NOTE: The top part of this post is background and basics. If you are a diabetic who wants the advanced techniques, they are further down a bit.
Being a Type 1 diabetic sucks. But, if you know anyone who is diabetic then you likely already know that. Over the last twenty years I've tried many different drugs, diets, techniques, and hacks all meant to keep me alive as long as possible. Diabetes is the leading cause of blindness, liver failure, kidney failure and a bunch of other stuff that also sucks. It would be really awesome to die of regular old age rather than some complication of diabetes.
Every few months a diabetic should get a blood test call an hA1c that is a measure of long term blood sugar control. A normal person's A1C is between 4% and 6% which roughly corresponds to a 3 month average blood sugar of between 70 and 120mg/dl, which is great. My A1c has been around 6.0 to 6.7 which is under the American Diabetes Association's recommendation for Type 1 diabetics of 7.0, but not as low as I'd like it.
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I recently redoubled my efforts and lost about 30lbs, started working out more and removed more carbohydrates by implementing a relaxed paleo diet. This, combined with some medical equipment changes that I discuss below have resulted in my latest A1c - just in last week - of 5.7%. That means for the first time in nearly 20 years I have maintained near-normal blood sugar for at least 3 months.
Basics
A Type 1 diabetic doesn't produce any insulin, and insulin is required to process sugar and deliver it to the cells. Without insulin, you'd die rather quickly. There's no diet, no amount of yoga, green tea or black, herbs or spices that will keep a Type 1 diabetic alive and healthy. Type 1 diabetes is NOT Type 2 diabetes, so I'm not interested in your juicers, raw food diets or possible cures. I've been doing this with some success for the last two decades and I plan to continue - also with success - for the next two.
If you blood sugar gets too high you'll die slowly and rather uncomfortably. If your blood sugar gets too low you'll die rather quickly (or at the very least lose consciousness). The number one goal for a Type 1 Diabetic is to effectively manage insulin and blood sugar levels by simulating a working pancreas where there isn't one. You eat food and your blood sugar rises. You take insulin and your blood sugar lowers. You can prick your finger and check your blood sugar directly then perform some calculations and inject yourself with insulin. If everything works out well then your blood sugar is stable just like a "normal" non-diabetic.
Unfortunately it's never that easy, and in the case of Type 1 diabetes there's a number of factors that complicate things. Sometimes blood sugar rises on its own, sometimes due to illness, hormones, or any of a dozen other factors. The most difficult issue to deal with is that of lag time. When you check your blood sugar you're actually looking at the past. You're seeing your blood sugar in the past, sometimes 15-20 minutes ago. When you take insulin it won't start working for at least 30 minutes, often as long as 60 to 90 minutes. I talk about this in my post Diabetes: The Airplane Analogy. Try flying a plane where your altimeter shows you the past and altitude adjustments are all delayed. I would imagine it's not unlike trying to pilot the Mars Lander. Sadly, there is no such thing as "real time" when it comes to diabetes management.
Basic Management
Basic blood sugar management typically comes down to carb counting and insulin dosage. You'll learn from a Diabetes Educator that your body (everyone is different) will react to insulin in a certain way. You'll learn that, for example, your insulin to carbohydrate ratio might be 1U (1 unit of insulin) to 15g (grams) of carbohydrate. You'll read food labels and if there's a cookie with 30g of carbohydrates or sugars that you'll need to "cover" it with 2U of insulin.
That's the basics. Things quickly get complicated because not all sugars are alike. A cookie with 30g of carbs will "hit you" - or cause a blood sugar rise - much faster than an apple with 30g of carbs or mixed nuts with 30g of carbs. The speed at which carbs hit you is known as the glycemic index of the food. Fruit juices, starches, candy, all have high glycemic indexes.
Why should a diabetic care about how fast food raises their blood sugar? Because the faster your blood sugar moves the hard it is it control. If a cookie can raise blood sugar in 15 minutes but insulin won't start lowering it for an hour you can see how a daily rollercoaster of blood sugar spikes can get out of control.
