Type-1 Diabetes, Mental Health and The Stress Of Living Every Day As A Performance
Life With Diabetes: 180 Extra Daily Decisions
According to a research by Stanford Medicine people living with type-1 diabetes have to make an average of 180 additional daily decisions - one decision every five minutes - compared to people who do not have this condition. These decisions include everything and more, from what and when to eat, if and when to move, how much insulin to inject, whether or not to start any activity based on the blood glucose level and so on.
Each minute of each day is ruthlessly affected by what the screen of the Continuous Glucose Monitor (CGM) indicates: blood glucose too high? Move. Blood glucose too low? Don’t move and eat sugar. Blood glucose in range? Go ahead and keep it there if you can.
What often goes unnoticed is that the blood glucose level at any given moment is the mere result of a chain of past decisions, those 180 decisions. And since these decisions affect every area of our lives (food, work, exercise, relationships, and all the rest), they are not at all easy calls. There are so many moving parts at each split on the road, both seen and unseen, that the “diabetes management” process can take quite a big chunk of our mental energy, and its cognitive load can overwhelm us when we lose clarity on the purpose, the reason we stick to it even when the frustrations kick in.
“Are You Joining Us For Lunch?”
Let’s imagine I wake up with an excellent glycemic index of 119, I do my workout, eat my breakfast, log my carbs and my insulin intake, calculate my ratio and commute to the office.
I see my blood glucose being perfectly in range the entire morning and I am happy. The lunch time comes and my colleagues invite me for a lunch together. That would be a quick and easy “yes” in most cases, but for a person living with diabetes this innocent invitation can turn into a turbulent spiral of thoughts. What if the restaurant is serving foods that will affect my blood glucose? For sure I will have to estimate the serving amount because I don’t ave my scaler at hand, so my carb-to-insulin ratio will not be reliable anymore. Then, I do not know the quality of the ingredients, how much processed food is in the meal, and I can only guess how my insulin sensitivity will handle it. Then, if instead of walking after the meal we will be sitting at the table to have a conversation, that will also affect the way my organism processes the meal and its load. On top of all that, our colleagues might even get offended if we turn down the invitation.
Now, imagine that my blood glucose was high during the entire morning. That would make things even worse because my body is already in a state of inflammation and make every meal a possible sh*ts-how of blood glucose management. In that case, I might have to reject the invitation altogether and go for a walk instead of eating, or go grab some salad and enjoy that as my main serving.
One innocent lunch invitation from a colleague, ten thousand decisions to make.
Lots of Seen And Unseen
Let’s add some more.
It is a stressful period at work or in family, and my blood glucose is undulating between extra high highs and extra low lows, which makes my phone ring overnight to signal that I need to eat sugar or make an injection.
I am constantly half-awake at 3am in the morning eating sugar against my will or calculating how much insulin to inject only to keep my phone shut and hopefully get back asleep somehow.
Due to my continuously sleep interruptions, my focus, mood, productivity and overall energy are severely diminished during the day. But people around me don’t know this, so I must keep up with their rhythm.
I have no energy nor will to talk to anyone, but people will still talk to me. I don’t want to eat and need to wait hours to bring my blood glucose under control in order to eat again, but people will still invite me to eat together at a place where the menu won’t help me. And the social pressure makes me hesitate to reject the invite.
And I can’t keep my focus but the presentation still needs to be delivered before 3pm.
And I can’t be bothered with small chats but I have to preserve my relationships.
And I can’t talk straight because my blood glucose is low, but I am in the middle of a work meeting and must stay in the room.
The brain load behind these basic daily actions and situations - which is, decisions that we have to make - can turn life into a walk in the fire. And these decisions determine our short term and long term health. And they are easily measured by a very concrete, unmitigated and merciless numerical output: your blood glucose is out of range, or in range. It’s a number telling us whether we’re doing good or bad.
Chasing Numbers: Life As A Performance
Yes, life as a type-1 diabetic is a life lived as a daily performance. We must optimize for these daily metrics every single day.
I must keep my blood glucose in range at least 80% of the time, because chronically elevated blood glucose can directly damage the vasculature of the brain.
I must keep my carb-to-insulin ratio as high as possible, because “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)”, to quote Peter Attia’s Outlive.
I must move every day to stay insulin sensitive.
I must avoid junk and processed food to avoid blood glucose issues and insulin resistance.
The ruthless objectivity of daily life with type-1 diabetes.
Missing one day is not a problem, we all have worse days and better days. There are also periods and seasonal events and situations that make blood glucose management trickier than normal (Christmas holidays, to name one).
