How I Get Out Of Diabetes Crises
Bed time CGM reading: 106. Wake up CGM reading: 270. I woke up three times during the night and I feel hammered.
My blood sugars keep fluctuating and any bolus correction is in vain. It actually compounds the problem: I am frustrated now, so my excessive rage bolus has sent me into hypoglycemia. I pick whatever food is available, stuff it in my mouth, and one hour later I am back at 300.
I am trying to focus at my desk, but it is impossible. I’d like to eat with my friends, but I must wait one hour for the hyperglycemia to come down.
It doesn’t. I am hungry and angry, so I decide that today’s a lost day, and I go eat some comfort food, which further strengthens the vicious cycle.
Sounds familiar?
That’s what I call a “Diabetes Crisis”. Last week I wrote about diabetes and burnout, stressing the importance of understanding the part of diabetes management that are under our control and tackling those head on. Diabetes crises are a great use case because when I figure I am into one I immediately know I must get out of it as soon as possible. While all crises and emergencies feel overwhelming at first, with the years I’ve found that confusion can be tamed and the clarity required to guide effective action can be found again.
How? Let me outline my “self-rescue plan”!
Embracing The Suck: Recognizing I Am In A Diabetes Crisis
First of all, I must acknowledge that I am in a rut, and that is not easy to do, because I am often so busy living that I am setting the autopilot and jumping from thing to thing without much reflecting becomes the default. That is why I emphasise the importance of journaling so much.
When I write down that my blood glucose has been out of control for one day, it might go unnoticed. When I do that twice, I am at least turning up my nose. At the third time, I recon there’s something going on, and I can only ignore it for so long before I decide it’s time to do something. Writing stuff down with pen and paper is the single best way I found to hit the pause button for a few minutes during my day and observe what’s happening.
It also helps me draw some lines between life events and hypothesise some patterns. Perhaps I am stressed at work, I am losing some sleep and that reflects on my blood glucose levels. Perhaps I’ve been enjoying more junk food than I should’ve, who knows. Whatever it is, it is on paper now and I can see it.
Even a mere one to two minutes note on the phone can do the trick, but I prefer having no devices around when I want to think.
Once I have written down my two lines and am sure I am in a rut and my diabetes is out of control, I can finally take a moment to embrace the suck of the situation, and the upcoming suck of having to solve it. Living through blood glucose swings is not fun! I have to skip meals, I can’t work properly, I can’t sleep well and every activity I decide to embark on is likely to be brutally interrupted my my CGM alarm.
Moreover, my frustration often leads me to binge on junk food, which makes everything worse. I know it’s bad for me but I can’t stop eating, and I feel bad.
So yes, at this stage embracing the suck is all I need to do.
Then I take a breath and encourage myself, because there are many things I can do to improve the situation. I am ready to embrace all the suck of the world and to take action.
The Alignment Habit: I Read My “Values Sheet” And My “Objectives Sheet”
I start from the big picture.
I have a google doc bookmarked on all my devices listing all my objectives for the year and on a longer time span, and one that lists the core values I live by every day.
On the document listing my objectives (related to health as well as all other relevant areas of my life), I have answered to two questions:
What do I want to celebrate 12 months from now?
How do I want to live my daily life when I am 100 years old? (What Dr. Peter Attia has defined as “The Marginal Decade”)
The first row of both documents’ states “My Health is My Top One Priority”. And every day that passes I am more convinced this is a great priority to have at the top, because everything else depends on it: the quality of my work life, of my personal life, of my ability to use my body, of my emotional life, and so on.
Among other things, I have stated that over the next year I want to celebrate a 90% time in range over the entire year, an improved insulin sensitivity (which I proxy using my carbs-to-insulin ratio). I also want to be running marathons when I am 100 years old and do that with ease and thanks to a healthy body.
These objectives are tangible and measurable. They are voluntarily ambitious, but they clarify what needs to be done, what is the priority every day of my life: the pursuit of health. There’s no confusion surrounding what every action must be aligned too now.
While they might seem vague, they bring immediate clarity and leave no room for hesitation about what the next action, today, now, should be. A 90% time in range over an entire year means that on most days I have eaten correctly, I have dosed my insulin appropriately, I have moved, I have slept well, etc. To make it happen, the best thing I can do now is to make the right call on food, to fill my journal with the latest CGM reading, and so on.
