“The price of light is less than the cost of darkness.”
ARTHUR C. NIELSEN
We have too much darkness in diabetes – negativity, confusion, frustration, exhaustion, blame, guilt, and fear. For those of us living with diabetes and the people we love, the cost of this darkness is high. We often don’t know what to do, aren’t doing what we “should” be doing, feel bad about what we are doing, or are told we’re getting it wrong.
We can do so much better!
This is a hopeful book about making type 1 and type 2 diabetes easier, and the premise is simple:
Identify what works and focus on doing those things more often (Diabetes Bright Spots).
What’s going well in my diabetes that I should keep doing? What happens on my best days? What foods and decisions keep my blood glucose in the tight range of 70-140 mg/dl (4-8 mmol/l)? What puts me in a positive frame of mind? How can I do more of these things each day?
Uncover what doesn’t work and find ways to do those things less often (Diabetes Landmines).
What decisions do I make repeatedly that explode into out-of-range blood glucose values over 200 mg/dl or less than 70 mg/dl? What happens on my most challenging days with diabetes? What choices do I always regret? What repeatedly brings on negative feelings? How can I do fewer of these things each day?
What you are about to read is the actionable guide I wish I was handed at diagnosis, focused on the Diabetes Bright Spots that have most improved my blood sugars and mental outlook, and the Diabetes Landmines I’m always working to avoid. Each chapter – Food, Mindset, Exercise, and Sleep – shares exactly how I increase my Bright Spots and steer clear of my Landmines. This framework has proven remarkably powerful for me, particularly because Bright Spots are so useful and so often ignored.
Everything in this book has made a difference in my life with diabetes, and nearly all my suggestions include a small step that can be taken immediately. Ironically – and painfully – some of the most effective strategies are the opposite of what I was told at diagnosis, particularly around what to eat and the mental side of diabetes.
I’m excited to share my journey with you, and far more important, I hope this book is valuable to you – whether you were just diagnosed or have had diabetes for 50 years. There are hundreds of effective tools, tips, and questions in here, but even one small change can make a difference today.
WHY I WROTE THIS BOOK
For the last six years, I’ve had the privilege of writing at diaTribe, where our mission is to help improve the lives of people with diabetes and prediabetes. I have written over half a million words on the latest advances and research, and I have covered leading thinkers at hundreds of diabetes conferences from Melbourne to San Francisco to Dubai.
Living well with diabetes, I’ve learned, comes down to a handful of strategies: relentlessly learning and experimenting to find what works for me, using glucose data to help me make better decisions, policing my own negative mindset, optimizing my habits to put more things on auto-pilot, and finding support.
But 15 years ago when I was diagnosed, all of this was foreign to me.
I grew up in rural New Jersey as the oldest of six children. I always believed, from a very young age, in the power of hard work and hustle. I played basketball outside in our driveway in the ice and snow, pushing through the cold to constantly improve. I also had an unwavering belief in the power of knowledge as a vehicle for self-improvement, and I remember Googling things like “How do I increase my vertical jump?” or “How do I improve my dribbling?” As a small and scrawny basketball player, I figured these skills might give me an edge. I would go down into our basement and do hours of drills and hundreds of bodyweight squats, jumps, and calf raises. School was never a problem either; I did whatever it took to get good grades, and my mom never had to bug me to do my work. Self-motivation and discipline were part of my identity.
So when I look back on my diabetes diagnosis, that drive to work hard and constantly improve should have served me well. But the tools were not as good back then, and the instructions on what to do were poor. I remember feeling shocked and crying at the news – “You have diabetes” – and most of that time is a blur. But I do remember struggling mightily, and I certainly recall feeling like a failure at every doctor’s appointment.
I checked my blood glucose (“BG”) around four times per day, rarely finding myself in an ideal range. My A1c was far too high at 8%-9%, and the daily swings from 45 mg/dl to 300 mg/dl put me at high risk of seizures from extreme low BGs (hypoglycemia) and long-term damage from extreme high BGs (hyperglycemia).
