Help get Nagbot on his feet – a virtual caregiver from Lifebringer

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Herb Meehan lost his vision in one eye due to diabetes. “I was a TERRIBLE diabetic,” he wrote me. “I didn’t test regularly and when I lost my vision something inside me snapped.” Herb’s snap caused him to spend two years creating an intelligent software and voila Nagbot was born – an avatar buddy currently helping hundreds of people with diabetes. 

As Herb wrote, “I created Nagbot because way too many diabetics need encouragement to test regularly. I engineered this avatar into the application to be caring, like my wife, because not everyone has someone like that to help them.” This cute little avatar Nagbot reminds people to test, stores blood sugar and a1c results, gives positive reinforcement and as Herb says, is just bad ass. 

Below is some more info from Herb, including a bit of his story, and, Nagbot’s future is hanging in the balance on Herb’s Kickstarter campaign that you can be a part of. 

Message from Herb

My name is Herb Meehan. I’m a type 2 diabetic and the creator ofLifebringer, a free diabetes management tool available to anyone with an internet connection. 

Lifebringer is a web application that is at home on your computer, tablet, and mobile device. Lifebringer goes beyond simply storing data. It’s a diabetic journal, blood sugar test reminder system, test strip inventory manager, report viewer, and encourager. 

What makes Lifebringer unique is Nagbot. Think of Nagbot as your virtual caregiver. Nagbot helps you remember to test. Nagbot talks to you in plain English (no medical jargon used). And if your blood sugar is too low or too high, Nagbot suggests what you should do. If it’s within range, Nagbot happily encourages you to keep it up, as in keep checking. Nagbot also sends reminders and reports to you if you ask him to.

My Story

I was diagnosed back in 1999 and was on oral meds for the first few years. I eventually had to ditch the pills and go with insulin to manage my diabetes. It wasn’t enough though. A few years ago, I lost vision in one of my eyes due to complications with diabetes. Simply put, I didn’t do enough. After that event, I became the model diabetic. My wife and I began eating healthy, home-cooked meals, and I now test regularly.

Why we don’t like diabetic journals

Let’s face it – data entry sucks. One of the chores of using a diabetic log is that data input isn’t fun. Lifebringer is easy and streamlined. Lifebringer doesn’t just collect your blood sugar information but will also forecast your A1c (a snapshot of the last three months of your blood sugar control). Here’s a look:

We have turned to Kickstarter to fund this dream and we’re hoping to continue to help everyone else with diabetes.  Please take some time to meet Nagbot.  My wife, Maryam, and I would be incredibly grateful if you would and also share or tweet this news. 

Believe in yourself to manage diabetes

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I’ve been doing an ongoing Thursday shot-in-the-arm of inspiration from my book “The ABCs Of Loving Yourself With Diabetes.” 

Emotional strength and resilience is critical to keep on keeping’ on managing our diabetes. Here’s today’s powerful thought for reflection.

Excerpt:

How you feel about yourself influences how well you will take care of your diabetes. Do you treat yourself with the same regard, kindness and compassion you reserve for a friend?

When you believe in yourself, you live life expecting the best. When you believe in yourself and feel confident, the world responds to you with a very special magic; things seem to just go your way.

If you have spent much of your life saying “yes” to everyone around you, leaving you little time and energy for yourself, practice saying “no.” You can’t truly take care of anyone else when your own energy is depleted. And if your past has not reflected your greatness or your ability to manage your diabetes, remind yourself with love, that today is a new day; today you will take a new step.

Reflection: Today write down three things you’re good at and three good qualities you have. Look at the list throughout the week and allow yourself to take it in. 

Also, before you jump out of bed and when you’re drifting off to sleep, take a minute and see yourself at your best. Remind yourself, you always have this fantastic person inside you.

Your history doesn’t have to be your future when managing diabetes

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Here’s my Thursday d-lesson – a little reminder that no matter what we’ve been doing, we can do a little better today if we decide to do so.

My kangaroos, by the way, were inspired by the year I lived in Sydney, Australia. Here’s today’s excerpt from my inspirational D-book,

“The ABCs Of Loving Yourself With Diabetes.”

Excerpt:

Whether you’ve spent years ignoring your doctor’s advice, or even avoiding your doctor, today you can decide to be the master of your diabetes. How? Begin by shifting your thinking.

If you’ve been seeing your diabetes care as something you “have” to do, see it as something you “choose” to do. You’ll feel more in control. 

Then see the benefit of doing the task. For instance, “By testing my blood sugar, I can keep it in target range and reduce my risk of complications.” Focusing on the benefit helps remind you why the task is important.

The truth is everything we do in life is a choice. Changing your mindset from “have to” to “choose to” gives you more energy. With all there is to be gained, isn’t it time you hopped to it?

