Manage in the Moment

Here is a quote from a d-parent I know:

“Our daughter has had type 1 diabetes for 6 years, her A1C runs as high as 8%. We’ve recently been using the insulin pump but can’t seem to control or balance the blood sugars during activities or after changing the infusion site. Can you advise us on how to adjust the pump?”

Ok, reasonable and common concerns I’ve heard for years. And I certainly understand the intent. But the focus might better be placed somewhere else besides primarily on the device. Patients and parents often tell to me they want to get themselves or their child “back in control” of their diabetes.

Questions like these are often asked in a way that implies that I’ve got a secret I might be able to share with them. Fact is, there IS a secret formula for high quality type 1 diabetes control. I’m going to post that secret right here for everyone to see and share. But here’s a hint: it has less to do with the prescribing of medications or specific devices.

Discussions about improving diabetes control too often revolve around finding or prescribing a different insulin dose, getting on or off an insulin pump, or changing the dosage settings on an existing pump. Too often it’s just all about the insulin. The "objective" trumps the "subjective".

It seems to me that some patients view diabetes “control” as something to be prescribed or dispensed by the health care provider. I actually don’t find that surprising. In almost every culture: the medicine man, the shaman, or the doctor are supposed to possess some power, magic or skill that the person in need can’t obtain on their own. And while this is quite true in modern medicine for many different disease situations, it’s less so for type 1 diabetes, which is a largely self-managed disease.

Staying alive and staying in control are two different things to me. While reasonable insulin use ‘keeps me alive’, there are hundreds of other daily actions and decision points which, properly orchestrated, ‘keep me in control’.

So…the ‘control’ of type 1 diabetes is not a static preordained set of actions. Rather, it’s a dynamic series of 1) information gathering steps, 2) self analysis, 3) decisions, and then 4) acting on the decisions made and repeating the cycle all over again just a bit later. This is what I mean by “diabetes care (control) is an ongoing series of choices”. Knowledge and experience are what fuel this self care cycle.

Control IS a process, not an isolated action or a prescription from a doctor. I see my control (displayed on my CGM monitor) as existing ‘in the moment’. I’m quick to point out that I don’t have a bucket of “diabetes control” that I can dip into and dispense to my patients to live on between their office visits. It just doesn’t work that way.

Control is a practicable skill, not and act. Dialing up an insulin dose, checking a blood sugar or measuring a portion of food does not mean I’m a well controlled d-patient any more than sawing a piece of wood, hammering a nail, or using power tools makes me a skilled carpenter.

My personal example makes my point: on a basic insulin schedule consisting of a single evening insulin degludec (Tresiba) dose (14 units) and well considered doses of insulin lispro (Humalog), frequent review and self analysis of my BG patterns, knowledge of the glycemic effects of the meals and snacks I consume, plus my CGM device, I can maintain a mid 5% hemoglobin A1C.

You see, it’s all about the PROCESS and less about the tools themselves. I feel entitled to say this since I wore a pump for 30+ years, and a pump-sensor combo for 3 years, before I simplified to injected insulin, BG meter and CGM data. As I said, staying alive and staying in control are different things entirely. You might say one must reside within the other and I would agree with you wholeheartedly.

We all must develop a sense of balance between our lives and our diabetes self care. It’s different for everyone and is influenced by age, attitude, and aptitude. Don’t despair when results don’t match expectations. Try to learn different tactics, different strategies, and consistently apply them towards the reasonable goals you set for yourself. Most of all, be realistic in your expectations. I’ve written already about the virtues of patience, consistency and resilience.

Many patients and parents search for this Holy Grail information like I did. I’ve found it (as have many other friends). You’re welcome to consider and use it as often as you wish or can.