But the hard truth is that there must be a process that we commit to, that we make our default and follow daily to make sure we hit these numbers on a consistent basis. Doing things randomly and crossing our fingers that everything will be fine eventually is, to put it down brutally but honestly, a sure path to a shorter life.
Part of this process for me involves identifying my “hard NO” and my “hard YES”.
If I am struggling with blood glucose and I am invited out for lunch: hard no.
If I am on a good streak of blood glucose management and I can keep eating healthy and move - even when that means eating at different times or different things than others: hard yes.
If to keep my glucose stable I need to walk after my meal: hard yes. Even if that means getting back to work 10 minutes later.
If I want to have a good sleep and not wake up in the middle of the night to eat sugar, then I’ll do whatever it takes to make sure that happens: hard yes.
Accepting Reality
My initial aim with this article was to find a way to ease the pill, to say that yes, there are decisions to make to make diabetes work but that we can also allow the flow of things to just lead us sometimes. And hopefully free some of that mental load that takes so much capacity.
But the more I write the more I grow a bit uncomfortable with the realization that I don’t have an easy way to put this: the truth (for me, at least) is that this process takes every bit of me every day. I don’t nor can’t rely solely on will power, I just apply pure discipline.
Being a human means coming to terms with the fact that days when I just feel like throwing everything out of the window and just “live life” will happen. But exactly because I am a type-1 diabetic human being I need to have clear in my head that a set of poor decisions will have a clear, severe impact on my health. And that while one bad day will not screw me over, multiple bad days most certainly will.
Thus, although will power is still necessary for me at times to tame the temptations that are hidden behind the corner and the version of me who wants to surrender to them, I need to be present, to know the Purpose behind my actions and direct every cell of my body toward it. And to reduce the cognitive load of this entire thing, I need a clear set of rules and principles, so that I maximize the odds that my default decisions are still good decisions even on my bad days. I will live my life like this, after all, so I must make it sustainable.
How I Deal With The Stress
And as far as my 10+ years with diabetes go, I almost never found it to be stressful or to overwhelm me. I simply welcomed diabetes as my best friend on day one, making it a my life partner and roll with it.
It would be and could be stressful if I pretended it did not exist and tried to oppose it by eating randomly, not counting my carbs, my insulin doses, and ignoring my condition. But the feedback would be instantaneous, ruthless and absolutely disruptive of my every single daily activity, because I would not be the one in control, but rather be controlled by diabetes.
What I do is [keeping everything simple](https://www.thecuriousdiabetic.com/blog/mastering-diabetes-made-easy) and predictable, so that every decision, every call I have to make requires the smallest mental capacity and can be as frictionless as it can be.
Practically speaking, I eat the same meals every day, so that I don’t have to calculate the carbs intake every time and can adapt my doses more quickly, knowing what my insulin sensitivity is. I avoid unknown variables, or at least those I can control. I won’t eat at a restaurant, for instance, because I know the food served there can screw my levels for days.
My every day breakfast for maximum insulin sensitivity and minimal mental work: bowl of fruit and leafy greens.
I walk, do some physical chores or simply move the body for a few minutes after every meal, because that helps tame a potential spike in blood glucose.
I run and exercise often - even when I don’t want to - because movement make me more insulin sensitive. Running also helps me meditate and relax.
I sleep 8-9 hours a day because diabetes is simply unmanageable when we’re sleep deprived.
And I manage stress every day: I read, write, walk without music or podcasts in my ears, spend time in nature and meditate.
My Pillars For Health And Happiness
These are my pillars: simple meals, simple processes, predictable decisions (where I have control over them), movement, sleep and daily moments to decompress and relax. My life is a performance dictated by numbers, and that will not change. But there we all have a chance to be all-in without being all-consumed. It just takes discipline, intentionality and mindfulness.
We can’t control the outcome but can do our best to control the process and make most of those 180 daily decisions successful decisions.
Mindful discipline is how I do it. Discipline will ensure that the “right” process, the one that is made of good decisions, will sustain my long-term health and happiness, is my default process.
Mindfulness is essential because this process, this life, requires presence and observation and thinking. It requires us. If we’re there for ourselves, accepting reality and welcoming its multiple facets, then each one of those 180 decisions will be a bit lighter on us. Our clear Purpose will make a “disciplined act” just an “act”.
While I am not pretending this to be a universal truth, I find mindful discipline to be the most potent and sustainable way to live with diabetes without being burned out by it. So far, mindful discipline has somehow allowed me to keep a big, relaxed smile on my face. Hopefully for many more healthy years to come.
