Month: April 2024

The 12 Levers You Can Pull To Manage Diabetes

leontribe2 Comments

My perspective on managing diabetes is it requires a multi-faceted approach. I refer to the strategic elements of this approach as ‘levers’. The way I see it, it is a case of working out how hard you can personally pull each lever and which ones work for you.

What are your Goals?

Before a strategy can be put in place, we must have an idea of where we are heading, what are our goals? These can be big, hairy audacious goals (I want completely normal blood sugars) or smaller ones (I want to reduce my HbA1c). With goals in mind, we can start to use the levers to get us there.

My goals are:

  • Minimise daily management to avoid burnout
  • Reduce my HbA1c to a point where my risk of long-term complications is no more than 2x baseline

That’s it! Goals do not need to be complicated and, in my case, one is qualitative (minimise management) and the other quantitative (based on my previous blog, getting an HbA1c under 7.0% is good, getting under 6.4% without hypos is better).

What External Factors Can Hinder Us?

In moving towards our goals, there are factors which may impede our progress. T1D Mum provided this great summary of “social determinants of health” which impact our lives.

While ‘Individual Lifestyle Factors’ speaks directly at the levers I am referring to, as we more further out, our ability to influence the impact on our lives becomes harder e.g. ‘Water and Sanitation’ without significant upheaval to our lives e.g. changing one’s job/home/country or, as t1d mum suggested through advocacy and demand for change. Perhaps we should include advocacy as a lever to address this although it is a slow moving one.

Levers You Can Pull

I brainstormed as many levers as I could think of and went to social media to see what other levels people could come up with.

These are the ones the collective came up with in no specific order:

Let us go through them.

Food

Arguably the lever which gets talked about the most and possibly one of the easiest to pull in some fashion. Clearly, reducing the amount of fast-acting carbohydrates will help with blood sugar spikes but, after this, we may adopt a different approach, based on our goals, beliefs, and social context.

For some, a ‘carnivore’ approach is the way to go given muscle tissue has many of the nutrients our body requires with zero carbohydrates. For others, a plant-based diet which reduces insulin resistance makes more sense.

Given how tightly food in woven into human culture, it is hard to give hard and fast rules about how to pull the food lever which will apply universally. Everyone will have an idea of the changes they can practically make to their diet to steer them towards their goals.

Sleep

The CDC gives a great summary of the benefits of sleep for people with diabetes. The very short version is a good night’s sleep is a relatively simple lever to pull to help you towards your goals. Tim Street correctly points out though that adjusting sleep patterns can have unpredictable effects to basal rates and glucose levels (Dawn Phenomenon) so make changes slowly.

Exercise

It is news to no one that exercise is beneficial to health in general and diabetes specifically. Again, I will pull out Dr. Dessi Zaharieva’s exercise slide to summarize the benefits.

Medication

Gone are the days when the only medication for diabetes was insulin. We now have drugs which reduce insulin resistance (Metformin), actively remove glucose from the blood (SGLT2is), and restore the satiety response (GLP1s) as well as many others and many more coming.

It may not be a lever any of us relish pulling but it is there for us to use as we see fit.

Technology

Even in the seven years since my diagnosis, technology has progressed significantly and continues to do so. We now have commercial looping systems which act as an artificial pancreas and, while not perfect, they can provide tremendous benefit in managing, for example, overnight levels.

Health Care Team

A good health care team is vital for good management. They act as a source of expertise as well as a sounding board for your own thoughts and discoveries. The ability to engage with the health care team or adjust its composition varies greatly from, for example, rural to urban areas which can limit how much this lever can be pulled and how effective it is.

Social Media, Online Resources, and Peer Support

Another resource for information and ideas, social media, online resources and peer support, like the health care team should be carefully curated so they work for you, rather than against you. Unlike the health care team, a lot of what is found online is unregulated so, even more than the health care team, critical thinking is needed to work out what is useful, what is unfounded, and what the agenda is behind the information. For example, I trust PubMed much more than medical ‘evidence’ from Twitter or Facebook. However, in terms of looping and success in managing LADA, online discussion groups have been essential. As Tim Street puts it “Peer Support…opens minds to methods that may help…”

Family, Friends, and Allies

Online support is one lever but support in the real world is another we can pull. As Tomorrow’s Gone suggests, having family and friends who are ‘followers’ to CGM data, who can help out on sick days, tell you when dinner is going to be ready so meals can be effectively managed, or do supply-runs when they unexpectedly run out is a great asset to have. Tomorrow’s Gone also mentions making allies of others such as the school a person with type 1 diabetes attends by providing a care plan.

Financial Status

There is flexibility in money and, therefore, financial status can greatly impact our success in managing diabetes. It is also one of the hardest levers to pull given the inherent expense in managing diabetes and the financial commitments of everyday life e.g. we may want to use certain technologies or medications but cannot afford them. Therefore, getting financial advice and stabilising finances with a budget can be a great lever to pull.

