Diabetes Tight Control

I have had Type I Diabetes since 1988. I have been pumping Humalog since 1998. My hemaglobin A1C tends to be in the 5.5 – 5.9 range. I have had A1Cs as high as 6.3 and as low as 5.4, not counting my long honeymoon period.

The reasons to maintain tight control and to improve whatever level of control each of us has have to do with the Diabetic Control and Complications Test (DCCT) that was performed years ago. That long term test of varying levels of control proved the intuitively obvious. Better control reduces diabetic complications. It also quantified it. Those in the tight control group saw a 50% reduction in all diabetic complications except one. For retinopathy the reduction was 60%. Tha’s a 60% reduction in the chances of going blind. That’s huge. It also proved that it was not a simple tight control yes or no type question but that improvements in control at all levels reduced risks of complications. So, that’s some serious incentive for maintaining the tightest control we can, whatever that is for each of us.

I am probably not qualified to give much information about type II diabetes, as it is a completely separate disease with similar symptoms. However, some of the information will overlap. And, since exercise years ago dropped my daily intake of insulin from about 75 units a day to about 25 units a day, with my current level at between 20 and 45 depending on food and exercise, I may have something to say about insulin sensitivity as well.

Please feel free to ask questions about any topics listed here or not. I will do my best to answer with any information I have. If I do not have an answer, however, I will NOT make one up.

So, my main topics for control will likely stay limited to testing a lot, guessing food (I do not count carbs, I just eyeball and let my brain recognize patterns, something the human brain is good at), exercising, adjusting for increased food and/or exercise, and temperature (an odd one that I notice because I spend a lot of time outdoors).

Testing a lot is really key to my control. I am not willing to give up and have a highly regimented life. So, for me, whenever I am not in my normal workday routine, I am constantly testing. How much was that large weekend meal with friends? Well, my estimate was almost certainly off. That’s a given. So, I may do a reading as early as an hour later. And, since it’s almost certainly rising at that point (something I can now tell with continuous glucose monitoring, but knew even before that), If it is above what I consider a normal post-meal range, I’ll adjust with a bolus. Pumping makes it easy to adjust often, even by small amounts. Sometimes, I do a reading when my blood sugar is level and adjust by amounts as small as a few tenths of a unit.

When I guess my bolus, I do not count anything. I just try to sum up what I’m eating. I try to guess if it has more or less carb content than normal.. I also pay attention to fat levels, which slow food absorption quite significantly. For higher fat meals, I may take a square or dual wave bolus due to the lower glycemic index. I also tend to take square waves whenever a meal is large. Even if it’s all carbs, it’s going to take a long time to digest a big meal. So, I’ll take a big bolus for a large meal but also take a large square wave bolus.

Exercise has a huge effect. However, I notice that hiking has a much larger effect than paddling a canoe. I expect that part of this is because I typically insert my infusion site in a leg and part is because the activity is genuinely more strenuous. Of the activities in which you participate with any degree of regularity, learn which are more strenuous. Downhill skiing for example, is not particularly strenuous. However, maintaining body temperature when out in the cold is strenuous. It surprised me to actually prove this to myself. However, when I went camping on an ice floe in the arctic, I needed to cut my basal rate in half and bolus less, despite the fact that all of the work was done for us and we rode around in sleds pulled by snowmobiles the whole time.

In fact, by far, the vast majority of the calories that the human body burns in a day are to maintain body temperature. So, when you’re outdoors, pay attention to the temperature. If it’s cold, you may need to cut your insulin intake, either through a lower temporary basal rate, lower boluses or both. And, whenever you depart from your normal daily routine, test a lot.

Exercise is important not only for your overall health and fitness, but also for insulin sensitivity. This is the biggest overlap in care between types 1 and 2 diabetes. Exercise allows your body to absorb sugar with less or no insulin during the time of activity. Regular exercise reduces the need for insulin over the long term. My gut feel, based on nothing, is that it also makes it easier to control blood sugar since the body is more receptive to the insulin.

Also pay attention to weight gain and weight loss. If you are dieting (or gaining weight), your insulin need will change over time. A lighter body needs less insulin. This won’t be sudden, but do pay attention to when you may need to adjust your basal rates.

I also feel the need to point out that although I am lucky and seem to have a relatively easy time maintaining good control and get high marks from my doctor every visit, I do still see blood sugars above 200 and even the rare 300 as well as lows at and even sometimes below 40. I have come to the conclusion that it is not worth beating myself up over these. They happen. It’s part of not having a working pancreas. I do the best I can and that’s all I can do. So take them in stride. If you can find the cause and not repeat it, great. If not, just keep doing your best.

Oh, and doctors are an interesting issue. Personally, I see an endocrinologist specializing in diabetes. In my very humble opinion, it would be very difficult to really stay on the cutting edge of diabetes care and still be good as a regular physician. There may be exceptions to this. When my A1C reached 6.3, which I considered high for me, my doctor was able to help me get back below 6 in ways I would not have thought of on my own. I would personally have to recommend finding a doctor that specializes in diabetes if at all possible.

Again, please feel free to ask me anything that comes to mind with respect to diabetes care. If it is specifically about continuous glucose monitoring, please try to keep that on the thread that I have started solely for that.

If you are new to pumping, I may also be able to give some advice about that. I remember when I started, I almost gave up because I kept pulling my infusion site out by getting it caught on stuff. My minimed trainer said simply, “anyone can pump.” Thanks. What I really needed to hear was, “Stick to it. That may happen for a while. But, in time, your body will develop new reflexes to recognize the first hint of a tug at the site and stop dead in your tracks.” This took about a month and a half for me, during which time, I probably pulled out my infusion site accidentally on average about every day or day and a half. Then suddenly, one day, I felt myself stop in my tracks without thinking about it and it has become a rare occurrence since then.

Nothing else like that stands out in my mind. But, if you ask, I may remember something.