Cameron’s Tips: Hacking MDI to Fit Your Lifestyle

My Experience

Insulin pumps dominate the modern type 1 diabetes management space. About 5 years ago, I found myself going through the motions on an insulin pump. I knew I could correct a mistake with the click of a button, which is admittedly nice, but it led me toward being more reactive than proactive in my diabetes management. As I considered my previous 20 years on a pump, I wanted to take more responsibility for my management and make more conscious decisions in my care. Thus, around 5 years ago, I jumped head-first into multiple daily injections. I found a sense of freedom with MDI that I had lost with the pump. 

Some benefits I found when I switched to MDI:

• No extra device in my pocket  
• No site changes every 3 days.
• No more morning highs from kinked or disconnected sites 
• No more ripped sites/pods from doors or doorknobs. 
• Less scar tissue formation since pen needles are much thinner and produced less damage to my body 
• More consistent insulin absorption and action 

MDI was even a great management style for me in the first few years of medical school while I was spending much of my day studying. Overall, MDI has both pros and cons like all aspects of diabetes management. The important thing is finding a management style that gives you the best opportunity to feel well and stay healthy for your life goals. 

Here are some tips I learned along the way that helped me thrive while managing with MDI.

Exercise

Exercise takes more thought and effort on injections. Pump therapy can easily manipulate insulin delivery with exercise mode, temporary basal rates, or insulin suspension to meet a person’s blood sugar goals. With injections, however, long-acting basal insulin cannot be turned off. Thus, there are a few considerations when exercising on MDI. 

• Check blood sugar ~30 minutes before exercise

Proactive blood sugar monitoring can help determine if a small snack or shot could help bring blood sugar into a safer range for the optimal workout.

• Understand how different forms of exercise impact your blood sugar

Each person responds differently to cardio, strength training, and flexibility exercises, so knowing which types raise and lower blood sugar is key.

• Use naturally occurring hormone fluctuations to your advantage

Human cortisol levels are highest in the morning and can elevate blood sugar. If you experience hypoglycemia during certain exercises, moving these workouts to the morning may help you avoid those lows. Similarly, cortisol levels are lowest in the evening. If you deal with hyperglycemia during certain exercises, later workouts may make it easier to manage blood glucose levels. 

• Benefits

MDI removes the burden of ripping out a pod with a barbell or sweating a site off in cycle class. As previously stated, there is no “one-size fits all” approach to diabetes management, and healthy, productive exercise regimens can be achieved on MDI.

# of Injections

• You are not confined to 4 injections per day

MDI does not limit people to a set number of insulin doses per day. Three mealtime doses and one basal dose is not nearly dynamic enough for the modern age and dynamic management is not reserved for pump users. Any bolus that is given with an insulin pump can also be given as an injection. While on MDI, I was giving myself around 5-10 injections a day, which underlines how personalized this treatment style can be. For comparison, those without diabetes secrete insulin 11-12 times per day on average, so we can take note that it isn’t natural to be boxed into a rigid insulin regimen.

• Insulin and injection guilt

I’ve found over the years that giving an extra bolus or injection often brings negative feelings and thoughts that I should’ve gotten the dose right the first time. However, as I’ve already written in this piece, diabetes is far too dynamic to be reliant on single doses of insulin for every meal or situation. My insulin requirements indicate my body’s needs, not a lack of effort or indictment on my character. Though this section may be a form of self-therapy for me, I hope that others can reflect and accept their needs without judgment.

Sleep

• Finding the proper basal rate

 Improper overnight basal rates can be corrected with automated delivery systems. When starting MDI, it can help to perform a basal trial by monitoring overnight trends and making small adjustments to basal doses. Long-acting insulin takes 2-3 days to reach a steady state, so it is important to give each basal adjustment time to take effect before making subsequent changes. The right basal rate can increase overnight time in range and amount of quality sleep resulting in happier, healthier days. Though flat lines are hard to find in diabetes management, the goal is to find the basal dose that keeps your fasting blood sugar in a steady range without a significant rise or fall. 

• Foods with high fat content

Pump algorithms assist with overnight highs caused by foods with higher fat content, such as the dreaded pizza spike. All people with diabetes should be able to eat the foods they enjoy, even while on MDI! Thus, those on MDI must be aware of their blood sugar trends when enjoying certain foods. For example, when eating pizza, you could set a custom high alert for 140 instead of 180 to catch the spike earlier.

• Dawn phenomenon

For those who know they have consistent morning blood sugar spikes, an injection upon waking up can be a simple, helpful action to prevent the spike before it occurs. Sleeping while on MDI can be tricky at times, but finding the right basal dose and proactivity are the keys to restful sleep.

Work

• Fear of judgement

I had concerns about how I would be perceived as someone on MDI during my medical school clinical rotations. I held worries that I would need to interrupt rounds for an injection or snack because I did not have a pump helping me manage in the background. However, I found that caring for myself within my work environment actually promoted my wellness. I observed that when people get a glimpse of the hard work that goes into diabetes management, they quickly become supportive of your health. Though not every work environment is the same, I’ve found that advocacy and self-care have done much more to benefit me than bring me down. MDI is a more visible management style than insulin pump therapy, but one’s privacy and health can be maintained even in the busiest of environments. 

• Find an ally

I am a person who is overly open with my diabetes. One of the biggest supports for me during my time in the hospital were my friends and peers who were aware of my diagnosis. Though it is everyone’s right to choose whether or not to share about their diabetes, I believe my support system went a long way in maintaining my health in a busy environment. If I ever had to take a quick break for an injection, I would whisper to a friend, colleague, or attending and they all understood the importance of maintaining my health. If any questions arose from my attendings, it was nice to know that I had multiple allies that had my back. I believe that communication is key, even if it means having one or a few trusted people on your side.

MDI can introduce complexities into care that aren’t encountered on pump therapy. With a little problem-solving and proactivity, anyone can find a dynamic MDI plan that works for them.