Improving Time in Range: Walker’s 8 Daily Habits for Optimal Type 1 Diabetes Control

I’ve been a type 1 diabetic for over 15 years now, and although I like to think that I have things pretty well figured out, I still experience days with diabetes that feel completely out of control. What follows are my “rules” that I use for regaining control when things get out of whack. I call them Walker’s rules because T1D is highly individual – what works for some people may not work for others.

Following these rules helps me achieve high time in range (TIR) and a low HbA1c score which rivals that of a healthy non-diabetic. My hope is simply that sharing them might help you or your loved ones achieve the same.

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Rule #1. Confront the brutal facts of your reality, yet never lose hope

I lifted this rule straight from a business book called Good to Great by Jim Collins.

One thing Mr. Collins identifies among leaders of great companies is that they are hyper aware of the truth of their situation. He argues that in order to find the path to greatness, you must first confront the brutal facts of your current reality.

He expands:

“When you start with an honest and diligent effort to determine the truth of your situation, the right decisions often become self-evident. It is impossible to make good decisions without infusing the entire process with an honest confrontation of the brutal facts.”

You’re the CEO, and your company’s mission is to survive and thrive with T1D. Now confront this brutal fact about diabetes: if you aren’t disciplined, you will likely suffer serious long-term health complications, including (and unfortunately not limited to) retinopathy, dementia, kidney failure, depression, heart disease, nerve damage, and cancer.

And here is the good news: you absolutely can avoid all of these complications with some effort. It’s entirely possible for us to live a long and happy life. This is the hope that you must never lose.

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Rule #2. Get a continuous glucose monitor

You need a CGM to effectively manage this disease, full stop. These devices let you see your blood glucose levels (BGL) every 1 or 5 minutes, which is the data you need to make proper decisions about insulin dose sizes and timing, meals, exercise, sleep, and so on. With a CGM you’ll have alerts when you’re heading high or low, you can look back at your data and learn from previous days, and you can share your data with others to get help. Use of CGMs is associated with higher quality of life, better peace of mind, and improved health outcomes.

Unfortunately for all of us, CGMs aren’t cheap. If you can’t afford one or otherwise don’t have access, check out Dexcom’s patient assistance program or visit Abbott’s affordability page. You can also try to snag a free trial here for Dexcom and here for Abbott. 

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Rule #3. Optimize your sleep

Getting high quality sleep should be one of your top priorities, diabetic or not. I’ve found that a bad night’s sleep seems to make management harder for the next day, if not the next few days. Some studies have pointed to the fact that insufficient sleep is linked with higher HbA1c levels. 

As a diabetic, you’re going to experience more sleep interruptions than the normal person, mostly due to alarms from your CGM when your BGL is too high or too low. My strategy for reducing these interruptions is to simply eat dinner earlier. When you eat a meal, you’ll have food and bolus insulin acting on your body for up to 5 or 6 hours afterwards, maybe more depending on the meal contents. Let’s consider two scenarios, A and B, where in both cases you’re going to bed at 11pm. 

In scenario A, you eat dinner at 8pm and by the time you fall asleep, you’ve still got another 3-4 hours of unknown glycemic behavior remaining due to your meal. If you were even slightly off in your estimate of carbs, or insulin dose amounts, or timing of the dose, or you didn’t account for one of the other untold number of factors that affect blood glucose levels, guess what: you’re waking up soon to a loud alarm, interrupting your valuable sleep (and perhaps your partners, too). You’re awake in the middle of the night, resulting in wide-ranging negative effects on cognitive function, mood, and overall well-being.

In scenario B, you eat at 5pm and have 6 hours until bedtime to monitor your BGL while it fluctuates up or down as the insulin fights to counteract the meal. You didn’t get the meal perfectly right (oftentimes no fault of your own), but by 10PM the fluctuations have mostly settled, and you make a small correction (either bolusing if you’re too high or eating a snack if you’re too low). Then you’re off to bed with only a very small amount of insulin and/or carbohydrates remaining in your system. You sleep like a baby while your brain, heart, and immune system get the rest they need to function optimally.

Eat dinner earlier whenever possible. The less insulin and carbohydrates you have active in your system when you go to bed, the better. 

(I know that not everyone can do this all the time. You may work late, or have kids to deal with, or have social commitments that happen in the late evening. That’s ok. Just keep this in mind to try for the next time you’ve got a Sunday evening with no plans.)

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Rule #4. Eat fewer carbohydrates

I will never tell you what to eat. There are countless pundits doing that already, telling us conflicting information about “healthy” diets across TikTok, Instagram, YouTube, or wherever you get your podcasts.

I’m just stating the fact that you will be better able to predict and control your BGL when you eat less carbohydrates. You don’t have to do this for every meal, every day. But when things are spiraling out of control, eating a meal with 120g of carbs is kicking yourself while you’re down. 

If you want virtually guaranteed perfect TIR after a meal, try eating <30g of carbs. There is a plethora of appetizing and nutritional meals that will work for this, just search for low-carb or keto recipes. Further reading about the value of low-carb meals: Dr. Bernstein’s Law of Small Numbers.

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Rule #5. Only use glucose tablets for correcting low blood sugar

Overcorrecting for a hypoglycemic event can lead to a real rollercoaster of actions and reactions. We’ve all been there. 

On this day of perfect control, skip the juice. Skip the cookies, the ice cream, and the corn syrup candy. These contain other ingredients (or different types of sugars) that only slow down absorption and add other variables that complicate your work. We want something as close as possible to pure dextrose, which can be immediately absorbed into the bloodstream. If you don’t want to pay artificially high prices for fancy “diabetes glucose tabs”, get some bulk mega smarties – they’re pretty close to the same thing.

