Self-Identity and the Four Habits of Healthy T1Ds

Behaviors are inextricably linked to our sense of self

Are you a diabetic? Or are you a person with diabetes?

Don’t like that question? Ok, try this on for size: Is your blood sugar well-controlled?

There is a connection between these two, and that’s what we’re here to explore.

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.

Building good habits—especially these—can be 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.

We can infer this because the Joslin Diabetes Center has presented more than 5,000 50-Year Medals since 1970, with an increase in the number of people who pass the 75-year mark, and now 80 years. Other organizations offer similar awards, and as each of these people are profiled, we find nothing in common: They come from dramatically different backgrounds, races, education levels, careers, and so on.

That said, there is one thing that they all likely have in common: They self-identify as T1Ds. While none of them have been formally asked this, it would be consistent with an approach to developing habits developed by 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, because people behave in ways that are consistent with their identity.

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

Self-determination theory and diabetes

Te Blue and Grey Ribbon is an international symbol for diabetes

Psychologists that work with patients suffering from diseases or mental illnesses that require self-management often utilize a principle called Self-determination theory (SDT), a macro theory of human motivation concerned with the degree to which human behaviors are volitional or self-determined. It posits that individuals are motivated by three basic psychological needs:

1. Autonomy: The need to feel in control of one's own actions and decisions. This involves feeling a sense of choice and agency.

2. Competence: The need to feel capable and effective in one's sense of mastery and accomplishment.

3. Relatedness: The need to feel connected to and accepted by others.

The challenge for T1Ds is that the disease makes it very hard to satisfy any of the three criteria: It’s hard to feel in control because diabetes is so volatile and unpredictable, making it hard to build competency. As for relatedness, all T1Ds have experienced being treated as lazy or lacking self-management skills.

Helping T1Ds face these challenges is difficult to say the least, so therapists that work with diabetics start with some conventional assumptions. The first is that a sense of autonomy is closely associated with identity. Here, we usually think of identity as a way to describe our affinity with things: a set of values, morals, ethics, political, religious, racial, ethnic persuasion, or gender, to name a few.

In our own minds, these are positive associations, an idea or characteristic that you’re proud of, or that you support (even if it doesn’t exactly describe you). In this sense, it’s hard to “identify” as a diabetic if it causes you distress or if you’re ashamed by it. So, people are told they are “not a diabetic, but a person with diabetes” to allow patients to differentiate themselves from that negative association.

The next tactic is to use empathy to help patients feel better about themselves, acknowledging that diabetes is hard, and that it’s a struggle. What you need to do is not what you want to do. Words like “warrior” and “fight” are used to motivate people to feel empowered, because diabetes is a “battle.”

Lastly, to give people a sense of competence, goals are reduced to make them easier to achieve, say by bringing their A1c down from 9% to 8.5% instead of 7%. When they succeed, they then given accolades from others: “You did it! Congrats!”

Whether this works in the real world has shown mixed results. In the literature review, “Self-Determination Theory and Quality of Life of Adults with Diabetes: A Scoping Review,” the authors cite ten years of published studies spanning from January 2011 to October 2021, and the results are rather complicated. Namely, “quality of life” was the primary goal, with health outcomes being secondary.

While these approaches showed a tremendous benefit psychologically—which is why these techniques are still used—actual health outcomes were both modest and short-lived. When patients returned to their daily routines, bad habits returned, and both their mental and physical health worsened once again.

There are other approaches that get less attention and have shown great success. For some, James Clear’s “Atomic Habits” approach may work. His research into how people build sustainable habits—even those involving mental health concerns—are summarized as such:

• Goal-oriented approaches are prone to failure, whereas process-oriented approaches are more successful.

• Difficult challenges should be reduced into very small, easily achievable tasks that must be done frequently so they become second-nature. These then accumulate to achieve progressively better outcomes, often exceeding what were once considered unachievable.

• Most importantly, one must first adopt, not reject, the identity of the archetype of the person who is successful.