Running marathons at 100 years is what defines my overall trajectory, my life journey. It means that, first and foremost, I am a healthy 100-year-old man, which is a victory in itself. It also means that I have not suffered complications that a bad management of type 1 diabetes can generate: my blood vessels are efficient, my cardiovascular health is there, my legs and my feet are still in great condition and my sight is not compromised.
When I feel a lack of motivation or feel confused in some way, I also revisit book notes or podcast episodes that bring the relevant theoretical information behind my actions right back to surface. If my body needs too much insulin, that’s a sign of insulin resistance, and Peter Attia’s book Outlive helps me remember why I must do everything in my power to avoid it:
[…] insulin resistance itself is associated with huge increases in one’s risk of cancer (up to twelvefold), Alzheimer’s disease (fivefold), and death from cardiovascular disease (almost sixfold)—all of which underscores why addressing, and ideally preventing, metabolic dysfunction is a cornerstone of my approach to longevity. […] chronically elevated blood glucose, as seen in type 2 diabetes and prediabetes/insulin resistance, can directly damage the vasculature of the brain. But insulin resistance alone is enough to elevate one’s risk. […] Clearly, it is helpful to get glucose into neurons; insulin resistance blocks this.
Otherwise, I re-listen to interviews to diabetic athletes who completed Ironman triathlons while eating well and being in control of their diabetes.
Or I might get a refresher on the science of junk food and why it is a good idea to stay away from it on this Huberman Lab’s episode.
And on and on. All these bits of information I’ve collected in time help me find the path again.
With this newfound clarity on my priorities, I move back to the present. It still sucks, but I have reminded myself about what I am striving for, and now taking some low friction steps to get out of the rut feels easier.
Environmental Design: I Put The Tools On The Table
Remember: it still sucks. My blood glucose is still all over the place. I am right in the storm and have very low motivation or energy to do anything too audacious. So, I start small and try to set myself up for success by redesigning the environment. This one comes straight from the Third Law Of Behavioral Change in James Clear’s book Atomic Habits: Make It Easy.
I must make it easy for me to log my carbs and insulin on my journal, to avoid cravings and junk foods, to exercise and all the rest.
Thus, I put my diabetes journal on the table, so I don’t forget that I have to count my carbs and my ratios.
I stop buying comfort foods because having them in the kitchen means I’ll surely eat them all, and I fill my fridge with green light foods - my favourite ones when I can’t decide are apples and dark leafy greens. Now, if I want junk food, I have to at least walk to the supermarket with the intention of buying it, which is a big enough barrier.
Reading my values doc has reminded me that while a comfort food might taste good in the moment, there’s nothing good in the detriment it creates in my body in the long term. So “enjoying life” has been redefined from “enjoying pizza” to “enjoying the type of food that will increase the odds that my daily life is still enjoyable ninety years from now”.
I also lay the yoga mat on the living room’s floor and keep it there, so it’s always ready to be exercised on. I keep my kettlebells at the center of the room, so I can pick them up and carry them around - and if I don’t want to, I stumble on them.
I keep my meals very very simple, so I spend little time cooking and spend even less money buying the ingredients. Raw apples are a go-to. A simple oatmeal or canned beans are always low friction options in this situation. No need to cook anything.
With these elements arranged in my environment, I am ready to welcome the food cravings, observe them and let them go - because all I can really eat now is apples, salad, beans and oats.
If this becomes too much to bear, I go find some peace outside, in Nature.
Finding Peace and Breaking the Loop: I Take Silent Walks
Nature heals us. Nature heals me. Sometimes I am at home and feel bombarded with stimulations. I keep opening the fridge in search for something to snack on, I become lazy on the couch, I try to resist the urge to do nothing and feel bad for continuing to do nothing. All while the noise of a Netflix show is hammering my ears.
So now not only my diabetes is out of control, but I also have a headache. Excellent!
The single best life hack to break this loop is so easy I always feel dumb for having done that already: go for a walk. No podcast, no music, no screens, nothing.
A silent walk smiling to people, observing the trees, the sea or merely the crowd walking by, breathing deeply. This puts my mind at ease for a while and helps me reconnect with my intentions and with the fact that not everything is lost.
Nature and silence are key. And yes, they help me a great deal when diabetes management gets tough. In my experience, confining myself in a room is the fastest and most effective way to burnout. I can’t control my food cravings, I can’t make sense of my insulin, I can’t understand anything. Plus, since I am sitting on a couch binging some shows, I am not moving, and I am breathing stale air.
