Holidays. Even from T1D?

The holiday

For the past two weeks, I’ve been on a bit of a holiday of a lifetime, taking in the Big 5 (elephant, rhino, buffalo, leopard and lion), the Marine Big 5 (seals, whales, sharks, dolphins and penguins), plus a host of other amazing animals and sites.

To put this in context, it was an 11 hour flight, with multiple shorter internal flights, eating a lot of food with breakfast, lunch and dinner often included, as well as multiple snacks throughout the day.

Most of my time has been spent in a far more sedentary fashion than normal (either weekdays or weekends).

As frequent readers will know, I’ve identified two different exercise patterns at weekends and weekdays, and whilst on this holiday, have adhered to neither, giving myself on average, 6,760 steps a day, compared with an average of around 11,500 steps in normal life.

This has been down to sitting in jeeps and on boats, looking at various wildlife.

It also involved lots of sitting around editing photos and making sure I had what I want. And, okay, this is a bit of an excuse to show some of those off. So one last photo, while we set the context.

So, a great holiday, but what of diabetes?

For the duration of the trip, I’ve been using my Boost adaptation of the AndroidAPS system, with a combination of Dexcom One+ and Dexcom One sensors, and a mix of Accuchek Insight and Medtrum Nano pumps. I’ve also continued with Incretin therapy, along with GABA and Metformin.

What does the drug regimen look like on a daily basis?

• Symprove Probiotic on getting up every day
• 1000mg Metformin before breakfast, 500mg before bed
• 500mg GABA with the Metformin
• 2mg Tirzepatide split every 3.5 days as 1mg per dose
• Amlodipine and Ramapril before bed

My insulin therapy uses u200 Lyumjev diluted to u100 with saline.

The diabetes bits

Headline glucose numbers

During the vacation, my time in range (TIR) and time in tight range (TITR) data is shown below.

This happened with no mealtime bolusing or management of high glucose levels. That was left entirely to Boost, as were effects to minimise insulin delivery during periods when glucose was dropping, using high temp targets to limit any reaction to treatments.

There were two occasions where I knew there would be additional activity and as a result I triggered high temp targets to limit insulin delivery during that period.

These numbers appear to be pretty good for as little intervention as I could possibly get away with.

Other numbers to think about

Activity

As I mentioned at the start, I was generally more sedentary during this vacation than normal. About half as many steps, as I mentioned previously.

Not quite so much as the rhino shown above, but, well, pretty bad.

Food

To add to this, the meals were typically accompanied by a variety of carbs in multiple ways.

• Breakfast: Fruit juice, Fresh fruit, pastries, toast, muesli
• Lunch: Rice, potatoes, pasta, bread, desserts
• Dinner: Pasta, Rice, Potato, bread, Dessert (including ice cream)

There was also a variety of honey, sweet liqueurs (Amarula, I’m looking at you), and interesting coffee, the “Mokka, Chokka, Rolls, Vulu-Vela” which was essentially hot chocolate and coffee with added Amarula.

And I’d be lying if I said I didn’t hoover these things up. I’d estimate my daily carb load at around 250g-300g per day.

Insulin

Now given the food consumed above, you’d be right in thinking that my average insulin consumption changed a little.

In fact, it changed a whole lot, and wasn’t helped by some day three set issues on a couple of occasions.

The chart above shows the difference in the mean and distribution of total daily dose. Prior to going away, my average Total Daily Dose (TDD) was 45.2u per day

Whilst on holiday, it rose to 61.2u per day. A 35.6% increase.

Prior to vacation, the TDD range was 30.6u-58.5u.

On vacation it was 32.1u-102.6u

Not only was Boost having to deal with my higher levels of sedentariness, it was also having to cope with hugely varying insulin needs, which the statistics suggest it did effectively.

Incretins

As I mentioned early on, my Tirzepatide dose for the duration of the holiday was 1mg every 3.5 days. This is below the minimum recommended amount. The main reason for dropping low was to I ensure I didn’t feel too full to sample the delights that were going to be available to me.