I was oblivious to these cold, hard facts – the future threat of “complications” is not a good motivator today, particularly for someone newly diagnosed. Plus, I didn’t really know how to get better or what to do differently.
I had a terrifying episode of severe hypoglycemia in those initial months following diagnosis – I took too much insulin at lunch, passed out, and woke up with paramedics around me. Insulin is a very dangerous drug; no one made that clear enough, and no one told me how to make it safer. Perhaps this should have served as a wake-up call to take diabetes more seriously, but in reality, I just felt embarrassed.
The food advice I got at diagnosis was unquestionably the biggest problem, and in retrospect, a true travesty: “You can eat what you want, as long as you take insulin for it.” That was a blank check not to change my diet at all, so I didn’t: sleeves of crackers, triple cheeseburgers with fries, stacks of cookies, plates of pasta the size of my head – you get the idea. As my mom told me recently, “We were a carb-centric family and always had a treat after supper!”
Those choices didn’t seem like a problem at the time, but they translated into large, haphazardly estimated insulin doses followed by many highs, lows, and dangerous glucose swings. What I was doing was dangerous, but as the oldest of six kids, I felt confident I could handle it. Responsibility was my middle name: I grew up without a father figure, which added extra pressure to be the man of the house. In the case of diabetes, unfortunately, being responsible isn’t enough to achieve in-range blood sugars.
One day we got takeout – a foot-long ham and turkey sandwich – and I proceeded to chomp it down soon after we got home. Then reality hit: “Wait, I now have diabetes and was supposed to take insulin for these carbs!” I freaked out, recalling the question that raced through my mind after diagnosis: “What’s going to happen to me?!”
Nothing did in that moment, of course. I took the insulin and carried on with my day. My blood sugar probably went sky high, but I would have had no idea at the time – checking it four times per day didn’t give me nearly enough data to learn and make changes.
No one told us back then that white bread is a nightmare for dosing insulin.
No one warned us that eating 92 grams of carbs at once is a huge glucose load in a condition with one big challenge: an inability to deal with huge glucose loads.
Reflecting back, I’m simply glad I survived all the wild, uninformed guesses we took each day. I don’t fault my mom or myself; I fault the tools we had in 2001 and the lack of useful, specific advice we received on what to do. In diabetes, the little stuff really matters, the little stuff is easy to forget, and botching the little stuff can lead to serious problems.
The great news is that these challenges can be avoided, and this book is about how to do that.
Six years ago, three positive events happened in quick succession, and these Bright Spots changed my diabetes for the better – and unquestionably, the trajectory of my life.
First, I started learning about nutrition and eating fewer carbohydrates, which subtracted most of those highs and lows, dangerously big insulin doses, and worries. I also became close friends with a bodybuilder, who showed me first-hand what better food choices can do.
Second, I nervously joined a small organization, Close Concerns, as a summer intern in 2010. I figured it might be fun to learn and write about diabetes for a few months, even though the vision of writing every single day scared me. I also wrote for diaTribe, a free once-monthly online patient resource (at the time) that we usually scrambled to finish on Friday evenings.
Third, I started using a continuous glucose monitor (“CGM“) in 2010, a transformative Bright Spot for living well with diabetes. Armed with a glucose reading every five minutes, I now had a powerful feedback loop to discover what worked for my diabetes and what didn’t. My learning curve accelerated dramatically, and as I began to identify my own Bright Spots and Landmines, my BGs and quality of life improved dramatically.
Since 2013, I’ve written about my own diabetes tactics, learning, and mistakes in a diaTribe.org column, Adam’s Corner. It’s been some of the most gratifying work of my life, but I’ve also had a nagging feeling: far too many people are still struggling like I did. I wondered…
Can I compile my biggest discoveries into a single, actionable guide from which others might benefit? Can I bring a little more light to the diabetes darkness? And can I make it accessible to everyone who wants to learn?
