became a thing of the past. Plus, she came to love her pump.

But then her health insurance company, in its infinite wisdom, decided that our clinic wasn’t qualified to prescribe pumps and refused to cover her supplies unless the script came from an endo.

Fine. Pay for the endo to say the same thing, you dumb A-holes. So I sent her to the endo. Who yelled at my patient. Told her she was using her pump “wrong,” and then proceeded to reprogram it, including setting the daily delivery limit at about half of my patient’s total daily dose.

My little ol’ lady came back in tears, and with the highest blood sugar she’s seen in two years. Wrong, shmong. I’m about results, not technique.

I called around and found her another endo. One who was more interested in watching a good A1C on the VCR rather than the fact that the clock was blinking “12:00.”

Disclaimer: As mentioned way up above, this is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.

Disclaimer: Content created by the Diabetes Mine team. For more details click here.


This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn't adhere to Healthline's editorial guidelines. For more information about Healthline's partnership with Diabetes Mine, please click here.