Time

As we can plan our finances, so too we can plan our time and give ourselves flexibility to explore other levers such as exercise or sleep. While none of us want to be a slave to a strict time regime, some planning and organisation can provide benefit.

Stress/Wellbeing/Mental Health

Stress hormones can cause havoc with blood glucose levels and maintaining good mental health is vital to keep the diabetes gremlin in its cage. Whether it is doing something relaxing such as meditation or yoga, or regularly seeing a mental health professional, there are ways we can keep our mind clear to tackle the demands of the body.

Education

This arguably overlaps with some of the other levers such as having an effective health care team and making good use of online resources but, as it also covers physical media such as books or university courses, I have called it out as a distinct lever.

Also, you are your best advocate in managing this disease. You know your body better than anyone and have the greatest motivation to keep you healthy. Arguably, this can only be done if you are educated about your body, about diabetes, and about the levers you intend to pull.

Education regarding your own body is an interesting one because this knowledge can only come from self-experimentation and not from the internet, a book, or a university. Dave Dikeman mentions practical knowledge of insulin dosing as an example which is vital if manually injecting and can be quite individual, depending on insulin resistance and diet.

Education can come from a variety of sources, such as those mentioned, and, for me, empowers and amplifies many of the other levers available.

No Lever Acts in Isolation and Levers can be Inconsistent

As you read through it may have occurred to you that some levers affect others, as mentioned with education. Also, levers may not always act the same way. For example, with a women’s monthly cycle insulin resistance can significantly change, affecting the way insulin, food, and exercise impact the body.

For this reason, I believe there is not one lever which is more important than any other and over-reliance on any one lever can set us up for failure. For example, an over-reliance on technology means we may be in big trouble if it fails. Using diet, being educated on how to inject safely as a backup, and having a robust support network means we have contingencies if technology fails. As Steve Norris sums it up “I think the problem is that the levers don’t pull consistently, nor do they act in isolation. A holistic, yet unburdened, approach is important…”

ATTD2024: Making Exercise Practical For Type 1 Diabetes

leontribe1 Comment

The standout talk for me at ATTD2024 was by Doctor Dessi Zaharieva on making exercise guidelines practical. It was standout for a couple of reasons. Firstly, it was a great talk, accessible to people of all academic levels and secondly, it was practical: the guidelines presented can be used by people with type 1 diabetes easily and without a pocket calculator/slide rule (am I aging myself with that reference?) on hand.

You may also recall that, back in November, I did a post on a talk by John Pemberton at ISPAD2023 (also mentioning Dessi) on the same topic.

This blog will look to bring together the two talks (and my own experiences running the Blue Circle Cycle Club) so others can use the knowledge and, hopefully, it will encourage them to incorporate exercise into their type 1 management routine. The focus will be on bike riding but feel free to follow the links for tips on other forms of exercise.

What Did John (and Dessi) Say at ISPAD 2023? A Recap of my Previous Post

In my previous post, I had the following key points:

  • Exercise, as it increases your heart rate, makes insulin stronger and last longer as it gets to circulate around the body more before it is broken down by the liver and kidneys
  • Aerobic exercise tends to lower blood sugar levels which, combined with the ‘amplified insulin’ can make hypoglycemia more likely
  • Exercise has many benefits and Dessi expresses it really well in just one slide
  • A Continuous Glucose Monitor (CGM) is really useful when exercising as it gives you near-real time feedback on your blood sugar levels, allowing you to address any hypos before they become an issue. For people not using CGMs, Hypoactive suggests “test your blood glucose (BGL) at least twice, 15-30 minutes apart before you exercise.” to understand the direction you are trending and regularly test during exercise.
  • Non-Looping Food Strategy: Eat before exercise to bring you up to around 7-10mmol/L (126-180mg/dL) to act as a buffer against going low
  • Non-Looping Insulin Strategy: Reduce basal insulin by 20% leading up to exercise, adjust in subsequent rides if too high/low
  • Looping Food Strategy: None. Cannot eat to raise BGLs as the loop will counter it, unless you deactivate the loop and follow the MDI/Non-Looping strategy
  • Looping Insulin Strategy: Raise BGL target level to, say, 8mmol/L (144mg/dL) and set system to ‘exercise mode’ if available when exercising
  • Roughly speaking, if you are at your target level when exercising, take around 15g of carbohydrates every 20 minutes to maintain it. If you are above but dropping fast, take the same, if you are below and heading upwards take the same and if you are below and flat or heading downwards, take more than 15g of carbohydrate per 20 minutes
  • Hypoactive suggests monitoring glucose levels for at least 24 hours after exercise and Diatribe recommends reducing bolus insulin by 50% for meals or snacks up to two hours after exercise.

What is Dessi Saying at ATTD2024?

Dessi, via Dana Lewis, generously gave me a copy of her slides so I have much clearer images for this blog than my original tweets.

