A voice for living well with Type 1 Diabetes

This is not a comprehensive list of how to live well with T1D. (You can find those in the categories that make up the Living Well Model.)  But here are the handful of moves I consider the best – and worst – for living with type 1 diabetes.

Best 5 Moves

#1:  Getting Basal Rates Right

For the first 25 years of living with diabetes, I wasn’t familiar with the term basal insulin. It wasn’t until I went on an insulin pump in 1989 that a nurse educator shared the concepts of bolus and basal insulin. Here’s what I learned.

Basal insulin is the ‘base level’ of insulin all humans require to maintain constant blood sugars. Think of it as a continuous drip of insulin and the amount needed to keep blood sugars level if we’re fasting.  For most, basal requirements change several times over 24 hours.  For people with a healthy pancreas, it happens automatically.  For type 1s, we need to figure it out.

I’ve found that nailing basal rates is the best daily move to living well with type 1 diabetes. Why?

  • The most obvious is that it solves a constant variable over 24 hours.  Basal insulin is the foundation for other insulin decisions like meals or exercise.  With a solid foundation, we can …
  • Concentrate on one-time events, including meals (pizza or salad?) and exercise (yoga, running, or weight lifting?).  Each of those items in parenthesis is very different and requires effort to estimate the amount and duration of insulin.
  • Live and act with more confidence.  I rarely eat or bolus insulin when I’m ‘ON.’  (Why? Too much active insulin from meal boluses can move my blood sugars low. And just knowing bolus insulin is active makes me anxious that my blood sugars will plummet.)  For me being ‘ON’ means work presentations, facilitating meetings, and exercising.  With the proper basal rates, I concentrate 100% on what I’m doing because my basal rates should keep my blood sugars stable … and, most importantly, not go low.
  • We feel better when blood sugars are in range … and good basal rates facilitate that!
  • You’ll sleep better and get 25-35% of your day in range.

Lesson learned:  Getting basal insulin right (*) gives us a real advantage … 24 hours a day.

(*) For a good article on determining basal rates, here’s a link to our friends at mySugr:  https://www.mysugr.com/en-us/blog/basal-rate-testing/


#2:  Fewer Carbs, Less Insulin

A quick fact about human bodies:  Insulin is required to break down carbohydrates into sugar, our body’s energy source.

The more carbohydrates we consume, the more insulin we type 1s need to estimate, time, inject and understand its duration. My experience is more insulin results in higher variability in blood sugars. Conversely, less insulin is a move to more stable blood sugars.

Less insulin means fewer carbohydrates in our diet.  Does that mean we’ll starve or be hungry?  Quite the opposite. By replacing carbohydrates with protein and fats, I  feel full longer (the sugars from protein and fat enter our blood over a more extended period).  I’ve been doing this for the past 20 years with a 40-30-30 approach to nutrition (*), and spending less time on the blood sugar roller coaster is nice!

Lesson Learned:  Fewer carbohydrates = less insulin => more consistent blood sugars

(*)  40-30-30 is an approach that has 40% of calories from carbohydrates, 30% from protein, and 30% from fats.  For more 40-30-30 nutrition, check out this link:  https://www.ideafit.com/nutrition/the-science-behind-40-30-30/

#3:  Exercise … the Great Equalizer

As a kid, I was active and enjoyed playing sports.   This continued in college and into adulthood as I began my world of work.   Although most of my career hasn’t been physically demanding, I have always wanted to go for a run, work out, or do something active several times a week.

The benefits of exercise to the human body are well documented:  less stress, better circulation & blood profiles, improved moods, and a sense of accomplishment.

As a person with diabetes, though, exercise provided me with even more. It’s been the great equalizer.  With so many variables influencing blood sugar, exercise proved a soothing influence. My insulin requirements are lower when I exercise, and my blood sugars are less varied than when I haven’t gotten the blood pumping. In addition to its’ positive influence on my blood sugars, exercise has provided me with the following:

  • an escape – a place where my mind and body could concentrate on something else. A nice mental break from the daily grind and the stress that comes with it.
  • A way of lowering high blood sugar fast. What … unexpected high blood sugar? I found that exercise lowered my blood sugar faster than insulin.
  • Something positive. I enjoy exercise – more endorphins floating around in the brain.

