Staying Between The Lines, Riva Greenberg

Riva is probably my favorite author for her articles, blogs, and books on type 1 diabetes. The article/blog below is the best I have seen on day-to-day care of adult type 1 diabetes. You can learn a lot from Riva. She and I had a long phone conversation a few years ago. You might want to look at her books, they are excellent. Click on the link below, and look at the bottom for her books.

As always a great article from Riva. She always expresses my feelings so much better than I ever could. Thanks for posting this.

Thanks for bringing our attention to Riva's blog; it is outstanding.

Riva Greenburg does a good job of communicating to non-diabetics what life is like for T1Ds. This is a challenging proposition since the general public doesn't generally want to read about disease details. For we T1Ds and those that care about us comprise a fairly small audience.

Riva successfully avoids getting bogged down in too much detail and clearly portrays how pervasive the thoughts of diabetes management are in our moment-to-moment life. Looking at the various snapshots of her CGM, she looks like she's in excellent control.

I think the piece would have been even more interesting if she had portrayed more traces that showed aberrant BG excursions (both hypo and hyper) that many of us struggle to counteract and minimize. Maybe Riva doesn't have bad BG days and if that's true, I congratulate her on this success.

Overrall, Riva hits the target on this work.

I too am a big fan of Riva's work, for all kinds of reasons including but not limited to the ones expressed here. I routinely recommend her books to people.

Terry, about her not including more examples, I think I can make a pretty shrewd guess as to the reason why she didn't. Two reasons, actually.

First, I expect she felt that delving much further into the technical nuts and bolts of how a diabetic manages their BG would risk losing the general audience. Since we do live with these matters 24x7 and they're almost never out of our minds, it's easy to forget that this stuff isn't second nature to most people, and more than a small amount of technical information can get overwhelming pretty quickly. (Remember when diabetes was brand new to you?) When that happens, you lose the reader and they either stop reading altogether or else their eyes metaphorically glaze over and nothing else you say really gets in. Kind of like reading the fine print in an insurance policy. ;-)

Second, brevity is one of the keys to communication and every good writer or speaker knows it. Make it too short, and you don't communicate what you want to. Make it too long, and the same thing happens. The writer must always be conscious of the reader's attention span and try not to exceed it. That's part of the art.

For those reasons as well as others, a writer walks a very fine line. It's always a judgement call that you have to make according to your own sense and experience. And whatever choice you make will work for better for some in the audience than for others. You can't ever bat 1.000. Just the nature of the game.

I liked her article. And I think you are right, she actually has admirable blood sugar control. Better than mine. And you are right, it would have been stronger if she showed the wilder, unexplained and seemingly uncontrollable variations that is the bane of existence for many.

David - You are right, of course. Managing the level of detail when describing diabetes is crucial to effective communication. We've all had the experience of mentioning a technical term, like hypoglycemia, to a listener and immediately see the eyes glaze over.

Riva's excellent control and graphic illustration may lead some readers to believe that the task of keeping BGs between the lines is not really so hard. She did show one picture of hyperglycemia and that did add some balance to her communication. I should have described my criticism of Riva's column as more of a "nit-pick." I like what she did.

Well, I'll be contrarian here.

This was my introduction to Riva, so I'm judging here with very limited information. As such, I won't venture an opinion about her, but rather just about the article linked.

I was disappointed to see some of the same old prejudices and ignorance about T2 appear in her article.

I agree that most T2's have it much easier, but not because it is easier to deal with T2 -- rather, the standards for treatment are inadequate. So T2's are not expected to be monitoring their BG closely, generally have no idea what their BG's doing, and just get sicker.

The stricter regimen for T1's is driven by the prospect of immediate life-threatening consequences. Yet, why should the consequences have to be this dramatic to bother treating the disease? Do we tell smokers, don't worry about it until you have lung cancer?

Well, that's basically our approach to treating T2. Sad that some T1's buy in to this.

Brian - Thanks for the confirming that my observation is shared by others. I often wonder if my observation is just me or if it's more general. I have a tendency to stake out positions in the minority.

As David mentions above, Riva's challenge in this column was gaining and keeping the attention of a general public audience. I don't agree that she espouses any T2 ignorance and prejudice. Here she pushes back on the common prejudice that T2s bring on the disease with obesity:

But please, if you're a sneerer, stop. Thin and normal weight people get Type 2 diabetes too, and there's controversy whether weight is a cause or outcome of Type 2 diabetes.

I agree with you wholeheartedly that the medical professions standard treatment of T2D, especially in the beginning, is woefully inadequate.

T1D is just a sliver of the diabetes population. As such we must live with dominant perception of the public that confuses our condition with T2D. Our interest in drawing a distinction between the two diseases should not be confused with disrespect or lack of empathy. I believe that Riva's article artfully and fairly draws this distinction.

Fair comment and analysis, Terry. To be clear, my criticisms are mild.

I do think, however, she portrays the burdens on a T2 inaccurately. I qualify this with the context of a T2 that is actually actively managing their condition with the goal of minimizing any health impact from it.

This does not describe most diabetics.

So, in my opinion, she puts forth the common misconception that T2 is pretty easy to live with, and that's my point: Sure, if you're not really going to treat it effectively, it's pretty easy.

And that, to me, is the single biggest contrast between T1 and T2 in a practical sense: T1's must treat effectively, or they die. T2's can skate, and just deteriorate over years to decades. However, we mostly wind up with the same health problems.

If you're going to have similar goals to T1's -- and why shouldn't all diabetics? -- of maintaining the best health you can, avoid complications, keep the disease from getting worse, etc., then treating T2 is very intensive, intrusive, burdensome, and on and on.

She gave a very different impression.

Case in point: Which type of diabetic trying to achieve tight control needs to test more? T1 or T2? (yes, it's a trick question :-))

Right on the money! There is an absolute divide between T2s who coast because they can -- or think they can, IMHO a tragic and self-deceiving illusion -- and those who manage aggressively.

Spot on.

A T2 whose goal is to achieve BG as close to normal as humanly possible has to work just as hard at it as anyone, and faces most of the same risks. Failure to recognize the gulf between the two subtypes is, I think, one of the principal contributors to the nauseating, perennial argument over who has it worse. We all do.