I will focus on presenting the ‘practical’ slides than give the full presentation.

Starting Glucose

Bike riding is considered a Low-Moderate Intensity exercise so the suggestion is to start between 7-14mmol/L (126-252 mg/dL) which is in broad agreement with the previous advice.

Mealtime Insulin Before Exercise

In my previous blog, Diatribe had suggested reducing bolus injections by up to 50% leading up to exercise and we see here this is in broad agreement, especially with Low-Moderate exercise.

Basal Insulin Before Exercise

For non-loopers, John’s position was to reduce basal insulin by about 20% before exercise. Arguably Dessi’s position is not as strong saying a 10-20% reduction is only needed if the day is unusually active but, with John’s suggestion to adjust based on experience, we can see there is a middle ground between the two positions.

Snacks During Exercise (CGM)

Again, we see broad agreement with John’s talk. In terms of what to do below target, the softer language here allows room for John’s ‘maintenance carbs’ that he suggests (around 15g every 20 minutes). I should note here that my experience has been that, while I initially needed a protein bar before exercise to stave off lows, as my stamina/fitness improved, the need to do so has diminished. For example, the 10km/6 mile ride I did today I did without breakfast and no protein bar and stayed flat.

Dessi also suggests a backup glucose monitoring kit (good idea, especially for longer exercise intervals) and makes the excellent point that, as CGM can lag the true BGL value, a drop in BGL should be attended to as early possible.

Looping Settings For Exercise

John also had a table of pump settings (screenshot in my previous article) and Dessi’s are in broad agreement. As they are friendlier to read, I am including hers here (sorry John).

Dessi’s Summary and What Really Happens

This was her summary slide combining tips for loopers and non-loopers. Again, nothing too unusual here, compared to previous tips but all good information.

Of course, as she was going through all the suggestions I was thinking “yes, I will do that” and “no, I will not bother with that” and, as if she was reading my mind, she showed the slide above which aligned perfectly with my thinking.

Points 3-5 all relate to pre-exercise guidelines. I had dismissed these because, with a family, I cannot guarantee exactly when I will be starting exercise. For me it makes more sense to start following guidelines when I am about to ride, making points 1 and 2 the most relevant/practical.

Her conclusions align to what many of us with type 1 diabetes concluded long ago when it comes to managing our blood glucose levels: Academic guidelines are well and good, but everyone’s diabetes is different, and we need to work out what works for us.

Things to Take on the Ride

From my own riding adventures, these are the things I keep on me while riding. For storage, you can pick up very affordable bike storage bags/panniers on the usual sites (Amazon, eBay, etc.)

  • A phone so you can monitor your CGM levels and/or a blood testing kit if you are not using a CGM. A phone can also be used to track your riding time and distance via apps like MapMyRide and Strava.
  • Hypo snacks (long and short-acting) to treat hypos and stave them off during exercise. John had some excellent examples
  • A medi-bracelet so, if there are issues, it can be quickly identified that you are a person with type 1 diabetes. Like the bike storage bags, these can be easily picked up online
  • Sunscreen, especially if you are cycling in the sun
  • Hydration: A riding bottle and bottle holder should be part of the bike or, you can also get wearable water bladders if you want to drink hands-free
  • Appropriate clothing: Some bike shirts have zippable pockets for storage or otherwise, simply clothes which allow movement and you will not get too hot in. I have picked up some excellent bike clothing and accessories at second-hand clothing stores
  • A smart watch: This is more a nice-to-have but I personally find it easier to check my BGLs on the watch by tapping it to my chin, than messing with the phone which is usually tracking the ride and not showing my BGLs

Bringing Together the Strategies for the Ride

Along with bringing the above along, here is the overall strategy summary for a morning bike ride, like those of the Blue Circle Cycling Club using my last post’s strategy as the foundation. Also note that, in the real world, people do not do all these things so work out which ones work for you.

Glucose Levels

  • Non-Looping: 1-2 hours before, have a Low GI breakfast to raise glucose levels with a reduced bolus (around 25-50%) to minimise insulin on board AND/OR reduce basal rates (10-20% reduction) to allow blood glucose levels to rise to around 7-14mmol/L (126-152mg/dL)
  • Looping: Skip breakfast, and 1-2 hours before set a higher loop target (around 8mmol/L = 144mg/dL) OR disable looping and follow the Non-Looping approach

During the Ride

  • Monitor glucose levels and, if they are dropping, eat a snack to counteract the trend.
  • If you already know how long you can exercise before levels start to drop, eat snacks accordingly. If unsure, start with eating around 15g of carbohydrate every 20 minutes of exercise.

After the Ride

  • Have a snack/coffee post-ride, especially if you are driving home
  • Monitor blood glucose levels for up to 24 hours
  • Reduce bolus rates by 25-50% up to two hours are the ride
  • Make any necessary adjustments to the approach for the following week.