How Times Have Changed: Diabetes Management

Kim A. Carmichael, MD, is a professor of medicine in the Division of Endocrinology, Metabolism, and Lipid Research at the Washington University School of Medicine in St. Louis. He is also the author of Consultant’s quarterly Diabetes Q&A column.

Carmichael, KA. How times have changed: diabetes management. Consultant360. Published online: August 08, 2022.


This Editorial is a personal reflection on an article from the Consultant archives: Georgieve EL, Berube LW, Farley, JC. Practical pointers: diabetes. Consultant. May 1990. 

To many, May 1990 does not seem so far away. Driving Miss Daisy won the Oscar Award for Best Picture, City of Angels won the Tony Award for Best Musical, the San Francisco 49ers won the Super Bowl, and the Cincinnati Reds won the World Series.

Scientific advances in 1990 included the beginning of the Human Genome Project, development of the Hubble Space Telescope, and the invention of the first Web server, later restructured into the World Wide Web. Diabetes management was still in the growing phase, however, with the major available insulins being Neutral Protamine Hagedorn (NPH) and regular insulin, as well as pre-mixed combinations of NPH and regular insulin. Although insulin pens were initially available in 1985, they were expensive and uncommonly used in 1990. Insulin lispro did not hit the market until 1996 and insulin aspart in 2000. Insulin glargine was also introduced in Europe in 2000 and later in the United States.  

Although the first blood glucose meter (glucometer) was introduced in November 1981, it required water washing and was difficult to transport. Home-use glucose meter technology did not meet inpatient hospital acceptance for more than 10 years later. As shown in this legacy article, glucose strips in 1990 were used by colorimetric visual estimation with an option for use with a glucose meter to provide a more precise digital readout. Now technology has advanced to widely adopted, accurate home-use glucose meters, and multiple available forms of continuous glucose monitoring.1

The issue of mealtime insulin administration was also challenging in 1990, as regular insulin often had to be administered 30 to 60 minutes before the meal, to allow for it to become active when food was being absorbed. Regular insulin would also last 4 to 6 hours, so it would pose a risk of late-afternoon hypoglycemia, particularly if the morning NPH was reaching its peak activity at the same time. Therefore, the concept of incremental lunch intake was applied so as to provide a smoother, safer mid-day control. Now, we have faster, shorter-acting insulin options which can provide better timing to match nutrient absorption.2 However, these insulins are generally a log-order more expensive than the “traditional” insulins, so it is important for practitioners today to know some of the older concepts when affordability is an issue.3

Insulin pump technology was rather rudimentary in 1990 and required use of regular insulin. In current times, pumps can provide far superior control, particularly when combined with continuous glucose monitoring.4

The issue of dietary fiber and glucose absorption is still meaningful dietary information.5 There have consequently been calls for the food industry to provide a greater supply of fiver-enriched functional food products.


  1. Cedeno A, Carmichael KA. What do you need to know about continuous glucose monitoring? Consultant. 2021;61(2):14-16. doi:10.25270/con.2021.01.00006
  2. Hollar L, Carmichael KA. What do we need to know about the newer insulin analogs? Consultant. 2019; 59(1):18-19.
  3. Carmichael KA. What Do You Need to Know About Traditional Insulin Formulations? Consultant. 2020;60(11):14-17. doi:10.25270/con.2020.11.00002
  4. Carmichael KA. What do you need to know if your patient is using an insulin pump? Consultant360.  Published online January 17, 2018.
  5. Goff HD, Repin N, Fabek H, El Khoury DE, Gidley MJ. Dietary fibre for glycaemia control: Towards a mechanistic understanding.  Bioactive Carbohydrates and Dietary Fibre. 2018;14:39-53. doi:10.1016/j.bcdf.2017.07.005