There is one area where exercise has caused caution and care.  When exercising, I found that I must understand & monitor insulin levels.  My blood sugars frequently go low when exercising with insulin boluses recently injected for meals or to lower blood sugar (sometimes called ‘insulin on board’ or ‘active insulin’).  So I either reduce my meal bolus or exercise only with basal insulin active.  Even then, I usually reduce the basal when I exercise aerobically for more than 2 hours.  I want to emphasize that this is what works for me.   In conversations with other diabetics, insulin modification with exercise is highly individualized.  The critical point is to know that while exercising for long periods, you’ll need to monitor & understand your body’s insulin requirements.

#4:  Dental Care

Ignore your teeth, and they’ll go away.  And make you sick.  And for type 1s cause higher blood sugars.

For a brief period (yep, my 20s), I did not care properly for my teeth and gums.  As a result, I became sick often … viruses like the flu and colds took me down for prolonged periods. I ended up with periodontal disease.  And once the damage was repaired, I was advised to take better care of my gums and teeth.

Since then, I floss, brush my teeth daily, and get dental cleanings every three months. As a result, I don’t get sick much, and good dental hygiene has helped my blood sugars stabilize.

Lesson Learned:  Healthy gums and teeth improve overall health, including blood sugar levels.


# 5:  Proactive Insulin Moves

Injected insulin starts working later than insulin delivered by a healthy pancreas. To compensate, I adjust insulin for activities I can anticipate … like eating and exercising.

Before meals, I pre-bolus 25% of my total estimated insulin to cover the carbs.  Why not do the entire bolus?  Either food isn’t ready immediately (especially when eating out), or I change my mind about how much I eat.  As I start to eat, I dose the remainder of the bolus.  It’s a move that gets insulin active before meals.  The result?  Smoother post-prandial (after meal) blood sugar levels.

I exercise with little, if any, active insulin from boluses.  I’ve found that exercise amplifies the impact/action of insulin.  If I’m running high blood glucose before an aerobic workout (running, cycling, walking) or if I eat during the workout, I dose 30-50% of the normal bolus amount, depending on the intensity and duration of exercise.  If it’s an anaerobic workout (e.g., weights), I dose 75% as the anaerobic work keeps my blood sugars up.

As for stress, my proactive decision is to wait. But … is that really proactive?  I say absolutely, as I’ve found the influence of stress on blood sugars to be highly inconsistent.  Sometimes a cold or flu will send my numbers south, and other times up. I’d rather wait and see the trend and then treat it. Because it’s a reactive move, this is an area where the algorithms guiding a closed-loop system can be effective.

And speaking of closed-loop tech, I’ve found their automated adjustments with basal rates – especially in anticipating and reducing lows – effective outside of meals and exercise.  But they can’t know in advance when I’m eating or exercising.  And because closed-loop algorithms react to these events, the insulin is either late (when eating) or too much (when exercising).


Bonus Tip:  Relationships with Medical Device & Pharmaceutical Company Representatives

Want to know who’s motivated to help with our growing number of medical devices and meds?

If you answered our endocrinologist and diabetes nurse educator, I agree.

But another group has more time – and vested interest – in us using products and medications the right way:  the people working for the medical device and pharmaceutical firms.

Want to know about a blood meter, insulin pen, pump, or CGM?  Find the name of the local sales rep or clinical specialist that serves the area where you live.  They will help educate you (*).

The other benefit of knowing your local rep?  You’ll know who to reach when you are in a pickle.  An example is when I started using a Tandem TSlim X2 pump with Basal IQ.  I wore a Dexcom G6 intermittently with my previous pump but could not locate the Dexcom transmitter.  I reached out to the local Dexcom rep, who, within 2 hours, had a Dexcom Starter Kit in my hands (**).  Now that’s service!

Lesson Learned:  Besides the team at your endocrinologist’s office, get to know the medical device and pharmaceutical reps that support your area.  (Your endo team can introduce you.)

(*) Please understand their motive is to sell a product, but I’ve found most clinical specialists and sales reps to be good listeners and share how their company’s product could work for you.

(**)  This made a huge difference as basal IQ saved me numerous times over the upcoming stressful weekend when travel was constant, and food was not readily available.


