).
I love the fact that I rarely have to prick my finger, and the alerts have saved me from many highs and lows.
Perhaps the best thing about them is that they provide context to glucose values.
Knowing that you’re 100 (5.5) is one thing; knowing that you’re 100 (5.5) and dropping or rising is another entirely.
I was officially sold on CGMs when I completed my first ten-mile run, the Broad Street Run in Philadelphia.
I ran the entire course with my CGM receiver held tightly in my fist, glancing at it as I approached each rest stop to see if I needed to grab water or something with sugar in it.
My control was immaculate, and I finished the race without having to stop once.
Several years ago I added another injectable medication to my treatment program: pramlintide (Symlin). This hormone, produced by the beta cells of the pancreas (and lacking in those of us with type 1 diabetes) helps to slow down digestion so that blood sugars don’t spike right after eating. The combination of rapid-acting insulin and Symlin worked wonders. Gone were the 300-(17)-plus blood sugars right after eating; instead, the readings stayed remarkably stable between meals.
Unfortunately, Symlin had its share of drawbacks for me, including some pretty intense nausea every morning right around 11 a.m.
So I switched over to an injectable GLP-1 receptor agonist (don’t sweat it, these medications will all be explained in detail in Chapter 3 ), which provides modest improvements in after-meal control without all the side effects.
More importantly, it produces around-the-clock appetite suppression.
Without it, right now I’d either be too busy snacking or too distracted by hunger to finish this story.
I’ve also dabbled with a few oral medications intended for type 2s, such as metformin and SGLT-2 inhibitors.
The latest innovation that has me dancing in the streets is an off-the-grid technological advancement called Loop.
Loop is an app that takes an old insulin pump, mixes in CGM data, and applies an algorithm that automates several aspects of insulin delivery.
Commonly referred to as a hybrid closed-loop (HCL) system, Loop has given me the best glucose control I’ve experienced in over thirty years.
Granted, there are other HCLs on the market, systems developed by major pump companies that have been tested and deemed safe by government experts, and chances are by the time you read this, there will be newer and even better systems available.
But at this point, none is as customizable or downright effective as Loop.
You’ll read more about Loop and other HCLs in Chapter 4 .
But technology aside, the thing that has made the greatest difference in my ability to control my glucose levels is learning how to match my insulin to my needs. No more molding my life to fit my insulin program. No more taking fixed doses and hoping for the best. Now I shape the insulin to fit my lifestyle. And that’s what I try to teach my patients to do, to think like a pancreas!
As proud as I am of what we have accomplished in diabetes care and treatment, I can’t help but recall how proud my original endocrinologist was with the state of things back in 1985. Heck, I was pretty proud of the state of things back in 2010 when the second edition of this book came out. But ten years from now, I’ll probably look back to today and think, “Did we really do all that just to manage diabetes? That was totally medieval!”
Me and my Loop app, 2019
Research is progressing at a rapid pace.
We’re closing in on a cure from multiple angles: Artificial pancreas (full closed-loop) technologies.
Islet cell transplants.
Novel immunotherapies.
Even “smart” insulin that only works when needed.
The cure will arrive some day, but we can’t sit around waiting for it to happen.
We have to take care of ourselves here and now, because our long-term health and short-term quality of life depend on it.
So support research efforts wherever and whenever possible, but think like a pancreas while you’re at it.
And maybe, with a little luck, I won’t ever have to work on a fourth edition.
CHAPTER HIGHLIGHTS
• I, like you, think diabetes is a royal pain.
• My diagnosis took place in 1985 in Sugarland , Texas. God’s honest truth.
• Diabetes self-management has evolved considerably over the past several decades.
• Support diabetes research, but don’t forget to take care of your diabetes today.
Think Like a Pancreas
TWO
“Glucose. Control, Y’all. What Is It Good For? ”
(*sung to the tune of “War,” by Edwin Starr, 1970)
P icture this. You show up for your regularly scheduled appointment with your doctor, credit card in hand, ready to pay for your copay or deductible or whatever. “Hold on,” says the receptionist with a cheerful smile. “That won’t be necessary. Here you go.” She hands you an envelope filled with cash. “This is for all the diabetes management work you’ve put in since your last visit.”
That’s when the alarm clock goes off. Dream over.
Managing diabetes takes serious work, and at times it may seem like there’s no real point. Every day involves a series of repetitive tasks, decisions, costs, and time we could apply toward other things. So why bother? Why make all the sacrifices? You could do just the bare minimum to keep yourself alive, but that would mean missing out on some major benefits.
You could do just the bare minimum to keep yourself alive, but that would mean missing out on some major benefits.
What’s in It for Me Now?
We’ll get to the long-term benefits of proper diabetes management a bit later on. What motivates most people is immediate gratification . Not next year. Not tomorrow. Right now . Here is just a partial list of ways you can be rewarded immediately for managing your diabetes.