Whats perhaps more interesting is that, despite eating more, I had zero weight gain over the two weeks, even with greater insulin use, lower activity levels and more food.

I can’t explain the reasons for this, however, I presume that the benefits of using an Incretin agonist probably play into this. On an n=1 level, gaining no weight while eating quite a lot more than usual was an unexpected outcome.

Perhaps more of note is the correlation between lower incretin dose, higher food consumption and TDD. It further raises the question as to how much the insulin reduction we saw in the retrospective study from 2024 was simply down to reduction in food consumption and how much is directly linked to the incretin use?

Other things to think about that aren’t eating and numbers

Kit

Whilst the day-to-day management was easily and reliably left to Boost to deal with, and that in and of itself is almost fantasy in the results it produced, there were plenty of other things to think about that didn’t play into the fantasy that you’ll hear about, described as “Fully Closed Loop”.

First up, hiking truck loads of gear and insulin around with you. As you’ve probably guessed by now, I’m a keen photographer, so I had to get that gear into my hand luggage. Along with all the diabetes gear, spares emergency spares and emergency, emergency kit that were accustomed to taking with us. Could’ve used an elephant to help with that…

On some of the smaller planes we flew on, I was right on the edge of fitting hand baggage in the locker.

And of course it’s summer in Southern Africa, and the sun is hot, so bags containing insulin can’t be left in direct sunlight without getting hot. Something to keep an eye on and be aware of when necessary.

Then there’s remembering to check fridge temperatures and then remembering to clear the fridge out. Again, things that you just have to do.

People without diabetes don’t have that overhead.

Changing things

I’d be remiss if I didn’t mention changing things and the hiccups that can sometimes bring.

At the average TDD I was using, my Insight cartridge was emptying every two to three days. That entailed regular changes (and saw me switch to the Medtrum Nano halfway through for the longer duration).

But not only changing insulin. There were still regular set changes and an additional occlusion that needed to be dealt with.

And let’s not forget the CGM. Although I had started off with a One+ and started a One with an Anubis transmitter, it decided that I’d need to reset it to work, so there was an hour of faffing with Anubis tool to sort that out, along with the low level anxiety that it wouldn’t work and I’d need to go and source a Libre from a pharmacy somewhere (the backup plan).

I know for some these might be major issues. They’re things that I’ve got used to just living with with diabetes.

But that’s type 1 diabetes for you.

Where are you going with this?

I’ve covered off both holidays and diabetes bits and pieces in this article. And still I’ve not answered the direct question in the title.

I think the answer is evident.

Whilst developments like Boost provide respite from the onus to bolus, and therefore reduce the need to focus on day-to-day diabetes management as much, they don’t eliminate it. And as I’ve grown accustomed to the capabilities of Boost, I’ve spent far less time managing diabetes on a day-by-day basis. My decision making every 15 mins has dropped to every 3 or 4 hours. Mainly based on “Am I going to eat that?”.

The other part of Boost is that, despite the community naming convention of “Fully Closed Loop”, unless your life is regimented, with very repetitive timing around activity, eating, sleeping, etc, Fully Closed Loop is a bit of a fantasy name. You’ll still need to figure out strategies to help with spontaneous exercise, for example.

As a result, rather than focusing on mealtime management, you instead focus on insulin on board at appropriate times.

Where Boost helps is that it uses some simple tools to adapt it’s behaviour taking things like activity and inactivity into account, as well as intraday variation in insulin delivery.

Aside from the above, there are plenty of other things to remind you that it’s with you and always present, whether that’s gear, tech, tech not working properly, alarms, etc. So while you can set a higher target and mostly ignore the day-to-day processes, there are still enough occasions where you know it’s not really a holiday.

Sadly, the answer to my initial question is that no, there are no holidays from T1D, but there are ways to increased time in happiness.

Thanks to the tools I was able to take with me on holiday, my time in happiness was close to 100%. I can’t ask for more than that.

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If you’re interested in the images shown in this article, you can find a host more over at 500px. Feel free to go and take a look at my photography!

For more information on Boost, take a look at GitHub.