The product of those questions is the book you are about to read, made available to you by The diaTribe Foundation – the nonprofit that publishes diaTribe.org.
HOLD UP! WHAT COUNTS AS A DIABETES BRIGHT SPOT OR LANDMINE?
I first encountered the idea of “Bright Spots” in the masterful book on behavior change, Switch, by Chip and Dan Heath. It’s radically different from what we typically do in diabetes: find problems and focus on what’s going wrong.
Diabetes Bright Spots are positive behaviors and choices I want to replicate as often as possible. They are the things I’m doing right that I should try to duplicate: what helps keep my BGs in range, improves my mental state, and if repeated consistently, would improve my health and quality of life? Most of this book is focused on these Diabetes Bright Spots, such as eating fewer carbohydrates at meals (I aim for less than 30 grams), remembering why in-range BGs benefit me TODAY (I’m happier, more productive, in a better mood, and a kinder person to loved ones), walking after I eat, and getting at least seven hours of sleep.
Diabetes Landmines are the mistakes I make over and over again that drive my BG out of range, ruin my mood, or make life more difficult; I want to find ways to stumble on them less often. I first wrote about Diabetes Landmines on diaTribe.org after I noticed something important: I tend to make the same mistakes repeatedly, such as overeating treats to correct low BGs; eating white bread and potatoes; and asking unproductive questions like “How is this possible?” or “Why am I so terrible at this?” Clarifying these Landmines upfront has helped me develop a plan of attack: What safeguards can I set up to avoid them? How can I build routines that reduce the chances of stumbling onto them?
It’s easy to come up with a vague list of things I “should” and “should not” do, but Bright Spots and Landmines need to be useful. That means hitting three criteria:
1. Specific and actionable: “Eat healthy” does not count as a Food Bright Spot – it’s too vague. “Fill half my plate with vegetables” is much clearer.
2. Realistic and sustainable: “Not eating” does not count as a Food Bright Spot either – it’s impossible to sustain. “Eat slowly and stop before I’m 100% full” is more realistic.
3. In my control and changeable: “Bad weather” is not an Exercise Landmine – it’s out of my control. On the other hand, “overeating after exercise” is a Landmine that is changeable – I can find ways to avoid it.
BRIGHT SPOTS ARE MORE IMPORTANT THAN LANDMINES, BUT WE DON’T PAY ATTENTION TO THEM
Bright Spots outnumber Landmines in this book by more than 2:1. That’s intentional, because Bright Spots are so overlooked, so undervalued, and have had such a huge impact on me.
Many psychology books talk about the brain’s survival instinct, which looks for things going wrong and zeroes in on problems. In diabetes, this inevitably leads to negative self-talk: “I screwed up,” “I’m terrible at this,” “I can’t do anything right.” It also leads to finger-wagging advice from others: “Don’t do this,” “Stop doing that,” “You’re unmotivated,” “You just don’t care,” “You’re lazy.”
After my girlfriend and I adopted our dog, Sencha, I was surprised to hear only one piece of training advice from the shelter: use positive reinforcement to encourage good behaviors. In other words, focus on Bright Spots – what is the dog doing right that should be reinforced and encouraged? What a radically different approach from what we usually do in diabetes: focus too much on those negative Landmines.
Research from Dr. Barbara Fredrickson (author of Positivity) suggests that a ratio of 3 positive emotions for every 1 negative emotion is critical for human flourishing. 3:1! Focusing on Bright Spots is key for any of us to live well, and for me, they have redefined my daily journey with diabetes.
This is not to say we should all live in a land of false positivity – sometimes the best way to improve is to look at what’s not working and do less of it. Indeed, Dr. Fredrickson points out that a 3 positive to 0 negative emotion ratio is not in touch with reality – we all experience challenges. My approach has been to find and focus on Diabetes Bright Spots as much as possible, but not to ignore Landmines. This book is organized accordingly.