Going outside is like a medicine. And I’d argue it’s even been better than most medicines for me. Out there I get natural light exposure, breathe fresh air. Perhaps get to see something interesting. If not, I am ok getting lost in the ordinary. I also keep my body in motion, getting my eyes to stare at the horizon, the trees or the sky.
In essence, I am decreasing the levels of stress, reconnecting with mother nature and moving, three of the biggest levers I can pull to fix my blood sugar rollercoaster.
And I am doing a good mental clean up, clarifying my intentions, restating my values and renewing my vote to live by them.
I like to use my walks to brainstorm and identify one, only one, aspect I want to improve. If I’ve been binge eating pizza slices or medjool dates, this might be committing to eat one less than yesterday. Not even “stop eating that”, just “one less” is something I can celebrate as a win. And it will build the momentum necessary to eat two less the time after, and ultimately get back in control.
All I need is to gather some evidence that I am the one in command. Eating one less piece (or filling my diabetes journal or counting one meal’s carbs) are all tiny and quick actions I can always rely on to build up my confidence again and find the strength needed to get out of my crisis.
These decisions and insights only occur to me when I detach from the noise of every day’s life, from the busyness and the chores and the overload of information coming from my laptop. In silence, I can make better decisions and pursue better actions.
As Robert Pirsig wrote in Zen And RThe Art Of Motorcycle Maintanance,
The silence allows you to do each thing right.
One small, good action after the other, and you’ve suddenly stacked ten good actions. And they compound. And they make you feel good again!
Brute Force: I “Goggins” the Issue
I have one last tool in the box, a last resort of sorts. If I am too weak to commit to anything, even the smallest of things, I “Goggins” the issue.
As David Goggins put it in his appearance on the Huberman Lab Podcast, sometimes
No, you're lazy, you know exactly what to do, exactly what to do. Because even me, in my state of, I can't read and write, I knew exactly what to do. It just sucks doing it, it sucks to do it. It sucks to wake up every morning of your life and say, God, man, I'm not smart. So guess what I gotta do? I gotta study the same s**t that I get one of the highest scores in the nation on, and do it again, do it again, do it again.”
[From Huberman Lab: David Goggins: How to Build Immense Inner Strength]
When I find myself complaining too much about something, I just apply brute force. That pizza looks tasty? I throw it all in the trash. Those dates? In the trash too. Don’t feel like doing ten steps? Lace them up and go run 20 kilometres. Don’t want to count your carbs? Not only I am going to count them, I am also going to read a scientific paper on the role of whole sources of carbohydrates for the regulation of blood sugar levels.
And I am only going to see the next medjool date once I’ve done everything perfect for one year straight.
Applying brute force is sometimes necessary and effective. It is the wake up call that erases any feeling of victimhood and shows us that we can do what’s right, if only we stop complaining.
As a diabetic, I know what lifestyle habits are good for me: eating well, moving, sleeping, calculating my doses with care, and so on. Except that sometimes I am too lazy to do it, and then I complain about the consequences.
Of course, I won’t blame myself when life throws it at me despite my best efforts. In that case I just sit with the storm, take shelter and keep doing all that is in my power.
But if lack of effort to understand the problem and laziness to set out to solve it are the issues, then it’s on me. And if I need to go run 20 kilometres to compensate for not feeling like walking 5 minutes, then running 20 kilometres is the right thing to do.
Forging the mind is the last tool in the box.
Being Patient
Once I’ve done everything I can to solve the diabetes crisis, I simply trust the process and wait. If the blood glucose was chronically high for “no reason”, and I’ve done all the right things I know I could do (de stressing, moving, sleeping, fixing my diet and my tracking habits etc.), then I can be confident that my hormones will regulate.
I am a human being, so I must take care of the basic pillars every human needs to be healthy: water, air, light, movement, nutrition, sleep, nature.
Things will get better, I’ll have grown in confidence and become more experienced. Next time a crisis happens, or I find myself in the hole, I’ll have a few extra pieces of knowledge to dig myself out of it.
Being clear about my values and my long-term health goals, being process oriented, rigorous, forgiving, mindful, tough and disciplined.
And if I am still in high waters, I know that small wins compound, no matter how small they are. As David Goggins puts it in Never Finished, there’s still a chance to steer the wheel
When your entire day is messed up, make sure that you achieve something positive before lights out.
That’s how I got out of my last diabetes rut, and how I’ll get out of the next.
