The Four Habits of Healthy T1Ds

Behaviors are inextricably linked to our sense of self

Let’s begin with a truism that decades of research from academic literature and the American Diabetes Association shows: The healthiest diabetics are those who employ four simple habits:

• Watch glucose levels frequently

• Take insulin or carbs in a timely manner

• “Log” events and activities, and

• Exercise.

These may seem like vague, overarching concepts, not necessarily tasks. But ask yourself what your blood sugar is right now. How about 30 minutes ago? How many times do you glance at your CGM per hour? Yes, per hour, not per day.

Or, try this one: How many times did you forget to bolus for a meal? Or do it too late?

Then there’s the question of exercise: Do you do any physical activity after a meal?

Building good habits that stick, and that you do all the time—especially these—is often seen as “hard”, so it’s tempting to assume that those who do it must have a common personality type or something else, but they don’t: They’re not necessarily Type A, ambitious, or goal-oriented. They don’t necessarily excel in their career or sports. They aren’t necessarily disciplined or organized. They don't necessarily follow similar diets. They aren’t necessarily highly educated about diabetes or metabolic health. They come from dramatically different backgrounds, races, education levels, careers, and so on.

That said, there is one thing that they have in common: They engage with T1D by taking agency over their fate. They don’t succumb to the feeling that it’s all too complicated. That you’re just a rag doll being thrown around by forces greater than yourself. It’s for these reasons that many fall into despair or depression. So, developing a sense of agency—the ability to take control—seems out of reach.

But again, there are those who do this well, even though they have been faced with the same emotions at points in their lives. And one way to get through it is to simply build little, tiny habits at first—easy tasks—that progressively aggregate into larger successes. This is the thesis of James Clear, author of the wildly popular 2018 book, Atomic Habits: An Easy and Proven Way to Build Good Habits and Break Bad Ones.

Despite its self-help-sounding title, the book is an investigation of the science of habit-building, where Clear has studied a variety of different programs dealing with everything from substance addiction to pain management to depression, and a host of diseases and ailments. It’s not just about coping; the approach has been effective at building new skills, like mastering a musical instrument or becoming a surgeon.

What Clear has found is that people are more successful at building good habits when they first identify as the archetype of the person who does them. That is, they model their behaviors on those who are already successful. As those little achievements build, positive emotions follow.

As Clear says, “be the architect of your habits and not the victim of them.”

That may seem like a lot to accept, but Clear’s framework is worth considering.

The Four Atomic Habits for T1Ds

The four habits listed at the top of this article feel large, lofty, and overly generalized, which is why it’s both hard to teach and hard to accept:

• Watch your CGM frequently? How frequently? I refuse to obsess over my glucose levels.

• Take insulin or carbs in a timely manner? How?! Got any advice on that?

• Logging data? Not gonna happen, but even if I did, what do I do with that?

• As for exercise, that’s a non-starter. One word: hypoglycemia.

When viewed at this level, it’s easy to get overwhelmed and fatigued. Here, Clear says, “Too often, we let our motivations and desires drive us into a frenzy as we try to solve our entire problem at once instead of starting a small, new routine.”

This is where he suggests identifying small, simple, easy, actionable tasks. Or, as Clear calls them, “atomic habits,” like the atoms in the periodic table. Atoms are small and inconsequential on their own, but when they aggregate to build larger molecules, they perform functions as part of a larger system. Atomic habits may feel inconsequential on their own, but as they aggregate into larger behaviors, like the four listed above, desired outcomes follow.

Before we list the four habits, let me assure you with a simple analogy: I often compare this process to driving a car. When you first learn, there’s a lot going on—it’s easy to be overwhelmed. And, you start out pretty young. Many of these habits aren’t easily adopted if you’re not ready. Some degree of maturity is essential. But even small children can learn really basic things by just watching the speedometer and how other cars on the road behave.

As you get more experience behind the wheel, driving becomes easier, and second-nature. You steer big for the big turns, but when the car is just going straight, you learn to nudge the wheel gently this way and that, or the car will drift. You also glance at the dashboard now and then to be sure your speed is, well, “safe,” just like you did when you were a kid.

Same thing with T1D self-management. It feels complex in the beginning—because it is—but when you build the habits, it’s not hard or imposing or dehumanizing. You keep your eye on your CGM—your “dashboard”—to make sure you’re going in the right speed and direction. You nudge your insulin and carbs in very small microdoses now and then to stay in range, and you make sure you fill your tank (or plug in) to get the right amount of energy (exercise).

