The “Bang for Your Buck” Principle in Diabetes Management

You have to love Dr. William Polonsky. He's the author of Diabetes Burnout, and founder of the Behavioral Diabetes Institute in San Diego, CA. He's also one of the smartest and most empathetic people you'd ever hope to meet. And he seems to "get" life with diabetes like no other non-diabetic ever has. Today, some insights from his treasure trove.

A Guest Post by Bill Polonsky, PhD, CDE

Managing diabetes effectively means you must do at least a million different things, and do bill-polonskythem correctly and at the right time each day. Well, maybe it isn’t a million, but it seems like a lot, doesn’t it? You should be eating fewer bad fats and more good fats, fewer bad carbs and more good carbs, more fruits and vegetables, but watch those blood sugars! Eat smaller portions, but eat everything in moderation, drink more water, or perhaps drink less. Don’t forget your vitamins, but which ones? Take medications faithfully, check blood sugars regularly, don’t forget to exercise, quit smoking, don’t drink too much alcohol, see your doctor often, lose or perhaps gain some weight, keep your blood sugars down but be careful about hypoglycemia, don’t forget to watch your blood pressure and cholesterol, and the list goes on and on.

The ugly truth is that most people—despite their best intentions-- can’t do it all. Whenever I speak to large groups of people with diabetes, I ask for a show of hands, “How many here take care of their diabetes perfectly every day?” While there is always one or two who proudly raise their hands, there are hundreds of others who sit quietly with their hands at their sides.

Why can’t most people follow all of their diabetes recommendations day in and day out? Unfortunately, good diabetes care must compete with other priorities in your daily life—taking care of your children, working at your job, errands around the

house, and so much more. There is just too much to be doing. So almost everyone compromises with their diabetes care, doing as much as they can with the limited time available. You must choose what is important, and let the rest go. But of the million-plus tasks that diabetes requires, which are the most important? Which ones will give you the most bang for your buck? In other words, which will have the biggest impact on your long-term health? If you don’t really know, you may be working hard on your diabetes management and still not getting the results you want. After a recent diabetes education program, one woman told me that she was now going to concentrate on drinking more water, while another fellow mentioned that he was going to focus on eating less junk food. Unfortunately, neither of them was taking their diabetes medications regularly, and they didn’t see this as critical to their health. Their well-intentioned efforts were not likely to improve their health, especially if they were not taking their medications. These were not stupid people, but no one had helped them to think thru their diabetes priorities. To be fair, even health care professionals don’t agree on this issue, because—at least until now-- it was hardly ever discussed.

To start the conversation, here is my own list, in order, of the top ten diabetes-related tasks likely to give you the biggest bang for your efforts. Please, please, please don’t take this list as gospel. Different patients have different needs. Your physician knows you best and he may have his own opinion:

  1. Know your own numbers (at a minimum, A1C, blood pressure and cholesterol), know what they mean, and get these tests done regularly. When you know exactly how well you are doing, this can provide the enthusiasm you need for all the tasks to follow.
  2. If you smoke, find a way to quit.
  3. Make sure you’re on the right medications, and take them faithfully.
  4. Engage in regular physical activity.
  5. If you are overweight, focus first on reducing portion sizes.
  6. Identify and reduce the fat in your diet, especially saturated and trans fats.
  7. Eat more fruits and vegetables.
  8. Check your feet daily.
  9. Monitor blood sugars regularly
  10. Stay educated about diabetes

Given your own circumstances, you and your doctor might set these priorities in a different order, and might even include different items. If you have Type 1 diabetes, for example, you might put blood sugar monitoring higher on the list. If you are not overweight and your blood sugars are well controlled, you might not worry about reducing portion sizes. In any case, since no one can do it all, sit down with your doctor and determine your own self-care priorities. Learn which of your many tasks will give you the biggest bang for your buck. You are already putting out plenty of effort, so let’s make sure it counts.


Thank you, Bill. Getting the most out of our efforts is always the name of the game, of course!



10 Responses

  1. Hans
    Hans August 17, 2009 at 7:52 am | | Reply

    Nicely written but far too complicated for my liking. Why not just go on living like people without D and just keep the daily bg curve mostly within the non-D range?

  2. Lauren K
    Lauren K August 17, 2009 at 5:35 pm | | Reply

    Hans - my thoughts exactly! That is the realistic way to manage type 1. I generally ignore and avoid CDEs because they do not understand the on-the-ground daily realities of living with this problem. Diabetics are not robots, we're people leading complex lives. I check my glucose 10-15x a day and have super-tight management, but diabetes is far from the center of my life. I keep it in the back of my mind, and check, eat, and exercise responsibly, but I do not tailor my life to my diabetes. That is unsustainable and foolish.

    The bottom line for me is to manage my disease so I can live like any other person, and have blood sugar levels like a person without diabetes for the majority of the time (A1c under 6). And so far so good. Thank God I didn't listen to the CDEs who've crossed my path, toting their misguided "one size fits all" information kits and working within their very limited understanding of type 1 diabetes.

  3. Marcia
    Marcia August 18, 2009 at 5:05 am | | Reply

    I think because of the increasing rates of obesity, the media is much more focused on Type II diabetes nowadays, with less of an emphasis on Type I.

  4. Carb O'Phile
    Carb O'Phile August 18, 2009 at 1:29 pm | | Reply

    It is so refreshing to heat someone voice opinion that matches my own.

    I would argue that, with limited face time, no-one knows me better than, well, err, me, and that the prioritisation needs to be a consensus of opinion 'twixt physician and patient; ultimately both have the same outcome in mind - what's best for the patient.

  5. susan f.
    susan f. August 19, 2009 at 11:29 am | | Reply

    Honestly these recommendations are too general and will do little to improve the a1c of a patient. My advice to those who struggle is to focus on perfect numbers overnight. Yes, it is hard with carb counting and schedule during the day to keep perfect numbers, BUT...

    Just imagine that everyday from 9pm to 9am you have perfect numbers, your a1c will improve dramatically. How do you do this? Mainly by tinkering with your basal rates until you have nailed them. In addition, cut out a bedtime snack to avoid a bad carb count guess and/or delayed rise in bg. Test 2.5 hours after dinner, correct if needed, and then enjoy your stable night.

    Yes it may take some sleepness nights to nail the overnight basals, but it is so worth it in the long run.

  6. Olga
    Olga August 20, 2009 at 9:52 pm | | Reply

    susan f. -- cool hint! you're right, that's half a day right there. thanks for the perspective tweak!

  7. Kelly Rawlings
    Kelly Rawlings August 21, 2009 at 11:12 am | | Reply

    Hans, one of the reasons that there's much more to diabetes management than just blood glucose control is that blood pressure and cholesterol management are also very, very important for avoiding complications (as Dr. Polonsky mentions in his first point). It's estimated, for example, that nearly 75% of people living with diabetes also have high blood pressure. And high blood glucose plus high blood pressure work in tandem to increase risk of both micro and macrovascular complications.

    Although a young person with type 1 may have perfectly good blood pressure and blood cholesterol numbers during the first years of his or her life with diabetes, we're all prone to blood pressure and cholesterol issues as we age. Those problems are, of course, compounded by overweight and inactivity. Plus, even without having high blood pressure, the blood pressure drugs ARBs and ACE inhibitors actually provide some kidney protection (which is why I'm on one of them after living for 36 years with type 1--no protein in the urine, but I want to keep it that way).

    It's very cool if you are able to live like a person without D and keep the daily bg curve in the non-D range--but how exactly do you manage that without any blood glucose testing, regular activity, and attention to what you eat?!!! Do share.

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