Retrospective #486: Too depressing not to write about.

I have been haunted for the last few days by the memory of a luncheon my wife and I recently attended at the home of friends. There were six of us, and we were told not to bring any food; the hostess would prepare everything. I knew her husband had been a long-term, non-obese type 2 diabetic, but I wasn’t comfortable leaving the menu entirely up to her, so I decided at the last minute to make a new keto recipe I had seen the day before.

My sausage and cheese meatball appetizer is made with ground-up pork rinds instead of the usual bread filler. I used hot Italian (ground pork) sausage, grated Pecorino Romano cheese, and Epic BBQ pork rinds. I made and tasted them the night before and thought they were a bit dry, so I made a garlic aioli to serve with them.

The hostess reheated and graciously served my meatballs before lunch (with other zero-carb offerings), and it’s a good thing I ate more than my share. Lunch was what appeared to be instant rice and a chicken casserole covered in breadcrumbs. The side was fruit jello. Rolls and butter completed the offerings. Dessert was a (very good) store-bought cheesecake (brought by the other couple)! I had a little of the chicken casserole and…dessert.

In table conversation the other male guest asked to know the time. It seems his doctor had called him the day before and said she wanted to see him as soon as possible. He had a 2:30 pm appointment. He said he didn’t know what the rush was all about. I asked him if he was diabetic. He nodded yes. “That makes 3 of us,” I said.

This nice man is in his early eighties and looks 9 months pregnant. He carries his “baby” high. He’s a poster boy for visceral adiposity. Both of these guys carry their fat inside. The difference is our host husband looks only 6 months pregnant, not 9 months…and he doesn’t have a “command” appointment to see his doctor that day!

Here’s the depressing part. The poster boy’s wife is a retired Registered Nurse. And our hostess spent her work-life as an administrator in a retirement “village.” These women, and their diabetic hubbies, should know better than to eat the very foods that essentially caused their type 2 diabetes and which now make their diabetes worse: carbohydrates!

But these conscientious couples are apparently unconscious of the dietary cause of type 2 diabetes and the dietary strategy to prevent progression. If you pay attention to what you eat, type 2 diabetes does not have to be “progressive.” Instead, they (as most patients) pay attention to what their doctors tell them. THAT’S A BIG MISTAKE.

Doctors treat the symptoms of disease, including type 2 diabetes. When they diagnose a symptom, they prescribe a medicine to treat it. Anti-diabetic meds help control high blood sugar by lowering it. Some medicines force the pancreas to make more insulin to deal with Insulin Resistance. Then, when the pancreas eventually fails from overuse, they prescribe injected insulin, making the Insulin Resistance worse. These therapies only treat a SYMPTOM of type 2 diabetes. That is the current Standard of Medical Care. The doctor is just doing what he has been taught and paid to do. The doctor would probably be censured by her medical association and Medicare if she did not treat the symptoms of Type 2 diabetes as she does. Note: She is not paid to treat, or understand, the cause of Type 2 diabetes.

Most people rely on their doctor’s guidance.  Both the former nurse and her husband told us at lunch how wonderful his doctor is and how well she treats him. But she is only treating the symptom of this  disease, and type 2 diabetes is just one of a galaxy of diseases with the same symptoms: visceral adiposity, high blood pressure, dyslipidemia (characterized by high triglycerides and low HDL-C), type 2 diabetes, and a host of others.

In addition, people who have these disorders – symptoms, really, of Metabolic Syndrome – have double the susceptibility to heart disease (CVD and CAD), stroke, fatty liver disease, many types of cancer, and even macular degeneration. These are all the “diseases of modern civilization,” of simple sugars and other processed carbs, and manufactured vegetable oils—in the words of Weston A. Price, all the “displacing foods of modern commerce.”

It’s so depressing. That is why I had to write about our recent luncheon experience. I had to get it off my chest.

Retrospective #485: Grocery store bread is processed food.