Just as driving becomes very simple, so can the four habits of T1D management. You can do it while you’re at school, in meetings, hanging out with friends, on dates, in movies, or anything else in life. And yes, you can even text while dosing. You be you, boo.

Habit #1: Watch Your CGM!

That’s right, simply watch your glucose levels on a CGM. (If you don’t have a continuous glucose monitor—a CGM—find a way to get one.) I won’t recommend products in this article, as it’s a distraction from the main points. However, my article, “Continuous Glucose Monitors: Does Better Accuracy Mean Better Glycemic Control?” discusses how to analyze CGM data effectively.

The frequency in which you watch your patterns matters, and you must do it in real time. You’re looking for patterns, not just glancing at your current glucose number. Seeing a single value, like 100, tells you nothing. What was it 30 minutes ago? Was it 200 and dropping fast, or 70 and rising fast? Or has it been 100 for the past hour? Each of those patterns requires different interventions, or none at all.

This habit is solely to familiarize yourself with patterns, not to make interventions—that’s next.

If you’ve been a T1D for long enough, you may have tried this, but if you’re not doing it now, it’s time to give it another shot. Our focus is on building separate, individual tasks to a point where they’re so automatic, you do them without realizing it. When I’m on the computer, I prop my phone up next to it so I can glance at my glucose trendline. In my car, I have a mount that I attach to the air vent to prop my phone there too.

Constantly looking at your CGM may feel like the “wax on, wax off” routine from the movie, Karate Kid, where it feels like there’s no immediate benefit. It feels pointless. In fact, this is where most T1Ds just give up.

But there’s far more benefit than you think.

Meal Bolusing

One of the first tangible benefits of frequent CGM observation is that you remember to dose insulin when you should, which is good, because most people simply forget from time to time. In the literature review article, “Optimal prandial timing of bolus insulin in diabetes management: a review,” T1Ds who pay attention to glucose patterns are far more likely to remember to bolus for meals than those who do not watch their CGMs. Forgetting to bolus for only two meals per week results in A1c levels 0.5% higher than those who remember to bolus.

That’s right, you can reduce your A1c from 8% to 7.5% by doing nothing more than bolusing for meals that you might have otherwise missed. If you remember even more often, such as snacking, then your outcomes will be even better.

Correlating Patterns with Events

Another benefit of frequently watching your CGM is that it allows you to build associations between glucose patterns and events. When you eat this food, your glucose levels do that. When you take this much insulin for that food, you see another pattern. If you sit around and watch TV, your glucose behaves this way, but when you walk right after eating, it behaves that way.

You also notice how long it takes for insulin to take effect, peak, and taper off. T1Ds are told that certain insulins take X amount of time to take effect, and last for Y hours, but that data comes from lab studies, where people are lying in bed with data being over the course of hours. Same with food: T1Ds are told about the absorption rates of certain carbs, fats, and protein, but all done within controlled settings.

In the real world, both insulin and food are metabolized with greater variability. Everyone’s different from each other too; you can’t expect to experience what you heard someone else describe on social media.

The more you seek patterns, the more adept you are and finding patterns, and then studying the events surrounding it. Whether you make your own dosing decisions, or use an automated insulin pump to do it for you, you’ll be able to see in real time the effects of such decisions—when the dose was right, and when it wasn’t.

Recognizing when something’s wrong

When you’re experienced at correlating glucose patterns with events, you can pick out those situations where things aren’t working quite as expected, and you just can’t put your finger on it. Sometimes, it’s something else.

The biggest challenge facing T1Ds in the variability of both insulin absorption and food absorption, both of which account for more unexpected—and untreated—glucose excursions than any other factor.

In my article, The Insulin Absorption Roller Coaster and What You Can Do, I discuss the greatest factors associated with unexpected insulin effects and what you can do about them. The key here is watching for them by keeping a careful eye on your CGM.

Similarly with food absorption variability, which I discuss in my article, The Best Way to Treat Hypoglycemia.

When food and/or insulin absorption does align well with expectations, or with each other, then things get really out of control, fast. By watching your CGM often, you catch these much sooner, and can then treat them sooner.

All of this leads to the next atomic habit…

Habit #2: Make Small Interventions (and refine them)

When you become better at recognizing patterns, you also learn to assess how effective your dosing is, and if it could possibly be improved. This is the second atomic habit of well-controlled T1Ds: making small, tiny interventions throughout the day.

If your glucose tends to rise too high after a meal, perhaps you could have bolused sooner? Or maybe your glucose dropped too much, too soon? Here, you might try spacing out the total bolus across two or three microdoses over the course of an hour or two or three? If you’ve been recognizing patterns well up to this point, now’s the time where you can make these tiny little adjustments.