A reasonably low carb diet makes Type 1 diabetes much easier to handle and manage. I avoid bread, sugar and anything "white." That means no white rice, no white bread, no white sugar. If I'm going to have bread, it'll be whole grain or sprouted wheat.
Portion Size and Cutting Carbs
You should rarely be eating a meal that is larger than your own fist. Better you eat 6 fist-sized meals than 3 giant plates a day. Reasonable portions avoid high sugar spikes.
Cutting carbs is surprisingly easy. I've done personal experiments with hamburgers, for example. A hamburger might require me to take 6U of insulin but that same hamburger minus the top bun was only 3U. It was still satisfying and yummy but that top bun was just empty carbs. That leaves more room for salad (with dressing on the side) which is a diabetic's "free food." You can eat raw veggies until you're bloated and in some cases take no insulin at all, while a Small French Fry could literally set you on a miserable rollercoaster of a day.
Fries and starches are simply off limits. If you eat them, you will pay the price. Pizza, potatoes, tubers of any kind are all effectively raw sugar. Same with all fruit juices and any HFCS (High Fructose Corn Syrup.) In fact, any "-ose" is ill-advised, including Fructose, Glucose and Dextrose.
The Poor Man's Pump
Not that many years ago insulin came in many speed variations. Some were long acting and some short. In recent years we've standardized on two kinds, very long acting where one shot lasts for 24 hours, and fast acting where one shot starts in about an hour and is gone in about four.
We need some insulin running in the background all the time just to stay stable. This is all the basal rate or background insulin. Then when we eat we need a bolus of insulin to "cover" a meal. Long acting insulin can act as the basal and short acting as the bolus.
For those that don't have an insulin pump (more on that later) a pump can be simulated by a long acting shot of an insulin like Lantis/Glargene once a day to act as a basal and then short acting insulins like Humalog/Novalog/Apidra for means. You can simulate about 80% of a pump with this "poor man's pump."
Insulin Pumps
If you've got an insulin pump like I have then you actually have no long acting insulin in you. Instead you've literally got a pump and a tube dripping insulin into your body. I've worn one 24 hours a day, while asleep and awake for over a decade.
So where's the basal or background insulin coming from? The pump actually contains only short acting insulin but delivers it in extremely precise and tiny increments all the time. For example, I usually have my pump delivering 0.5U/hr all the time.
Note that none of this is automatic. Pumps are not automatic systems and will only do what you tell them, fortunately or unfortunately. If you're willing to put some thought and effort into it you can do some interesting things with pumps that you simply cannot do with MDI (Multiple Daily Injections.)
Square Wave Basal (Buffet Mode)
One of the things a pump can do that injections simply can't is basal adjustments. Once you've taken a long-acting insulin shot, it's in you and it's going to do its work for 24 hours. The only thing you can do with insulin in you already is add more food or more insulin.
With a pump, though, you can program a either a Square Wave Bolus or a temporary Basal. This can be useful when at an event where you'll be "grazing" and eating little bits over a long period, or in situations where you're eating foods that will take a long time to digest, like pizza.
Temporary basals are also useful for exercise and activity. You can temporarily lower your background insulin for a few hours while you're hiking, for example. Lowering your basal temporarily is your best way to avoid exercise-related lows.
Often Type 1's get into trouble exercising because they'll work out, burn a hundred calories, have a low blood sugar, then eat a few hundred calories thereby negating the original exercise. Lower your basal an hour or so before exercise and set a timer to keep it low for an hour or two. Better an exercise-induced high than an exercised-induced low.
Temporary Basals while crossing Time Zones
I do a lot of international travel and often cross a number of time zones in a single trip as a diabetic. Diabetics on pumps often have multiple basals rates programmed on a schedule and this can cause issues when going overseas.