“Grocery store bread is processed food” was scribbled on a “Post It” next to my laptop, so since I fancy myself as a lay type 2 nutrition educator, it must have been my intention to write about it. So here goes.

Most people grow up eating a lot of bread at home. I did not. I was lucky. My father grew up during the Great Depression. Later he had a good job and regarded our family as too bourgeois to use bread fillers like “Hamburger Helper.”  My mother didn’t put bread on the supper table either. Like most kids, though, we ate sandwiches. They were a lunch-box staple, together with fruit and cookies, to carry to school every day.

Store-bought bread, at least the kind sold in a plastic wrapper, has to have a long shelf life. Silvercup is the brand I remember. It was white and spongy. I didn’t learn until recently that what made it spongy was sugar. Here’s a challenge: Look at the label on any loaf of bread sold with a wrapper in the supermarket. I defy you to find even one brand or variety where sugar, HFCS, or some other form of sugar, is not, after flour and water, the third ingredient.

Did you know that white bread scores 100 on the glycemic index! The glycemic index is a scale from 1 to 100 which measures the rate at which a food will raise blood sugar. No other food will make a Type 2, or Pre-diabetic or Insulin Resistant person’s blood sugar rise faster and farther than white bread. Two slices of Walmart's white bread contain 23g of carbohydrate (including the added sugar) and 5g protein from gluten in the flour. Yeah, gluten is a protein!

Why is bread the very definition of a high-glycemic food? Because it is a PROCESSED food, made from highly REFINED white flour (and 3g of ADDED sugar). Flour starts to break down into glucose when enzymes in saliva contact it! And sugar is a simple carb that only needs to divide once (again, from the saliva in your mouth!) to become glucose.

Why is a processed food like white bread so much worse for you and your blood sugar control than say an apple? To be clear, I’m not advocating that you eat, as we learned as kids, “an apple a day.” I just want to explain the difference. The carbs in white flour are 100% glucose molecules. Glucose makes your blood sugar rise.
 

The principal nutrients of an apple are simple sugars: SUCROSE, a disaccharide of glucose and fructose. Glucose and fructose are monosaccharides. The glucose molecule goes into your blood to be circulated and taken up for energy. The fructose molecule does not. It goes, via the portal vein, directly to your liver, for detoxification. If you need more glucose for energy, your liver converts the fructose to glucose. If you don’t need more, your liver stores it as glycogen. But if the liver is already full of glycogen, it uses a process called “de novo lipogenesis” to convert the excess fructose to fat. That’s right! The liver makes fat from the excess sugars, glucose and fructose.

An apple also has high fructose content. After water (86%) and fiber (3%) the remaining 11% of an apple by weight are simple sugars: 20% the disaccharide sucrose (half glucose/half fructose), 23% “free” glucose and 57% “free” fructose. The “free” molecules are monosaccharides. So, when the sucrose breaks down to monosaccharides, an apple is 33% glucose and 67% fructose. Only the 33% glucose in an apple raises your blood sugar immediately versus 100% in a slice of white bread. You already know what the fructose does to your liver. Ugh!

Many years ago, I met a nurse in a swimming pool (in Mexico) who told me her husband had a fatty liver. This was at least a decade before Non-Alcoholic Fatty Liver Disease (NAFLD) was among the conditions associated with Metabolic Syndrome. We now know that you don’t have to be obese to have NAFLD. It’s the visceral fat within and around your internal organs, your liver specifically, that causes NAFLD. I wish I’d known that in the swimming pool in Mexico. The nurse became and is still a Facebook friend. Maybe she’ll read this, if she doesn’t know it already.

Today, white bread is the standard bearer for the “bad boy” foods we’ve eaten ever since we carried a sandwich to school eons ago. And government still tells us to eat it. Look at Choose My Plate from the HHS/USDA and Create Your Plate from the American Diabetes Association, respectively.

But don’t expect government to change. Agribusiness and Big Pharma have too much at stake to let that happen.

Retrospective #484: “He needs insulin to control his high blood sugar.”