If you’re using an automated insulin pump, you may notice that it won’t really do anything until your glucose levels start to rise, and that’s not ideal.

But, you could tell the algorithm that you ate—and even what you ate. And that’s the point (and always has been). Not only can’t pumps know this detail unless you tell them, they also don’t know what you’re going to do in the next 30-90 minutes. But you know—and you can tell them.

Many automated pumps will do the spacing of insulin delivery over the course of time as well, purportedly to make it “easier” on you. But you don’t necessarily want “easier,” you want to learn. So, let the pump do its work, but keep an eye on it. Is it performing well? As expected? Consistently? Would you do it that way and achieve the same results? Could you do better?

Spoiler alert: Yes, you can. All studies that show people get better glycemic control when they are more engaged with automated pumps, rather than using them in fully-automated mode. (See my longer article here.)

Of course, if you administer injections with an insulin pen, you’re always in full control, and you don’t need to compete with an algorithm to figure out what interventions are needed, how, and when. Many find this method much easier, but it’s a personal thing.

Small interventions such as those described here can clip peak glucose levels from 300+ down to 200+, which can reduce your A1c’s by .5% or more, while also improving your time-in-range dramatically.

The same goes for hypoglycemia. Being able to predict and intervene before hypos is far better than waiting for your CGM’s alarm to go off. It is estimated that up to 46% of T1Ds experience at least one severe hypoglycemia event each year, which is defined as an event requiring the help of someone else. Such events are responsible for more than 202,000 emergency department visits annually with approximately 25% being admitted to the hospital.

Those who watch their CGM frequently have a proportional decrease in hypoglycemia.

The other risk factor about hypoglycemia is that you’re taking in a lot of carbs that you otherwise wouldn’t eat. And let’s be honest: When your glucose levels drop to the 50s or lower, you’re going to eat like a ravenous lion. These carb-heavy, nutrition-free calories just turn into progressively more fat. According to the Lancet article, “Obesity in people living with type 1 diabetes,” the number of obese T1Ds reached 37% in 2023 compared to only 3.4% in 1986, due to two factors: “insulin profiles of automated systems do not match basal and mealtime insulin need,” and “defensive snacking to avoid or treat hypoglycemia.”

Speaking of basal insulin, most people learn that an adult needs a steady “drip” of insulin all the time, ranging from .8u to 1.5u per hour for most adults, depending on body weight. Accordingly, T1Ds take basal insulin (like Lantus or Levemir), or have an insulin pump deliver it at a consistent rate.

But, again, these numbers are derived from lab studies. In the real world, what the body actually needs is more inconsistent than a per-unit-per-hour value. Having that kind of steady “drip” is likely to deliver too much insulin at times you don’t need it, and not enough insulin when you need more, both of which contribute to erratic glucose swings, leading to higher A1c levels and weight gain (as per the Lancet article on T1D obesity).

If you’ve developed the habits of watching your CGM closely and effectively making interventions, it’s likely that many of those microboluses you were doing were compensating for the discordance between your basal dosing and your basal needs. If so, this is when you could dial back on the “automated” part of basal dosing (either the pump or the basal insulin), and use your microdosing technique to refine your insulin delivery more in line with your body’s actual needs. Slowly, surely, and above all, carefully.

If this feels overwhelming, it’s because you haven’t built the habits that lead up to this. Each task is very simple and easy on its own, but you do them incrementally, not all at once, making it far easier.

Habit #3: Data Logging

This one is likely to scare you off, but hang in there with me. That’s right, we’re talking about logging data. Carbs, insulin, exercise, sleep, and so on. All of these except for carbs can be logged via bluetooth on your smartphone from your pump or insulin pen, and a smartwatch. T1D management apps will ingest this data and can be plotted on a graph. The one exception is food: You have to manually add that.

I won’t kid you, most T1Ds don’t do this, and even those who do aren’t any good at it. Studies show that it takes many years before most people learn to properly log carbs.

So, why bother making carb-counting an “atomic habit?”

Interestingly, the mere act of attempting to log food has benefits. Namely, a phenomenon called The Hawthorne Effect, where people modify their behavior (usually positively) when they know they’re being observed. Logging activity is a “base case” of the Hawthorne Effect.