For example, here's mine:
- 3am - 0.75U/hr
- 8am - 0.5U/hr
- 6pm - 0.6U/hr
- 12am - 0.5U/hr
The 3am to 8am boost there is to manage the blood sugar rise known as the "dawn phenomenon." It's your body trying to get you ready for the day. It's part of your circadian rhythm and it's great for you. It's lousy for me though as it means my blood sugar will just start rising unchecked starting at about 4am.
When travelling, though, what's dawn to me? ;) It takes about a day to adjust for every time zone crossed. So even though I was just in Europe for a week, my "dawn" was slowly moving from the west coast of the US over the Atlantic all week. I needed to be aware of this as I set my pump's clock.
If you change your pump's clock to the destination time zone on the first day, your basals won't reflect your physical reality. You'll get more insulin at 3am local time, for example, but you likely needed it 4 or 7 hour before.
I've found that for simplicity's sake I set my basals while travelling to two 12-hour values, night and day. For example, on this trip I set to 0.6U/hr during the day and 0.5U/hr during the night. This allowed me to see when the dawn rise was happening and deal with it using a bolus, rather than risking a nasty and unexpected low at a seemingly random time. Use temporary basals to smooth things out. I'll set 4 and 6 hour temporary basals as well to "tap it down" or "float up."
Super Bolus
One of the most advanced and most powerful techniques is the Super Bolus. I tend to be a little prejudiced against CDEs (Certified Diabetes Educators) (sorry, friends!) unless they are diabetic themselves. No amount of education can match 24 hours a day, 7 days a week for 20 years. The Super Bolus is one of those techniques that we find after hard work and 3am suffering.
Since even fast-acting insulin often isn't fast enough you'll sometimes want a way to give yourself more insulin now without an unexpected low in 2 to 4 hours.
What you can do is turn off your pump effectively by setting a temporary basal of 0U/hr, and then give yourself the saved amount on top of your planned bolus.
Here's an example. You want to have some ice cream. You take 5U of insulin, your basal is 0.5U/hr. You eat the ice cream and have a bad high sugar in an hour and then a nasty low 3 hours out. The insulin didn't move fast enough to cover the ice cream, and when it did finally start working it took you low because your basal was ongoing.
Instead, you could take 6.5U of insulin and set a 3 hour temporary basal of 0U/hr. You have taken the 1.5U that would have been spread out over 3 hours and instead stacked it on top of the big bolus. The net amount of insulin is the same! You're just clipping that big high and bypassing that nasty low.
You'll need to find numbers that work for you, but the Super Bolus is a powerful technique for avoiding highs and still being able to eat some carbs.
Off-Label Drugs
There are a number of interesting new drugs out for diabetics that aren't super common but if you're interested in hacking your diabetes and you have a willing endocrinologist they could help you.
Symlin is a brand name synthetic amylin and replaces another missing hormone in Type 1 diabetics. Symlin is another shot you would have to take in addition to insulin. We tend to digest food really quickly and that causes nasty post-prandial (after eating) blood sugar spikes. Symlin will slow your digested to that of a normal person and clip those high sugars and allow your insulin to work. Talk to your doctor because it's serious stuff and not to be trifled with. Symlin induced low blood sugars can be really challenging to pull up out of. If you can get past the first two to four weeks of nausea it can be a powerful tool. I took Symlin for a number of years but now I only use it for a few large meals a year like Thanksgiving and Christmas.
Victoza is a new drug for Type 2 diabetics and is explicitly not recommended for Type 1s. However, if your doctor feels it would help you as a Type 1 it can be given "off label." It is a GLP1 inhibitor that also slows absorption of food and its movement through the gut. Finding the right dose can be a challenge, but since Victoza is a daily injectable you can adjust the dose one day at a time.