This approach satisfies all three basic psychological needs described by SDT: By eliminating targets or goals, and instead focusing on processes, in the form of simple and easy tasks, people feel competency. As incremental successes accumulate, they feel an increasingly stronger sense of autonomy. The tangible and sustained health improvement fosters a stronger sense of self-respect, including acknowledgement from others.

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

Setting the right mindset is essential, so let’s start there.

The Identity-Habits Mindset

We begin, as Clear does in his book, with the notion that all our behaviors are inextricably linked to our sense of self, and vice-versa. It’s a feedback loop.

It’s in this context that Clear uses a different definition for identity than that of having a positive association with something. Instead, your identity is merely the net sum of all of your behaviors. Clear explains that the original word comes from the Late Latin word “identitas,” derived from the Latin word “idem,” which means “the same.” Identity finds its roots in a contraction of “idem et idem,” which literally means “same and same.” The original use of the word was to associate one’s identity to habitual daily behaviors. You are the net sum of all your behaviors.

What Clear’s research finds is that there’s a psychological tether between people’s behaviors and identity—that is, one follows the other.

He illustrates the point using an example where, if you offer someone a cigarette that declines it, they may say either, “No thanks, I'm trying to quit.” Or, “No thanks. I’m not a smoker.”

The first case is a person who identifies as a smoker, but is trying to be disciplined, and in so doing, hopes to eventually become a nonsmoker. This is the goal-oriented mindset that most people are familiar with. Whether it’s quitting smoking, losing weight, recovering from addiction, recuperating from injuries or traumas, or getting better at glucose management, people usually start by looking at the long-term goal or outcome they want to accomplish, and then asserting self-discipline to drudge through the tasks they really don’t want to do.

Quitting smoking is a struggle. What you need to do is not what you want to do, or that feels natural. This mindset of constantly feeling behind the game has never shown clinical benefit in any medical literature. On the contrary: It can lead to—or exacerbate—mental distress.

When your sense of self is the archetype of a person who is in control, you’re predisposed to behaving like that person, thereby making the tasks less burdensome and easier.

“No thanks, I don’t smoke.” Easy. Done. They identify that way, so they behave that way.

Small tasks like those we’re about to discuss are not goal-oriented, but process-oriented. The four habits of healthy T1Ds really get back to the fundamentals of T1D self-management that you might have been taught when you were first diagnosed. Nowhere in the list of fundamentals were words like “targets” or “goals.”

As many famous coaches of sports teams have said, “if you practice the fundamentals, the score will come, as will the trophies.”

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 lie you did when you were a little 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 correlating glucose patterns with events, you can pick out those weird, anomalous situations where things aren’t working quite as expected, and you just can’t put your finger on it. Sometimes, it’s something else.

For example, CGMs can sometimes get out of calibration, or insulin pumps can have a mechanical snafu where they don’t deliver intended doses (see this article), or insulin can go bad due to exposure to excess heat. (Insulin begins to denature when exposed to temps over 85ºF, and it’ll get progressively worse the longer the exposure. Pump users are particularly susceptible to this because the reservoir is on the outside of the body, so if you’re outside a long time, be careful.)

There could be other factors too, such as health-related matters: Insulin requirements start to rise prior to a new infection taking hold, or if you haven’t had sufficient sleep, or are under unusual stress. Recognizing when your patterns change like this is sharpened when you watch your CGM frequently.

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 it, 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 usually 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 do—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 during this experimental phase, you don’t 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 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. A 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"

Remember the long-haul T1Ds, who’ve passed 50, 75, and 80 years? I’m one of them, and 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! There were no A1c tests to track it. But T1D obesity rates were very, very low. Sure, there was lots of microvascular disease, but there always has been, and probably always will be.

When A1c tests and blood glucose monitors got widespread adoption in the 1990s, we used them. When CGMs were widely adopted in the 2010s, habits were even more effective. When smartphones and their apps appeared, habits got easier.

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.