HOW TO IDENTIFY BRIGHT SPOTS AND LANDMINES
Reflect and question:
I often try to ask myself, “Is this behavior a Bright Spot I want to encourage or a Landmine I want to avoid?” It also helps to review my day or week: What did I do well for my diabetes and how might I do that more often? The questions at the end of each chapter and the end of the book will help you identify your Bright Spots and Landmines.
Check BG more frequently (if possible):
It’s hard to know what works and what doesn’t – particularly around meals and exercise – without knowing what my BG is and how it changes in response to different choices. Using a BG meter more frequently or wearing CGM helps find cause-and-effect relationships, and therefore, identify Bright Spots and Landmines.
“When I do ____, what happens to my BG?”
I’m painfully aware and frustrated that not everyone has the resources to check their BG more often. This book does not assume most readers are on a CGM, and I know insurance companies still make it difficult to access enough BG strips. This is criminal, as more frequent glucose data truly saves lives. If this applies to you, read the tips in chapter one on getting more strips.
Ask loved ones and friends to observe me:
“When I have in-range BGs after a meal, what did I eat? What foods do I eat when my BG goes high after meals or when I become moody and grumpy? What stresses me out and what helps me relax? What happens on days when I’m super motivated and take care of my diabetes?” Explain the concept of Bright Spots and Landmines to loved ones – they can pick up a lot!
PLEASE KEEP IN MIND
What works for me may not work for you. I’m sharing deeply personal experiences throughout this book – including my own glucose data – not to boast or to show I have all the answers. What I truly care about is helping people with diabetes live better, and this book shares my own Bright Spots and Landmines in case they are:
- Useful for you to try.
- Strategies that you can adapt.
- Seeds to get you thinking about your own ideas.
This book is written for type 1 and type 2 diabetes, though a small number of Bright Spots and Landmines only apply to insulin users. If you don’t use insulin, feel free to skip these passages. There is a big focus on glucose monitoring throughout the book, since it’s a key feedback mechanism for identifying Bright Spots and Landmines. Even if you don’t currently monitor your glucose, I think many sections of this book will still benefit you.
Consult with a healthcare provider before making big changes to your routine, particularly if you do use insulin or medications that can cause hypoglycemia. Expert diabetes healthcare providers have reviewed this book’s content (see the Gratitude section), but I am not a licensed medical professional.
I have been profoundly lucky throughout my diabetes journey, and this book is colored by that experience. My daily struggles are small compared to the heroic efforts of many people with diabetes. Far too many still lack access to even the most basic medications and devices, let alone to newer products. That is a travesty. This book cannot possibly solve the challenges of everyone, but my hope is at least one tip or question or quote may help you.
HOW TO MAKE THE MOST OUT OF THIS BOOK
Build incrementally and do not attempt huge leaps of change. Try adding or subtracting one or two things before moving on to more. This book should be seen as a toolbox of tactics I’ve found helpful, not a checklist of things to complete every day. You can always come back to your list or to the book if the change isn’t working or if you’ve mastered it.
Feel free to skip to the chapter of the book you need the most: food, mindset, exercise, and sleep. I also encourage skipping around within each chapter. Everything in here has made a difference for me at some point, but I’m often struggling with one area the most. I’ve written this book so that each chapter can stand alone. The conclusion is useful even if you’ve only read part of the book.
Some Bright Spots and Landmines overlap. I’ve found that phrasing a specific insight in both a positive and negative context can help in different situations.
Try the questions at the end of each chapter – your answers will be more personal and valuable to you than anything I can write.
As I wrote this book, I tried to keep in mind your most precious resource: TIME. Bright Spots & Landmines is about half the length of a typical non-fiction book and contains only the most actionable tips that have made a difference for me. The four chapter summaries cover these in just one page each.
I hope you can encourage your Bright Spots, avoid your Landmines, and live better with diabetes. Please write with feedback by emailing firstname.lastname@example.org – I would love to hear from you!
San Francisco, California