“He needs insulin to control his high blood sugar,” the wife in the TV commercial says. That’s true. We all need insulin to regulate our blood sugar, so why was I so upset to hear her say that? Because of the wife’s misleading message. She was pitching for a drug company that was selling man-made insulin that her “husband” had to inject, after checking his blood sugar with a finger prick (or a continuous glucose monitor).

Everyone needs insulin to control high blood sugar. And everyone’s blood sugar rises after eating, even the healthiest peoples’ blood sugar (glucose). Carbohydrates, when digested, become glucose.  So do some proteins, to a certain extent, in a bit more time. And the pancreas secretes insulin, which circulates in the blood with glucose, to enable the uptake of glucose as energy. In healthy people, the insulin works. The cells open. The circulating blood “sugar” lowers.

Without insulin, either made by the body or injected, a person will die. Until artificial insulin was discovered in 1921, Type 1 diabetics, who had suddenly lost the ability to make their own insulin, did die. Until then, patients (mostly children) were kept alive longer by eating a diet that was very low in carbs and about 90% fat. Fat is also a very good, alternate energy source to carbs that doesn’t require insulin for transport and uptake. But with the invention of artificial insulin, the high-fat diet treatment for Type1 diabetics stopped, because it was no longer needed.

So, what’s my beef with a company just trying to sell its product? Answer: The patient in the ad was NOT a Type 1 diabetic who needed insulin to live because his body had stopped making it. He was a Type 2 diabetic whose body had become resistant to taking up glucose because it had TOO MUCH circulating insulin! Type 2 is a totally different disease from Type 1. Unfortunately, government, medicine and Big Pharma don’t see it that way.

They want to treat Type 1 and Type 2 diabetes as essentially the same. They want to treat the symptom, a high blood sugar, as if it were caused by the same thing. But Type 1 diabetes is an autoimmune disease where the pancreas suddenly stops making insulin, and Type 2 diabetes is a dietary disease where the cells have, over time, become resistant to taking up glucose because they have long been exposed to too much insulin.

Here’s the irony. Every time a Type 2 injects insulin, it makes their Insulin Resistance worse! How stupid is that?

It’s frustrating. I don’t have an expensive drug to sell – a drug that misleads you into thinking you’re treating the cause of Type 2 diabetes. Instead, this treatment is just masking the symptom by lowering your high blood sugar. Insulin Resistance is the cause of Type 2 diabetes. Injecting insulin is just making the Type 2 dependent on injected insulin.

So, in this TV commercial the wife should be saying, “He needs to control his high blood sugar by changing what he eats.” But I can’t afford that TV commercial. I’m not selling insulin. If I had a 30 second TV spot, I would say, “If he eats fewer simple sugars and other processed carbohydrates, his pancreas will need to produce less insulin, thus reducing his insulin resistance and preserving his pancreas. By having a lower blood insulin, his cells will become more insulin sensitive.” That means they will be less Insulin Resistant and take up more glucose; i.e., function more normally.

With a 60-second spot, I’d add one of my favorite pitches used by some diabetes drugs: “It might even help you lose weight.” Many Type 2 diabetes drugs use that as a “hook.” But that can’t be said with injected insulin. High levels of insulin in your blood – whether injected, or secreted – CAUSE YOU TO GAIN WEIGHT.

Insulin is the weight storage hormone. Long-acting (24-hour) insulin, by design, keeps your blood insulin high ALL THE TIME. In Insulin Resistant Type 2s, high blood glucose remains high because of Insulin Resistance. In Insulin Dependent Type 2s, blood insulin is high all the time, so you can’t burn body fat for fuel and YOU MUST EAT WHEN YOU ARE HUNGRY instead of letting your body access its fat stores for energy. Think about it! Eating “lower carb” 1) improves your Insulin Sensitivity naturally, 2) lowers your blood sugar naturally, 3) lowers blood insulin naturally, and thus enables weight loss by letting the body access to its fat stores, naturally.

Given that, why would any Type 2 diabetic inject insulin to control their blood sugar? 