Worst 5 Moves

#1: Living Alone

One super low hypoglycemic episode without help nearby is one too many. And that’s why living by myself after moving to Atlanta was my worst move living with diabetes. I knew no one when I moved there, so I didn’t have a connection to roommates. I bought a house and mainly lived alone for a decade until getting married.

During that time, I had a handful of mornings where I didn’t wake up due to extremely low blood sugars.  Each time I was fortunate to have friends or family check in and treat me to regain consciousness. I could have easily died due to extreme hypoglycemia (*).

Lesson learned:  If possible, live with others that know how to check and treat blood sugar levels.

(*) Although rare, sadly, a small number of type 1s die suddenly each year due to severe hypoglycemia. I found this sobering article:   https://www.diabetes.co.uk/diabetes-complications/dead-in-bed-syndrome.html


#2:  Judging My Blood Sugars

Blood sugars in range … Good.

Out of range … Bad.

That’s how I was taught to think about my diabetes. Medical professionals introduced the concept of grading and placing judgment on my blood sugars and it was reinforced by well intending friends and family members.

To this day, I continue to judge my #s. I can get frustrated and upset when my #s are high.  My competitive instincts take over when my blood sugars don’t land with my insulin to carb/exercise plan.  And it makes for a bad time for me and others.

What do I wish?  Stop thinking a blood sugar of 250 is bad. To not interpret a blood sugar of 115 as good. To look at them as just numbers.  That can be managed.  And moved.  Without judgment.


#3:  Not sharing my diabetes

Growing up, having diabetes made me feel different. From age three, my days started with an injection. I was required to eat at prescribed times. My elementary school teachers knew about my condition and kept an eye on me. I was excused from class and walked to a closet to eat a mid-afternoon snack without my classmates seeing.  At birthday parties, cupcake icing was shaved off for me only. Doctors were concerned and advised me not to be vigorous with physical activity.

People that knew about my diabetes treated me differently than my peers.

As a result, I shared my diabetes selectively, usually with people I trusted who would not judge or treat me differently. I never told my high school or college baseball coaches about my diabetes (*). The execs and managers at my first job working at a public accounting firm didn’t know. As for dating, I waited until a relationship became serious (**).

Sharing something important like diabetes is a personal decision. And the timing is different for each of us. But not sharing my diabetes with coaches, college professors, and business decision makers wasn’t fair to me … or them.  There were times in college, during work, and while playing baseball when hypoglycemia set in. Test scores were low, work performance suffered, and my fastball became a changeup. Had I explained my diabetes, it could have been understood, and people could have helped.

Lesson Learned:  Get an elevator pitch ready to share your diabetes. Practice it. Share it with those with a need to know that could be in a position to understand and offer help.

(*) I wasn’t alone. Ron Santo, a Major League Baseball Hall of Fame player with the Chicago Cubs, did the same thing early in his career.

(**) This sometimes resulted in … well, misunderstandings.


#4:  Stacking insulin

When elevated blood sugars don’t react to correction boluses, I sometimes correct them again … and again.

Why?  Because I become frustrated when a high number doesn’t budge.

This move has several names: over-bolusing, over-correcting, emotional bolusing, and stacking insulin. No matter what it’s called, repeated doses of fast-acting insulin at close intervals can cause a diabetic’s blood sugar to go too low.

Let’s face it … there are times due to illness, stress, exercise, or something we ate that cause a blood glucose level to stay high.

And there are times stacking insulin works.  But more often than not, it results in a wicked low, which leads to eating the kitchen sink and another high.  And we’re back on the blood sugar roller coaster.  ARGH!

When correcting high blood sugars, patience is a virtue.

Lesson learned:  Be patient with insulin. Let it do its’ job.  On its’ time.  Not mine.


#5:  Drinking alcohol on an empty stomach

Quick fact about our bodies:  Our liver processes the food and drink we consume … including alcohol.  Drinking alcohol without food can numb the liver.  And lead to dire consequences.

I’ve consumed alcoholic beverages on an empty stomach and discovered my blood sugar below 70 an hour later. Attempts to move the # up with carbohydrates don’t work … because the liver won’t process them.  Blood sugar continues lower.

It’s a helpless feeling that is only remedied by time (for me, it’s usually a couple of hours after drinking). Only then can the liver start processing the carbs lined up and ready to be processed.  The result?  Yep … massively higher blood sugars.  Ugh.

Lesson learned:  consume food before or when drinking alcohol.