frustrated

Not everything gets easier with time.

I have a 3 yr old little boy. It is really astounding and delightful to see him gain knowledge and skills so rapidly. Just as I go to help him with something he could not do on his own a few months ago, he triumphantly completes the task solo. He even chafes at my attempts to help him, demanding to master more of his world on his terms. Typically in life, as we do a thing we get more proficient at it and it becomes easier until we barely have to put in any thought or effort a all.  However, not everything has this linear progress path. Some things, with time and repetition get more difficult! (As a parent of a 3 yr old boy I can also tell you that the more times I ask him to repeat an act the less likely it is that he will do so! Being a parent longer is not making parenting any easier I promise!)  Diabetes is often one of these things. One thing I hear from patients a lot is “I’ve had diabetes for so long, I should be getting better at managing it, but it feels like I’m getting worse!”

There are a number of reasons behind this phenomenon, and knowing the causes can help us either adjust our management to adapt, or to at least find peace in coping with change.

Aging

Yes, unfortunately aging is a force that we just have to acknowledge in our diabetes management. Not just for seniors, but for children, teens, young adults, mid-life, and every stage in between. Our bodies simply are not static things. If our bodies never changed diabetes management would be much easier because what worked a decade ago would work today! However, that is never the case. Hormones change through different stages of life (And not just for females) This can lead to big changes in basal needs and sensitivity. Muscle mass increases through puberty and young adult years but starts to lessen as we then move into maturity which can cause a change in insulin sensitivity and the impacts of workouts on blood sugars.  Hydration and blood flow shifts so our CGm may become less accurate in some locations and insulin absorption may change as well. Even the fat layer we are pumping insulin into changes in density over time causing our duration of insulin action to typically lengthen. In short, we have to recognize that our bodies are not what they were when we began our journey, they are not what they were when we strode through diabetes management with ease either. My 3-year-old climbs and leaps with ease he could not imagine a year ago, and with ease, I can hardly recall from my years passed.

Awareness

Remember, in the past, the only indications we had to our level of diabetes management were our A1C and our feelings. How stressed we were by diabetes, how often we had lows or felt complications setting in. Frankly, ignorance was sometimes bliss. We also allocated our attention to other things, friends, fun, career, family. But now we have a CGM constantly giving us a report card, a pass/fail of our every diabetes decision. Knowledge is power, but power can be a burden too.  It very well may be that our A1C rises because we are now avoiding all the silent lows that used to skew the math and lower our average. We may be frustrated by how variable our blood sugars are because finger sticks only showed us the time we were closer to baseline.

Management tools

Over years of using insulin, we develop a lot of our own workarounds. Ways of making things work that have nothing to do with our usual ratios, bolus calculator or programmed basals.

These are tools that may not be “by the book” (even when the book is Think Like a Pancreas) “I always throw an extra half unit on when I wake up in the morning to fight a feet on floor rise” or, “I eat enough to carb to push my blood sugar up 60 points before I work out” or, “I bolus and wait until my blood sugar drops below 90 to eat breakfast”. These are some common types of workarounds that can really backfire when we use automated insulin delivery systems.

Throwing in manual boluses means these systems then reduce basal, negating, or even reversing our intended effect. Waiting for BG to drop means that rather than eating when insulin action is peaking, we are now eating while being shorted basal insulin leading to a problem that could take hours to show itself and even longer to fix! Letting blood sugars rise before a workout can lead to unintended boluses from a hybrid closed loop system that then leads to big drops in blood sugar while exercising with unintended insulin on board.  Automated insulin delivery is a paradigm shift in how we think about insulin management much like going from injections to pump therapy. As with that switch, we have times we need to relearn new habits and maybe unlearn some ineffective ones. We may also find there are times that it is easier and more effective for us to turn off automated features and use old proven methods.

Diabetes management technologies and pharmacology are changing at an increasing pace. We are likely only a few years from FDA approval of more advanced hybrid closed loop systems, and even dual hormone infusion “Artificial pancreas” systems. And to make best use of these systems,  ongoing learning is a must. Diabetes management is not something that necessarily gets easier with time. But if we are open to continuing to learn and grow with the needs of our body and adapt new strategies and technologies it also does not have to become more difficult.

Here at IDS we love seeing patients from the past returning to take on new challenges and learn new skills to adapt to their changing worlds. We also strive to empower those who have seen years and decades of diabetes pass and have adapted to those changes continue to grow and find how to find the most effective management path for them to continue with healthy and unencumbered life with diabetes.