Retrospective #483: “…when used with diet and exercise.”

Have you ever noticed how all the type 2 diabetes medications advertised on TV conclude with “…when used with diet and exercise”? That common refrain riles me a bit, but I’ve never asked myself why. I think it’s time I do.

First off, by self-examination I admit to being something of a curmudgeon. However, I tend to grouse only about the abysmal state of our collective health, including how we (including I) got into this mess. In other respects, I think I have a positive outlook on life, but you’d have to ask the people who know me best if that’s true. Regardless, my readers could fairly describe me as a crusty, grumpy old man. This column, however, is not about me. This column is about why the diabetes ads conclude with the caveat, “…when used with diet and exercise.”

It’s obviously a government (FDA) requirement. The Food and Drug Administration (FDA) has to approve all claims made by drug manufacturers. The FDA also dictates for what and when a drug may be prescribed. That includes as a first course of treatment, as well as any adjunctive therapy if the first medication fails to achieve the primary target. In the case of a drug to treat type 2 diabetes, that “primary target” would be lowering the patient’s serum blood glucose, a SYMPTOM of type 2 diabetes, as measured today by a blood marker, hemoglobin A1c (hgA1c), or simply, A1c.

Metformin is the first drug prescribed today to “treat” type 2, and sometimes pre-diabetes. But type 2 diabetes is CAUSED by Insulin Resistance (IR), as measured (too late)  by an Impaired Fasting Glucose (IFG). Metformin is generic, cheap and widely accepted as the standard-of-care, almost universally prescribed first after diet and exercise have failed. After Metformin, which is now generic, the clinician has a wide choice of drugs, depending on other risk factors and co-morbidities. That’s when the phrase, “…when used with diet and exercise,” usually appears.

And that’s what gets me riled. Every doc is supposed to tell their overweight and Pre-diabetic patients to “lose weight and exercise” before ANY meds are prescribed.  “Eat less and move more,” “eat a plant-based” or “Mediterranean” diet and get lots of exercise (to lose weight!). And everyone FAILS. By following the FDA’s and their doctor’s advice, hey fail to permanently lose weight or stop or reverse the slow but inexorable slide to drug dependence, eventually “graduating” to type 2 diabetes. So why do the diabetes ads still advise people to continue this failed strategy?

Answer: The FDA mandates it. But, what does Big Pharma care? It’s a throwaway line because so long as PATIENTS continue to eat what government and their doctor have “prescribed” as a “healthy diet,” type 2 diabetes WILL BE a “progressive disease,” and the PATIENT WILL continue to worsen.” And BIG PHARMA IS THE BIG WINNER.

There is no downside for Big Pharma. They’re not telling you how and what and when to eat, and certainly no one would tell you that exercise is not good for you. Besides, exercise and Metformin are well-documented ways for type 2s to slightly improve their insulin sensitivity, which is good. But for weight loss, exercise is not an effective method.

THE ONLY DOWNSIDE IS FOR THE PATIENT. By following the advice to eat what the government “prescribes” as a “healthy diet,” patients are being herded like lemmings into the hands of Big Pharma. Whether this is a corrupt cabal, I’ll leave it for you to decide. But more to the point, in your own self-interest, you might want to ask, why has the advice, “…when used with diet and exercise,” failed? And why does it continue to fail even as you take more and more medications. It is because exercise and eating a balanced diet are not good ways to lose weight? 

It is because the “healthy” diet the government prescribes is NOT REALLY A HEALTHY DIET? If eating lots of carbs (like corn) is a good way to fatten beef cattle in a “feed lot,” is it not also a good way to fatten people? Yet, the government’s Nutrition Facts label on all “processed” foods prescribes that the PERCENT DAILY VALUE (%DV) FOR CARBS RECOMMENDED FOR WOMEN (ON A 2,000KCAL DIET) IS 300G, OR 1,200KCAL, OR 60%. AND FOR MEN (ON A 2,500KCAL DIET), IS 375G, OR 1,500KCAL, ALSO 60%. DID YOU KNOW THAT? DO YOU THINK THAT IS TOO MANY?