UPDATE/Correction from Karmel: "Minor point, but Victoza and Bydureon are GLP1 (with a P for glucagon-like peptide) agonists (that is, analogs)-- they mimic the action of GLP1, not inhibit it. Some T2 drugs with similar effects like Januvia are DPP-4 inhibitors, where DPP-4 inhibits GLP1, making a DPP-4 inhibitor a positive regulator of GLP1. But GLP1 we want"
Bydureon has a similar effect to that of Victoza except you take it once a week. It's also a Type 2 drug that is off label for Type 1s. It takes about a month to build up in the system before you see its effects and it can also cause significant nausea.
Order of Food
What a silly heading, but yes, the order you eat can affect your blood sugar. If you drink juice and eat bread before eating a chicken breast your blood sugar will rise faster than if you eat the chicken breast first. If you have a meal with fat in it then eating the fatty part of the meal will slow down whatever comes next. While cheese isn't really good for you, you can slow down the food that comes after it by eating cheese before crackers and an apple, for example.
Lowering A1C by Sleeping
Here's another trick that was so fundamental to getting my A1c down. You're asleep for 6 to 10 hour a day. Nearly a third of your life you're asleep. This is the perfect time to have great blood sugar. There are few feelings worse as a diabetic than waking up after a long night only to discover that you've had high blood sugar all night long. You've been marinating in your own sugar and you didn't even know. What a horrible feeling.
I try not to eat after 8pm so that I have from 8pm until I go to sleep to even out my numbers. You want your numbers to be either normal or heading clearly towards normal as you go to sleep. Just as they say for a good marriage you should never go to bed angry. I say for good A1c results you should never go to bed with bad blood sugar. Even if your numbers are garbage all your waking hours at least try to get them smooth and low as you sleep. Avoid doing anything to move them around after dinner. Eat your dinner, get back to normal, then have a basal rate you can count on and set it for as long as you can.
Equipment
Always be on the lookout for equipment that might allow you to better manage your blood sugar. Sometimes this is covered by insurance, sometimes it's not. It never hurts to ask your insurance company or your doctor.
I've used a Medtronic insulin pump with an integrated CGM for years. It's a good integrated system but the CGM has as considerable lag time showing my blood sugar about 20 minutes in the past. I have also been unimpressed with my OneTouch Mini blood sugar meter. I grow tired of calibrating and coding the meters and I also feel they aren't nearly as accurate as one needs for tight control.
This year I moved from my Medtronic Paradigm Continuous Glucose Meter (CGM) to a Dexcom Seven CGM. I also switched from a OneTouch Mini to a OneTouch Verio.
The OneTouch Verio is a near codeless meter from OneTouch. That means I can just plug in a strip without entering any codes or calibrations. It is rechargeable with a standard mini-USB adapter and it even as a lighted sensor area so you can check your numbers at the movies. (This is a bigger deal than you might realize.)
The Verio, in my opinion, skews high in its readings. When compared to the OneTouch Mini the Verio values are consistently 20mg/dl higher. This is actually a good thing because when calibrated with the Dexcom CGM it nudges me towards an even lower blood sugar goal.
The Dexcom Seven CGM is the single greatest piece of new technology I've ever experience since I was diagnosed at age 20. It's so profoundly amazing and so utterly indispensible I truly can't imagine life without it. It reduced the lag time for my readings from 20 minutes to less than 5. It's far more accurate than the Medtronic and the sensors can stay in for a week or more. It doesn't provide as much historical data as the Medtronic but the accuracy of the Dexcom is a thing to behold. I'm looking forward to the new Animas Vibe with the Dexcom integrated and plan on switching the nanosecond it comes out. Even though the Dexco is yet another thing to carry and keep charged I credit this CGM with helping me get the best A1c test results of my diabetic life thus far.
As with all random blog posts your read on the internet, remember this. I'm not a doctor. I'm just a random dude you don't know. Try all this at your own risk and under your doctor's supervision.
If you'd like to make a tax-deductible donation to the American Diabetes Association and be a part of Team Hanselman, you can donate securely here http://hanselman.com/fightdiabetes/donate. It is appreciated!
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