Q: I am on the Keto diet and having difficulty
managing my glucose on the pump. Is there a
guide for the amount of insulin to use for the
proteins and fats to prevent lows and/or highs?A: Many people are giving the Ketogenic
(very-low-carb, high-fat) diet a try...some with
more success than others. One of the biggest
challenges from a blood sugar standpoint
is that our body needs a certain amount
of glucose each day in order to function
properly. What we don’t get from our diet is
manufactured by the liver (from protein and
other sources). So, when having low-carb
meals, we have to start considering protein
intake and dosing for some of the protein
as if it was carbohydrate. Many people on
very-low-carb diets start out by bolusing for
50 percent of their protein grams. Best to
give the protein bolus after eating, since
protein will take longer than carbohydrate
to raise the blood glucose level.
The effects of dietary fat are a little differ-
ent. Fat does not turn into glucose, but when
there is a great deal of fat in a meal, it can
slow down the rate of digestion. Delaying the
bolus or using an “extended” bolus can help
prevent post-meal lows followed by delayed
highs. Large amounts of fat can also cause
the body to become insulin resistant for the
next eight to 12 hours. When this happens,
more basal insulin is needed to keep glucose
levels stable. Pumpers sometimes raise their
basal rate (using a temp basal increase) to
offset this effect.Q: I’ve seen and heard a lot about continu-
ous glucose monitors that don’t require fin-
gersticks. Are these things reliable? Which
one is best to use?A: Sometimes new technologies don’t
really make life better, such as automated
phone systems. Continuous glucose moni-
tors (CGMs) are just the opposite. These
amazing devices use a tiny disposable fila-
ment, inserted just below the skin (almost
always painlessly), or a pellet-sized sensor
that is implanted just below the skin to mea-
sure glucose (sugar) levels. The filament or
sensor transmits a signal to a monitor that
communicates the information to the user.
Some systems require calibration (entry of
fingerstick values a few times a day) while
others require no calibration. When used
properly, the readings they generate are
very close in accuracy to the readings gener-
ated by fingerstick blood glucose meters.
But they also provide trending informa-
tion (is the blood glucose rising? falling?
stable?) and, in most cases, alerts to let the
user know if their blood glucose is starting
to trend high or low. To that end, most
professional organizations encourage CGM
use by just about everyone with diabetes.
CGM systems are made by Abbott
(Freestyle Libre), Dexcom (G5 or G6),
Medtronic (Guardian) and Senseonics
(Eversense). The choice of system depends
on a number of factors, such as insurance
coverage, out-of-pocket costs and desired
features. Some CGMs link directly with
certain insulin pumps; the pump will dis-
play the data, and some can even adjust
insulin automatically. Some CGMs provide
high/low alerts, while others don’t. Just
about anyone at risk of hypoglycemia (low
blood sugar) can benefit from low alerts.
The number of fingerstick calibrations
varies from system to system as well; some
prefer to keep checking blood sugar the
“old fashioned way” on a regular basis
just for validation purposes, while others
want to eliminate as many fingersticks as
possible. Costs and coverages also vary
considerably. Talk with your physician or
diabetes educator to discuss the pros/cons
of the various systems. Gary Scheiner, MS, CDE, is owner and
clinical director of Integrated Diabetes
Services (integrateddiabetes.com), a
private practice specializing in intensive
therapy for children and adults. He has
lived with Type 1 diabetes for 30 years;
is a certified diabetes educator and
named Diabetes Educator of the Year
2014 by the American Association of
Diabetes Educators.Have a question about diabetes?
Send it to Gary Scheiner MS, CDE,
at [email protected].Q
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ANEWS &
NOTES
Shutterstock/Geor
ge^ Dolg
ikh14 May/June 2019