If you want to avoid the inevitable “graduation” to a cocktail of anti-diabetic medications, including the ones advertised on TV, you might want to consider dropping your intake of carbs, to 40, 20, 10 or even 5%, like me. 

Retrospective #482: “What are you teaching these kids?”

In the Schwab TV commercial, Carl, a salesman for a rival stock broker, is addressing an elementary school class. When one of the students asks what his firm has to offer, Carl says, “Good question!” But when the kid replies to the broker’s answer with what Schwab has to offer, Carl asks, “What are you teaching these kids?”

Now THAT’S a good question! Both kids and adults in the U. S. have been subject to the government’s ideas about nutrition for over half a century. It all started in the 50s with saturated fat and cholesterol and got much worse in 1977 with the McGovern Committee’s Dietary Goals and then in 1980 with the very first Dietary Guidelines for Americans.

The result is plain to see. We for the most part have followed the government's advice. Many have no choice. The military eats what the government cooks for them, and they are getting fatter and fatter. You can’t blame that on a lack of exercise, can you? Our schools and hospitals are subject to these HHS/USDA dietary guidelines too.

So, what have they been teaching us and our kids? To lose weight and be healthy: eat less and move more! Don’t eat red meat or processed meat. Don’t eat meat! Or cholesterol or salt! Don’t eat saturated (solid) fat, found in animal products. Instead, eat a plant-based diet including processed “vegetable” oils (soybean, corn, Canola, etc.), all of them UNHEALTHY polyunsaturated fats manufactured and sold by Agribusiness and subsidized by the USDA!

Doctors too are having an increasingly difficult time under the influence of government Dictocrats. To survive, many are now part of large groups and hospital practices where corporate number crunchers are monitoring your personal medical records to see that the clinician is recording that he advised you to eat a mostly plant-based diet and you get the recommended amount of exercise. If your doctor hasn’t advised you to do this, you’re lucky; he or she is still in private practice but is at risk of HHS sanctions and increasing “negative payment adjustments” from Medicare if this is not in your patient notes. Their Medicare reimbursements will decrease by 9% by 2022.

So, what’s to be done about it? Obviously, the macro solution is to get legislators out of the business of telling people what to eat, but that is not going to happen. There will always be politicians, who take contributions from Agribusiness, who think they know what’s best for you. They will always want to impose their will on us, by legislation. They will argue that it is the proper role of government to look after the “general welfare” of the citizenry, to justify with legislation anything that is not expressly “enumerated” as powers granted to them by the Constitution.

In this they have been abetted by a Supreme Court which has extended the power of Congress to legislate away your freedoms, all in the name of the “general welfare.” Some, who espouse a civil libertarian point of view, objected, but others relented to pressure for the “general good.”

Today, however, the tide is changing. In 2002, on the advice of my doctor who just wanted me to lose weight, I started to eat Very Low Carb. He had been cajoling me for years, telling me to “eat less and exercise more,” but eat a “balanced” diet. I even worked with his dietician, all to no avail. Then in July 2002 he read a NYT Sunday magazine cover story, “What If It's All Been a Big Fat Lie.” He followed the diet himself, by mid-August had lost 17 pounds, and suggested I try it too. In the first week, I abruptly stopped almost all my diabetes med and eventually lost 170 pounds.

More and more people (and many doctors) are discovering this Way of Eating. There are now thousands of practitioners worldwide who publicly practice this way, and 10s of thousands more who would tacitly support your decision to change the way you eat. After all, doctors and related health professionals are interested in results and are persuaded by evidence. Not only will you lose weight easily this way, and do it without hunger, (body fat is food), your blood tests of metabolic markers, blood pressure and inflammation, will improve dramatically. That’s real evidence!