The difference between an 8g piece of chocolate vs. 8g of smarties is significant. The chocolate will raise your BGL slowly over a longer duration, which will overlap and confuse its effects with other things your body is doing. The smarties will hit hard and fast and be done within 20-30 minutes, making it easier for you to predict your BGL after the fact.

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Rule #6. Exercise regularly

I can only speak for myself when I say that a regular cadence of both cardio and resistance training seems to help immensely with day to day BGL control. To oversimplify a lot, by hitting the gym you’re improving your insulin sensitivity, which lets your muscles use insulin more efficiently to take up glucose.

The regular in “exercise regularly” is important here. If you do a real workout for the first time in a few weeks, you might be unprepared for the subsequent increase in sensitivity. Conversely, if you stop exercising suddenly, you might notice a few days later that your body isn’t responding quite how you’d expect. Consistency is key.

I’m no expert but I follow a pretty simple routine: cardio 2-3x per week and weightlifting 2-3x per week, alternating each day. For cardio I like rowing, walking, and a simple yet difficult Norwegian 4×4 interval run (in brief: 4 mins at a solid run, 4 mins walking, repeat 4 times). For weightlifting, I follow a simple free-weight routine: chest, shoulder, and triceps one day, then back, biceps, traps and legs on the next.

Remember that exercising intensely with insulin on board is going to dump all of that insulin into your system much more quickly than if you were sitting at your desk doing nothing. You can use this to your advantage if you’re skyrocketing up after a meal (go for a 20-minute walk and watch the magic happen in real time). Always carry some glucose tabs with you when exercising.

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Rule #7. Log everything

If you’re going for that shiny 100% TIR badge, logging your meals and insulin in an app is extremely helpful. I use Gluroo to quickly log everything related to my diabetes and see how it impacts my BGL. I work at Gluroo, and we’ve worked (and continue to work) damn hard to make sure it’s the best diabetes management app possible. It’s definitely the fastest tool for logging meals and insulin. Speed and efficiency are really important to me. If it takes a ton of taps and clicks, I’m not going to do it.

The key insight for me is knowing how many grams/units of carbs/insulin are in my system (“on board”) at all times, which prevents me from stacking on more.

For example, sometimes when my BGL is high, I’ll take a shot and then be frustrated an hour later when I haven’t started dropping. With Gluroo I can see that of the 4 units that I just took, there are still 3.4 units on board, meaning 3.4 units that have yet to affect my BGL at all. So, I shouldn’t take another shot quite yet.

(This is a made-up example – the rate at which insulin absorbs is dependent on the individual, the type of insulin, and much more, but you get the idea.)

Logging stuff is also great for reviewing and learning from historical data. I can search for the last time I ate a slice of pizza, pull up my CGM trace, and see exactly how much insulin I took. Then I can modify my bolus timing and dose size as needed.

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Rule #8. Don’t drink alcohol

This goes hand-in-hand with Rule #3. Alcohol is yet another variable that is only going to make things harder for you (read all about it here and here – I won’t go into the details). Again, I’m not telling you to abstain forever, but when you’re trying to get your diabetes dialed in for a day or a week, skip the drinks. I like having a beer with my buddies or a glass of wine over dinner as much as you do, but I also appreciate the fact that alcohol is terrible for me to begin with and adds unnecessary complexity to my life as a diabetic. 

Final thoughts

I can’t count the number of posts I’ve read in the T1D community that express frustration with managing this disease, ranging from snarky memes to suicidal ideation. I understand it – I’ve lived through the good and bad days myself. This post is for those people who have gone through hell trying to figure this disease out.

While diabetes management is never easy, I hope that if you use these rules, you’ll see that it is possible. If even one person reads this, tries out the rules for a day and regains some hope, I’ll count the many hours spent writing it as time well spent.

Thank you for reading.

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Bonus section: resources that have helped me

Books

• Think Like a Pancreas: A Practical Guide to Managing Diabetes with Insulin by Gary Scheiner (Amazon). I’ve met with Gary and he’s a great person – empathetic and extremely knowledgeable about managing diabetes. I revisit this book frequently to better understand the biological background of my disease.
• Dr. Bernstein’s Diabetes Solution: The Complete Guide to Achieving Normal Blood Sugars by Richard K. Bernstein (Amazon). This is a T1D classic. It’s a bit dated (or at least it was when I read it), and not everyone agrees with the ‘extreme’ principles outlined in it (like eating 12-15g of carbs per meal max). That said, it’s a wealth of information and an important perspective to consider.
• Bright Spots & Landmines: The Diabetes Guide I Wish Someone Had Handed Me by Adam Brown (Amazon, free PDF). Adam’s book is full of useful, actionable tips on the nitty-gritty details of managing T1D. It’s also compassionate, friendly, and sympathetic – a reflection of the author that makes you feel understood and welcome.

Blogs

• 42 Factors That Affect Blood Glucose?! by Adam Brown.
• The Laws of Small Numbers by Dr. Bernstein.
• Type 1 Diabetes: It’s Not That Simple by Dan Heller. If you want to dive deep into some serious and fascinating discussions about T1D management, biology, optimal research techniques, and more, Dan is your guy.

Miscellaneous

• Bulk Mega Smarties (Amazon). A cost-efficient alternative to expensive “diabetes glucose tablets” that are virtually the same thing (and taste better, in my opinion).