I. Take the right

insulin, at the

right dose, at

the right time

II. Take insulin for

all meals

and snacks

III. Honour your

teachers

IV. Honour your

family and

friends

V. Follow a meal

plan

VI. Do not overconsumecarbohydrates

VII. Do not inject invainVIII. Do not test invain

IX. Do not covetthy neighbour’spumpX. Honour thyself

10COMMANDMENTSfor better diabetesself-care By Prof David Segal

Paediatric Endocrinologist, CDE Parktown

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LIVING WITH DIABETES

Managing diabetes is achallenging task requiringdedication andcommitment to performing

certain self-care behaviours that havebeen proven over time to maintain goodblood glucose control. The followingcompilation of behaviours is derived fromthousands of interviews with hundreds ofpeople living with diabetes. Individualswho succeed in managing their diabetes,tend to adhere to more than a few of thesebehaviours.

I. Take the right insulin, at the

right dose, at the right time

Insulin is a wonderful drug that can keepyou alive, but it has inherent limitations.This makes it challenging to achieveperfect control without the assistancefrom the other behaviours set forth inthese commandments. Injected insulindoes not work like your body’s owninsulin. It is not injected in the rightplace, or at the right dose, nor is itsaction profile a good match for what is

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LIVING WITH DIABETES

needed. But, it is all we have. It has twomore major problems - it takes too longto start working and it does not work thesame way every day. Insulin is like noother drug, if your meal-related dosesare not taken at the right time (alwaysbefore meals, preferably up to 30 minutesbefore, depending on the type of insulinused and your individual response to it)it does not work as well as it should. Thedose needed will depend on meal size,meal type, exercise, the type of insulinused and many other variables. It takestime and a lot of trial and error to findthe right doses that work for you most ofthe time.

II. Take insulin for all meals

and snacks

Insulin is normally produced by the bodyat every meal and every snack. Theinsulin produced directs the incomingcarbohydrates to be used as energy orstored away for later use. Anycarbohydrates not adequately clearedfrom the bloodstream, cause the bloodglucose level to remain higher thannormal, contributing to long termcomplications of diabetes. Note: certaincarb free snacks may not require a dose ofinsulin – check with your dietitian (andwith your experience) which snacks doand do not need insulin cover.

III. Honour your teachers

Build a trusting and open relationshipwith your diabetes care team. They learnas much from you as you learn fromthem. They will keep you up-to-date with

the latest developments and can help younavigate the complexities of fittingdiabetes into your life.

IV. Honour your family and friends

Diabetes is like no other medicalcondition, it affects, and is affected byevery part of normal life. It is challengingand can be overwhelming. Let yourfamily and friends help you to maintainthe behaviours and care you are strivingfor. Do not allow them to becomeaccomplices in behaviours that sabotageyour best efforts.

V. Follow a meal plan

Learning how to eat and drink for betterblood glucose control is perhaps the mostchallenging aspect of life with diabetes.Eating has social, emotional, cultural andphysiological benefits. It can bechallenging to make the disciplined andoften difficult choices required to keepyou safe in certain situations. Having ameal plan and learning how to adaptmedications, portions and food choices toobtain good blood glucose control is animportant self-management behaviour.

VI. Do not over consume

carbohydrates

Carbohydrate is the primary determinantof blood glucose. History has taught usthat limiting carbohydrate intake is abehaviour often adopted by those withlong term good blood glucose control. Ithelps to overcome many of the limitationsof current diabetes medications.

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LIVING WITH DIABETES

VII. Do not inject in vain

Injecting insulin is an onerous andsometimes uncomfortable task. Injectinginsulin in the same place becomes a habitand eventually painless. A lump beginsto form at the injection site that severelyimpairs the absorption of insulin fromthat site, resulting in high and variableblood glucose. To compensate, the doseof insulin is gradually increased leadingto more variable blood glucose levelsand an ever expanding lump. To breakthis harmful cycle, it is imperative thatinjections follow a planned migrationpattern around the appropriate injectionarea. Start in one spot and then move thenext injection a centimetre away. Workyour way through the different injectionsites until you arrive back at yourstarting point and then begin again. Thisgives your injection sites time to healand allows for optimal and morepredictable insulin absorption.Following this pattern takes disciplineand putting up with slight discomfortfrom insulin injection - but it is vital.

VIII. Do not test in vain

“Between stimulus and response there isa space. In that space is our power tochoose our response. In our response liesour growth and our freedom.” Viktor Frankl

Blood glucose checking is anotheronerous and painful task. Each insulinor medication has a job to do. Testing atthe appropriate times on a structuredbasis is the only way for you to

recognise and adjust the input variablesthat affect your blood glucose levels.

Turn bad days into good data. Payingattention to the input variables - such asfood, exercise and insulin and measuringyour blood glucose before and 3-4 hourslater, will provide you with biofeedbackfrom which you can learn. Mindfulmonitoring allows you to test with a purposeand get the most out of a testing situation.

IX. Do not covet thy

neighbour’s pump

There are always going to be new andexciting developments in diabetes,including new drugs, delivery andmonitoring devices and the promise tomake life easier and improve blood glucosecontrol. In clinical trial settings, this is oftenthe case, but not always so in the real world.Many people living with diabetes over thelast 100 years have managed to achieve tightblood glucose control by adopting andadhering to the self-care behaviours describedin these commandments and by masteringthe tools they had at their disposal.

X. Honour thyself

Diabetes is a chronic condition that mayhave other unwanted companions that joinyou on your life’s journey. A belief inyourself and your ability to manage thiscondition is vital. Find meaning in your lifeand in your actions.

Viktor Frankl once said, “When we are nolonger able to change a situation, we arechallenged to change ourselves”…