The tide is also changing on the Supreme Court. The balance of power is now 5 to 4 for a more conservative interpretation of the “general welfare” clause. And soon it could be 6 to 3. Personally, I will be much happier if and when Congress and the Courts decide that government should have less to say about what we eat.

Retrospective #481: “I’ve lost 30 pounds,” said Tim Cook, Apple CEO

If you Google, “Tim Cook, ‘I’ve lost 30 pounds,’” you’ll find several pages touting Cook’s boast about how he used his iWatch to lose weight. Of course, he was mainly promoting the utility of a prospective Apple iWatch app in conjunction with emerging medical technology to help manage health conditions and make our lives better.

The quote appears at about the 8:15 mark in this May 2017 video interview with CNBC’s Jim Cramer. Cramer was trying to get Cook to reveal the next “new” product from Apple. Cook smiled and at first resisted, saying, “I can’t tell you” [about new products]; and then, here’s what follows in this scripted interview:

Cramer, egging him on with a cue, “Health?”

Cook replies, “You know, this, the watch, has been an incredible move into health, in the wellness and fitness piece.”

Cramer: “You too?” [more script]

Cook: “Yes, I’ve lost 30 pounds, partly [due] to my watch.”

Cramer: [prompting Cook again] “…because it prompts us.”

COOK: [finally getting to his pitch] “BECAUSE IT MOTIVATES YOU. IT CONSTANTLY GIVES YOU FEEDBACK. IT CONSTANTLY GIVES YOU REWARDS, AND THIS MAKES A DIFFERENCE…OVER TIME.”

What Cook and Cramer were talking about is an Apple iWatch app in development that tracks blood sugar continuously from a sensor attached to the upper arm just below the surface of the skin. The sensor captures the rise and fall of blood “sugar” in response to several factors, but primarily to food that is eaten.

If you eat something that causes a large increase, you know that that it will shut down any fat burning your body is doing to supply energy while the “sugar” (glucose from any type of carb) is burned off first. You learn that if you want your body to stay in fat burning mode, instead of sugar-burning mode, you should avoid those foods.

Cook’s pitch and Cramer’s interest are all about business, specifically the conjunction of health science and technology. It’s a crowded field. Scores of innovators are operating under the radar, clamoring to get on the bandwagon for a piece of the mass-market. The early birds certainly have an advantage, but…over time, as technology advances, the products will become commodified, and competition will bring costs down.

In the 2017 interview, Cook was certainly aware that a “high cost” solution was on the market. By March 2018 the FDA had approved the Dexcom 6 Continuous Glucose Monitor (CGM). It costs about $5,000 a year and includes an integrated mobile app which automatically downloads results to a Bluetooth-enabled device.

Then in August 2018 the FDA approved the new Freestyle Libre CGM (about $1,620 a year). It does not have an integrated mobile app yet, but a startup, Ambrosia, has a workaround called BluCon to download results.

Metronic is in the race too but lags at this writing. Stay tuned, though. By the time you read this, who knows?

Unfortunately for most type 2 diabetics, Medical insurance, including Medicare and “Supplemental,” will only pay for this durable medical equipment and supplies if you are an insulin-dependent diabetic who injects MEALTIME insulin. The government’s policy is designed to help patients avoid life-threatening hypos (hypoglycemia), which, for some diabetics, is an all-too-common and sometimes life-threatening occurrence, often requiring hospitalization.

But Tim Cook’s market is “the wellness and fitness piece” – i.e., the entire rest of the world – who will benefit from an inexpensive app and an affordable sensor that can be integrated with the latest Apple iWatch… BECAUSE IT MOTIVATES YOU. IT CONSTANTLY GIVES YOU FEEDBACK. IT CONSTANTLY GIVES YOU REWARDS, AND THIS MAKES A DIFFERENCE. And almost everyone could stand to lose 30 pounds. Lots of us, even more!

Retrospective #480: CGMs for Non-Insulin Dependent Type 2s?

That’s a question, friends, not news of a new Medicare policy on insurance coverage. The fact still is: Medicare will only cover a Continuous Glucose Monitor (CGM) for type 1s and type 2s who inject meal-time (not just basal) insulin.