Immediate Benefits of Diabetes Control
Increased Energy
More Restful Sleep
Improved Physical Performance
Appetite Reduction
Brain Power
Stable Moods and Emotions
Fewer Illnesses
Faster Healing
Softer Skin, Healthier Gums
Personal Safety
Predictable Periods
Cash in Your Pocket
Increased Energy
Raise your hand if you like being tired all the time.
Okay, raise your hand if you’re too tired to raise your hand.
Elevated blood glucose reduces energy levels.
High glucose is a sign that you may not be getting enough fuel into your body’s cells to burn for energy.
The fuel is there, it’s just stuck in the bloodstream, kind of like gasoline trucks that drive around aimlessly instead of unloading at local gas stations.
This shortage of fuel inside the body’s cells causes sleepiness and sluggishness.
Even if the glucose is only elevated temporarily, the lack of energy will be noticeable.
As soon as the glucose level returns to normal, energy levels usually improve.
More Restful Sleep
We all know how important a good night’s sleep is for feeling good and being productive the next day. Sleep is necessary for allowing the brain to clear out the clutter from the previous day and prepare for new information and adventures. Getting sufficient sleep is also linked to appetite control. Production of the hunger-controlling hormone leptin is diminished in people who are sleep-deprived.
It may interest you to know that poor glucose control reduces the quality of sleep. If your glucose is high enough (typically above
180 mg/dl, or 10 mmol/l), you might wake up during the night to run to the bathroom.
This is caused by urine diuresis .
When glucose levels are elevated, the kidneys have a hard time keeping all that extra sugar in the bloodstream.
Sugar spills over into the urine, and it drags a lot of water along with it.
As the bladder fills, the brain becomes stimulated to the point that we can’t enter the deep, restful stages of sleep (this is why we wake up to pee instead of wetting the bed).
Spending more time in your target range is associated with more time spent in deep and restful “slow-wave” sleep in children and adults.
So, if the thought of a restful, uninterrupted night’s sleep appeals to you, manage your glucose levels!
Improved Physical Performance
Whether you’re an elite athlete or just hoping to make it up a flight of stairs without gasping for breath, glucose control has an immediate impact on your physical abilities. Elevated glucose can reduce your strength, flexibility, speed, and stamina.
Keeping blood sugar near normal will result in improved strength, speed, flexibility, and stamina.
Sugar is our muscles’ preferred fuel for making rapid bursts of movement.
Limiting access to sugar is a detriment to one’s strength.
Extra sugar in the bloodstream also leads to something called glycosylation (sticking of sugar) to connective tissues like tendons and ligaments, thus limiting their ability to stretch properly.
Muscle stiffness, strains, and pulls are common in people with chronically elevated glucose levels.
Excess sugar can block the connections between muscles and nerves, resulting in slower reaction times and blunted reflexes.
Extra sugar in the bloodstream limits our red blood cells’ ability to deliver oxygen to our muscles.
This can cause fatigue and limited cardiovascular and aerobic capacity.
Dehydration and cramping are also common side effects of hyperglycemia (high blood sugar) as a result of urine diuresis.
When glucose levels are near normal, your reaction times will be quicker, and you will recover from injuries more rapidly.
Many of my patients have tracked their performance in a variety of sports and have consistently performed best when their glucose is in the 80, 140 mg/dl range (4.5, 8 mmol/l).
One young man received his first MVP trophy in a hockey tournament after he managed for the first time to keep his blood sugar from going high or low throughout the matches. (We’ll discuss details regarding sports and exercise control later on.) Overall, you’re likely to see improved performance in all sorts of activities, from carrying groceries to playing soccer to lovemaking, when your glucose levels remain near normal.
Appetite Reduction
This might sound totally bass-ackwards, but high glucose can actually make us crave more food, especially carbohydrate-rich foods. Remember, the amount of sugar in the bloodstream is not what counts, but rather how much gets into our cells. And if not enough is getting into our cells, hunger will be increased. So controlling glucose levels is a good way to keep your appetite in check, important for anyone trying to lose weight, maintain their weight, or avoid excessive between-meal snacking.
Brain Power
High and low glucose limits our ability to focus, recall information, perform complex tasks, and be creative. Research studies have repeatedly and consistently shown that as glucose levels go up, so do mental errors and the time it takes to perform basic tasks. Wide variations in glucose levels, such as postmeal spikes, have also been shown to hinder mental function. Likewise, if glucose levels are too low (typically below
55 mg/dl or 3 mmol/l), the entire nervous system lacks the fuel it needs to operate correctly. So if you want to perform as well as possible at work, in school, or in a friendly game of Fortnite, keep those glucose levels within range.