Friday, January 10, 2020 - 02:41

Hi. I’m Sairekha Suresh. I was diagnosed with Type 1 Diabetes at 11 years of age. My diabetes is 24 years old. 

I am an attorney, and I head the Bombay practice of an outfit that specializes in the prevention of sexual harassment in workplaces. Simply put, my work takes me to different cities across India to sometimes train clients, and sometimes mediate disputes. Dream job. Nightmarish schedules.

4 am onward flights. Late night returns. Long uber rides. Airport coffees. Airline food. Hotel food. And long endless, emotionally charged meetings. My job demands are not exactly suited to textbook T1 necessities – i.e. carb controlled, nutritious food; timely sleep; and ambient stress levels.  But I’ve never been happier not living by that book!

Now don’t get me wrong. I would never recommend burning both ends of the candle. I do believe our bodies are temples and we must be most kind to its needs. 

So how does one do it? Live life in the fast lane and stay in range? For one, I relentlessly work on staying in range – 24x7x365. I make few excuses. I am on a food leash. And I have my special little helpers - a pump (Medtronic 640G) with a CGM (Medtronic Enlite). 

Wearing tech is life changing! But it is a non-dreamy thing to do, to help you live the life of your dreams. For instance, on an average day, I remind myself of Pavlov’s dog - I eat on a bell (hypo alarm), I correct on a bell (leaving-range alarm) and I sleep whenever and wherever I can. I set off all public place metal detectors, and my pump alarm can go off, rather loudly in a meeting or a movie hall, if I forget to set my pump to vibrate. My friends say I put the Sai in Cyborg. And I love it! 

My very public T1 lifestyle is often the subject of great curiosity among those around me. But it is just that, coupled with how passionate I am about my work, which makes me stand out before my clients and colleagues. Honestly, I wouldn’t have it any other way. After all, am I not a (pun fully intended) Diabetic Advocate?

If you’re reading this, you probably are a fellow busy bee. You’re juggling a job/ course with family, friends, kids, pets, parents, workouts, hobbies and your T1. Phew! Or perhaps a loved one is. I am sharing with you my top five tips to stay in range if you have a crazy job/life. These are things that held me in good stead and I hope they help you too.

1.    Embrace Technology 

I cannot insist enough on how this is really the heavy lifter of your load. If you are already on a pump and/ or CGM, you’re probably nodding vigorously in agreement. But if you’re not, and you’re wondering what the fuss is all about, picture this. Let’s say you want to get from Mumbai to Pune. Let’s say you can do this journey by public bus or private car. You can say both are pretty good options. The bus is cheaper, but you have to do more things (like take a taxi in Mumbai, get to the bus stop, stand in queue, buy a ticket, get down in Pune, find a rickshaw that takes you to your destination... you get my drift. However, the private car is door to door. This is my MDI vs Pump argument. So why CGM? Well, unless you’re a regular on that route, you probably don’t know the way to get to Pune. The CGM is your GPS. 

Why use it? Why not wing it? Well, because living with diabetes is like camping in the jungle. You shouldn’t have to go in without a GPS. Of course, wearable T1 technology is a far leap from being pocket friendly. But you must consider investing in it, as you would in investing in any other expensive buy – like a car. It does make your journey comfortable and your diabetes easier to manage.

If you already made the investment, then do spend some time learning the workings of your tech. About setting ranges, staying in range, customizing alarms. About regular and wave bolusing. About tuning basal and using the temporary basal feature. After all, a radio works best only when tuned to the correct station.

2.    Correct, Correct and Correct

We all do well when we set goals and the same holds true in diabetes. My current goal is maximum time in range. I have set my CGM range from 70mg/dl to 160 mg/dl. Which means I have alarms going off when my blood glucose is around 75 mg/dl (hypo alert) and at around 155 mg/dl (the high/leaving-range alert). I respond to my alarms at all times. When my hypo alarm comes on and I have active insulin - I usually have a hypo (glucose) tablet or a tiny sweet like Mango Bite or even a coffee, because most probably the low is caused by extra / excess bolusing. After all, we are all visual meal carb counters and often anxious/ aggressive correctors. A little accidental extra insulin dosing is not unheard of.  However, if I have no active insulin, and I haven’t had a heavy workout, it’s probably just my basal. So the smart guard of the 640G that suspends and reactivates my pump is enough to take care of the incident.

It is a little trickier when the high glucose alarm comes on. Most common causes of this spike could range from latent spike (sugar spike any time after the 3 hour bolus mark), the morning spike (dawn phenomenon), the rebound spike (Somogyi Effect) to sick days. It is important to always respond to this alarm but after deducing the correct cause of the spike. Because different causes call for different corrections. For e.g. the latent spikes, the rebound spikes and the dawn phenomenon benefit from a corrective bolus. Whereas sick days or pre-menstruation days just need higher basal rates.