Current government policy is designed to help mealtime insulin users avoid hypos and is cost-driven. Hypos from accidental overtreatment with insulin by the patient are acute and can be life threatening if not addressed quickly. They frequently result in emergency room visits and hospitalizations. Regrettably, for non-insulin dependent type 2s, Medicare does not foster a long-term approach to blood glucose self-management (BGSM). They do not consider the costly complications and co-morbidities from higher levels of glucose in the blood. And, IMHO, as the cost of treating complications and co-morbidities of T2D soars, Medicare should cover CGMs for non-insulin dependent T2s.

Diabetic complications take many years to develop. Microvascular complications include 1) nerve damage (peripheral neuropathy), the leading cause of amputations; 2) loss of sight (retinopathy), and 3) end-stage kidney disease (nephropathy), requiring dialysis. The co-morbidities of T2D that are macrovascular include some cancers, stroke, and heart disease; the ADA "compliant" patients (with an A1c of 7.0%), have TWICE the risk of CVD as non-diabetics. See Type 2 Nutrition #345R - How Diabetic Do You Want to Be (Part 2).docx.

Why does the government set such a low standard for doctors and patients? Because achieving the ADA’s modest ≤7.0% A1c control goal is still difficult to achieve, given the government’s one-size-fits-all Dietary Guidelines. Type 2 diabetes is a DIETARY disease, but the Dietary Guidelines for all Americans are still based on an eating pattern that is very high (55-60%) in carbohydrates. All carbs become “sugar” (glucose) in the blood. Eating so many carbs while trying to manage your blood glucose requires increasingly more meds. But the USDA/HHS is stuck in the status quo.

So, if the patient understands this and wants to lower their blood sugars on a day-to-day basis, they need to know what foods (and other factors such as hormones) affect their blood sugar (glucose) over the course of the day. The best way to do that is to monitor your blood sugar continuously, and “eat to the meter,” i. e., change what you eat.

As I am not an insulin-dependent type 2 who injects meal-time insulin, my options for obtaining a CGM are limited to cash-only, i.e., out-of-pocket. I recently looked into this and learned the following:

For context, I treat my type 2 diabetes primarily with a Very Low Carb “Eating Pattern.” My only diabetes med is Metformin, and I am assured by my physician, “You can’t get a “hypo” (hypoglycemia) from just Metformin.” My own experience since 2002 confirms this. I am in no danger whatsoever of hypos, even with extended fasting.  Metformin works on the liver (and gut) and improves insulin sensitivity. Metformin has no effect on the pancreas.

So, if you are not able to use insurance to cover the cost of purchasing a CGM system (sensors and readers, or transmitters and receivers), you have 2 choices: Dexcom and Freestyle Libre. But, if you don’t have or aren’t eligible to use insurance, cost is the main factor. That eliminates one choice for me.

The new Dexcom G6, introduced 3/18, is about $5,000 US a year. That’s expensive. It is more accurate in hypos, includes alarms and has an integrated mobile app. It automatically downloads results to a Bluetooth-enabled device. The 10-day sensor is a little bulky, but if you’re insurance eligible, and get hypos, it’s definitely the way to go.

The new Freestyle Libre 14-day (8/18) is much less expensive, but still costly at $1,620 a year ($135/mo.). The old Freestyle Libre included sensors good for 10 days, but the new FDA approved 14-day sensor is now in pharmacies. It may be slightly less accurate than a Dexcom, but it has a shorter “warmup” period (1 hr. vs. 2 hr.) for new sensors. However, it has no alarms for hypos. It has a 90-day memory and an excellent suite of reports (daily reports and 14-day summaries). It does not have its own integrated mobile app and must be “read” every 8 hours. However, a startup, Ambrosia, has a workaround called BluCon.

Given my needs, and the cost disparity, it’s a no-brainer. If I decide to do it, I’ll opt for the Freestyle Libre 14-day.