CONVERSION THERAPY AND DIABETES


Robert Doucette [Attribution], via Wikimedia Commons

History and literature are overrun with examples of conversions: from Saul’s journey on the Road to Damascus in the New Testament, to the overnight transformation of the miserly Ebenezer Scrooge in “A Christmas Carol”.

For the first 40 of my 50+ years living with type 1 diabetes I operated under the assumption that if I only had the right combination of insulin doses and carefully measured what I ate, then I would have the best diabetes control possible. I also told thousands of patients to do the same.

Boy, was I misinformed!

Being a 'Dr. Gadget', I of course purchased a real time continuous glucose monitor as soon as I could get my hands on one. In the early days of cgm I used the Abbott Navigator which was a great sensor but short lived. Things would never be the same. More importantly, my fundamental approach to diabetes would undergo an upheaval of seismic proportions.

Somewhere along the way I experienced a conversion to using and refining many non-traditional blood sugar management techniques. Years later I would package this toolset as “Sugar Surfing”. What I tell you next may shock you.

 

“I do not believe there is any need to look at a CGM readout any more than 6 or so times a day.”

- Stephen W. Ponder, (circa 2005) Static Thinking Endocrinologist & Person Living With Type 1 Diabetes

 

That's what I told my co-author Kevin McMahon way back when. I even went so far as to express concern that my patients would become obsessed with these data and perhaps look at their blood sugars up to twenty times per day. Oh, the misery and frustration of chasing blood sugar. I even opined that there should be a way to limit how often a person can see their data lest patients suffer burnout from constantly looking at the data.

As a board certified diabetes specialist and certified diabetes educator for over a quarter century, I taught or passed on the diabetes dogma I was taught. I was resistant to change and clung to the old ways I had been taught.

After starting my CGM, for weeks I watched my blood sugar trend line dance across the screen like a drunken caterpillar. The metabolic control upon which I prided myself in (based on A1C levels of 7.0-7.5%) was in actuality associated with many spikes and plateaus of blood sugar levels well into the 300 mg/dl [> 16.7 mmol/L] range before settling down into the mid-100 mg/dl [~8 mmol/L] range, usually before the next meal. I wasn't quite sure what to do with all of this information.

They don't teach medical students, resident doctors, or most endocrinology fellows how to apply the information you get from a CGM device, at least in real time.

Foods that I thought had no effect on my BG slowly but clearly shifted my readings well outside the target ranges I aimed for with finger stick blood sugars collected at a single point in time. Likewise, slow downward trends would happen at unexpected times too. This technology humbled me by how it revealed the shifts and drifts in my BG that often seemed inexplicable and utterly capricious. And the stress I thought would raise my blood sugar most of the time every now and then lowered it as well. I could finally see the chaos in real time.

My curiosity kicked in. As time rolled on I began to experiment with my choices as I could quickly and easily see the results from those choices on the cgm trend line. Forget the super-advanced technique of taking insulin 20 minutes before eating. What if I took insulin long enough before eating to actually see the change in my blood sugar using the sensor and use that information to choose when to eat my meal? What if I took a small dose of carbs to treat a low BG that was smaller than the usual 15 grams I was always taught? What if I took small doses of rapid-acting insulin to see how far it would shift my BG trend line? How much would a Pe