In my experience, timing of correction is about as important as correction itself. Correcting a blood glucose spike at say 160 mg/dl requires lesser time and insulin than correction at 180, 200, 250 mg/dl and beyond. And preventing a low at 75 or 80 mg/dl is, needless to say, safer than going into a full-fledged hypoglycaemic episode. Having a CGM means having access to the rise/ fall trends of blood glucose as well. The arrows – single, double and triple often serve as a good clue to the cause of the spike. However, the biggest win of early correction is increased time in range. So if you hear the bell, correct correct and correct people. 

3.    Put yourself on a carb budget

One of the hardest, crummiest things about T1 is that it is a metabolic condition. And as much as I hate to admit it, unless you have magically ideal BMI or weight, with time most of our bodies lose the ability to eat vast amounts of carbs and stay in range. Atleast not without rollercoaster sugars or taking a mountain of insulin with food. A “carbivorous” lifestyle is not for all. Weight gain and insulin resistance are possible long-term effects (both of which I have first hand experience). When I first heard of Dr. Bernstein’s theory, I almost felt like Neo hacking into the Matrix. But eating 36 gms of carbohydrate in a day while running around like a headless chicken is like juggling while walking a tightrope. Can be done, but it’s not for all. 

I have however, vastly improved my blood glucose stats by limiting my daily carb intake. I eat about 60-70 g of carbohydrates in an entire day. I give myself around 20-30g for each large meal (lunch/dinner) and 10-20g for breakfast. And I carb count like a competitive sport. As meals go, it’s usually eggs and coffee for breakfast. A salad for lunch and a grilled protein with a side of vegetables for dinner. Or just dal, yoghurt, salad and vegetables without the bread/rice. Or kababs and raita. This kind of eating is sustainable in every kind of a public place – bus stop, railway station, airport, hotel or streetside dhaba. You may have to get creative from time to time. Limiting carbohydrate intake, even if you don’t go keto/ low carb means you benefit from the law of small numbers i.e. lower carbs = smaller doses = lesser errors (and by extension) = increased time in range = flatter lines on a CGM. 

But if lowering carbs isn’t already sounding like the el dorado for good control, picture this - when you are on the move/ are at work, your body is under stress and is probably making stress hormones. Reducing the load/burden by reducing carb intake is like removing one obvious stressor. This change has really helped me in having more good days than bad. 

4.    Stay Well Stocked

When you are constantly on the move, the last thing you need is a diabetic emergency because your pump ran out of batteries, your sensor discharged or malfunctioned, your insulin reservoir is low and you don’t have a replacement, you ran out of test strips, or worse, your quickset got kinked and you don’t have a spare/ the setter. I have been in each of these scenarios and I assure you that the panic is completely avoidable. T1 supplies, including insulin of choice is often not easily available in your corner drugstore. So stocking up of supplies at home on a monthly schedule is a game changer. And so is carrying your “dia-bag”. This is essentially a bag with all things necessary to monitor, service or backup your diabetic wearables (pump and CGM). My dia-bag usually has setters for pump and sensor, charger, adhesives, alcohol swabs, quicksets, batteries, spare reservoir and extra test strips. I also travel with an insulin cooling wallet for my extra insulin. All of this does not take up more room than a toiletries case. And has bailed me through several potentially stressful situations. 

5.    Listen to your body. And make good choices.

Okay I admit this last bit sounds like a wellness coach. But bear with me. Your body often gives you signs before your tech catches up. For e.g. I have felt tired or hungry right before a hypo alert. And angry or thirsty before a high alert. You need to trust your symptoms to stay ahead. And test when in doubt – CGM or not.

Also pre-booking airline meals is literally the only chance you’ll get a diabetic meal in this country. Switching fresh salted lemon water for juice, diet cola for regular, water for anything liquid, cucumber or raw mango or boiled peanuts for a packaged snack, a salad for a wada pav and a medu wada sambhar for a dosa has kept me out of many a pickle. I promise you, the hypo tab is better than your store pastry for a hypo. And not missing gym when you can or trading the lift for stairs each time are clichés that are great for your sugars. Little things do go a long way. And good choices do have good consequences. 

To sum it up, the cognitive burden on people with diabetes is often responsible for “diabetes burnout”, or at the very least people being so stressed out that they start giving up on things they would like to do. But staying ahead and taking care of yourself at all times can avoid getting there. After all, when life calls should you really be fixing your sugar?

DISCLAIMER “Issued in public interest by Medtronic. Any and all the information provided in the Blog are independent views of the Author for general overview and education purposes only. Recipients of this article taking any decisions and acting or omitting to act on the basis of the information contained in the Blog shall be doing it purely at their risk and discretion and they are advised to seek professional advice.”