In a study titled, “The Importance of the Hawthorne Effect on Psychological Outcomes Unveiled in a Randomized Controlled Trial of Diabetes Technology,” subjects were exposed to a series of tasks associated with T1D management, and the authors found that T1Ds who exhibited fear of hypoglycemia (FOH) saw a significant reduction in FOH, simply because they knew were being closely watched, even though there was no intervention by the clinicians. The T1Ds simply did what they knew they should do on their own. In other words, they know what to do, but will only do it when they know they are being watched.

Similar outcomes have been shown for T1Ds who are told to log carbohydrates, exercise, and yes, manually take insulin.

When you have to stop and think about what you’re doing—such as calculating insulin and carbs—you are more present with your choices.

Let’s say you’re at an office party and see a big plate of donuts. You may think to yourself, “Do I log 40g or 60g of carbs for this glazed donut that I know I shouldn’t be eating?” Believe it or not, just thinking about logging those carbs and taking insulin may actually deter you from eating that donut.

Or, maybe you eat it. The good news is that you will have the skills to know how to bolus for it, and correct for it later…

Eating the way you want is not “cheating.” You’re not taking a “vacation” from diabetes. That way of thinking is called moral licensing or self-licensing, where you feel you’ve earned this “treat” because you’ve been so good otherwise. Studies show that it leads to overindulgence and a slippery slope. The point is, eat the donut, but don’t rationalize it as an award or a cheat or taking a break.

You’re just evolving as a person. When you develop good habits, you’ll notice that your “bad habits” start to subside—not entirely, but sufficiently. Believe it or not—and this is dead serious—the routine habits of watching your CGM becomes so routine and second-nature, that not eating the donut becomes second-nature as well.

In fact, people who log data, regardless of accuracy, tend to be more mindful about their nutrition and tend to eat healthier, if only because they know they’re watching themselves. And most of those people are not even diabetics. They’re using the technique to help lose weight, or avoid getting T2D.

Over time, learning to count carbs becomes incrementally easier and more accurate, and that gradual fine-tuning yields progressively healthier outcomes. Don’t worry about how long it takes; you've got a lifetime to figure it out because, you know, well-controlled diabetics live longer.

Habit #4: Exercise

This one is short and sweet: Just move around. Most T1Ds are afraid of exercise, largely because it can quickly lead to hypoglycemia. Learning how to dose properly for it is not a fixed science. But, like all good habits, you tackle it in small, incremental steps.

I won’t get into details here; instead, read my article, “The Paradox of Low-Carb Diets: A1c vs. Metabolic Health,” which explains that exercise requires a lot more carbohydrates than one realizes (and other reasons why low-carb diets are bad, bad, bad). (So are high-carb diets, but I’m now drifting from the topic.)

A great exercise habit is a short, simple walk. The paper, “Walking for Exercise,” from Harvard’s School for Public Health, shows that walking for 15 after each meal can result in a 2x reduction in risk for all-cause mortality (compared to those with a poor fitness level).

Of the four habits of healthy T1Ds, this one is probably the easiest and healthiest, but it’s ironically the one that the fewest actually bother doing.

Summary

"I am greater than my highs and lows"

When I was diagnosed in 1973, I told to do the following: Test urine for glucose “spillage” (even though the results were entirely useless), write down food and insulin (even though no one looked at it), and take insulin at least four times a day—one dose of long-acting insulin, and then three shots for each meal. How much? Hell, who knows! Trial and error.

Did all that work? Who knows! But they were still habits.

Those of us who followed the good habits lived longer than those who didn’t, including those who adopted modern technologies.

It doesn’t matter that most of this was performative; what mattered was that we were taught to be engaged with our disease. That engagement formed a mindset that lasted a lifetime, and that’s what nearly all of the long-timers have in common.

If a “cure” were to ever materialize, I would probably still do all my habits, including wearing a CGM, not just because they’re habits, but because they’ll keep me on track so I won’t develop T2D. I mean, think about it, if you didn’t have to take insulin or watch your glucose levels, would you be disciplined enough to maintain a healthy lifestyle? Given the rising rate of T2D, even non-T1Ds are adopting these habits.

Living a long healthy life ultimately depends on having the mindset of a healthy person, as that drives behavior more than anything. And, as James Clear would say, that is the definition of self-identity.

For more, see these related articles:

• The Sound of Diabetes. In 1985, my deaf girlfriend introduced me to the concept of behaving like I owned my condition, not the victim of it.

• Why I Haven’t Died Yet: My Fifty Years with Diabetes. Fun stats that span my 50 years of T1D.

• You’ve Got Type 1 Diabetes! Let the Fun and Agony Begin: A Humorous Journey Through The Three Stages of Self-Management.