Reflection: Right now list on a post it note 3 diabetes tasks you perform and how they benefit you. Keep this somewhere you’ll see often. 

Create a personalized pill card

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My husband was just cleaning out his piles of papers, and amazingly found an interesting sheet titled, “Patients Don’t Remember Doctors’ Instructions.”

Shocking as it sounds between 40 and 80 percent of what doctors tell patients they forget – immediately! Only half the information they tell us do we remember correctly, and the more information they give us, the less we remember correctly. Well, frankly, that doesn’t surprise me.

There is, however, a useful tip offered on the sheet if you need a little reminding what pills you take, when and what they’re for. It’s a tool called a “Pill Card.” And the best thing to do is create one for yourself based on what you’re taking. 

The card includes the name of each medicine you take, how much, what it does and then uses pictures to remind you of these things. You can find instructions, graphics and templates at the Agency for Healthcare Research and Quality.

Have fun. Turns out 94% of people who were given a pill card said it helped them remember the information their doctor gave them correctly.

Dr. Anne Peters reviews new CGMs

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For those of you who use a Continuous Glucose Monitor, or think you’d like to, here’s an excerpt from Dr. Anne Peter’s review of Dexcom’s newly available fourth generation, the G4, and MiniMed’s CGM, Enlite, which will be available in the Spring. Dr. Peters is an extremely respected endocrinologist, well known in the diabetes community, who practices at the Keck School of Medicine of the University of Southern California in Los Angeles.

I love that Peters wears the sensors, although she doesn’t have diabetes, to understand what it’s like for patients. With all their advantages, one thing she finds burdens patients is the devices many alarms. Funny, we think of the benefit, alerting us to low and high blood sugar, but not the annoyance factor – I guess unless you wear one, I do not. 

Excerpt: With Dexcom G4 continuous glucose monitoring, the patient can easily insert the sensor under the skin — …on the abdomen or the back of the arm. A small transmitter is then placed on top of the sensor. The transmitter sends the interstitial glucose value to the device so the patient can see the blood sugar level. It transmits this information wirelessly every 5 minutes, so a patient can get a sense of whether their blood sugars are going up, going down, or staying the same.

…the new Dexcom G4 is somewhat smaller [than the earlier-generation device]. It is not as wide, similar to an iPhone, and is easy to put in your pocket. It has a pretty good range so that you can be moving around in your house and the signal will still reach the device. A blood sugar level that is 100 mg/dL and is going up may require much different treatment from a blood sugar level of 100 mg/dL that is flat and the patient might be just fine. Or, if a blood sugar level is falling fast, it may mean that the patient needs to ingest carbohydrate to avoid a low. The patient can get a lot of information in real time from this device. Then, in my office, I download the device and interpret the data for the patient so I can help the patient analyze the data retrospectively, so that in real time patients can make more reasonable choices.

we also have the new MiniMed continuous glucose monitor, the Enlite™ sensor, which is supposed to be available in the spring. This is similarly inserted under the skin and taped down. In most cases, this device is talking to the patient’s insulin pump. The insulin pump has the tubing necessary to give the patient insulin, but now this pump also becomes the receiver for the signals from the sensor. The patient can look at the pump and see what the blood sugar levels are doing.

A lot of patients want the pump to automatically give insulin based on their blood sugar levels, but that is not what happens. This is truly a sensor, and the patient then needs to use the Bolus Wizard [calculator] to interact with the pump to calculate the insulin dose. That coupling of the sensor and pump is part of the development of the artificial pancreas. Substantial research is being done to make pumps that can use continuous glucose monitoring data so that the patient does not have to think as much about diabetes management. [Those advances] are in the future. 

For now we have sensors that sense interstitial fluid, giving continuous real-time data, and we have pumps that patients interact with to give themselves insulin. You can couple the MiniMed sensor with the MiniMed pump. The Dexcom device does not interact with a pump, although the manufacturer is working on collaborations with some pump manufacturers.

Peter’s full review appeared in Medscape Diabetes & Endocrinology Jan 25, 2013, “Continuous Glucose Monitoring: Practical Uses in Diabetes.”

More tips for timing insulin

A few posts ago I extracted some very valuable information from an article CDE and dietitian, Hope Warshaw wrote titled, “Rapid-Acting Insulin, Timing It Just Right” and I’d like to share a little more of her knowledge.

 Fine-tuning the timing of your premeal boluses or injections is important, but no more so than knowing how to count the carbohydrates in a meal or snack. If you don’t know how to count carbohydrates or to match your insulin dose to the amount of carbohydrate you plan to eat, speak to your health-care provider. Many people find themselves in a reactive mode when it comes to dosing insulin, taking it in response to high blood glucose rather than using enough of it before a meal to cover the rise of blood glucose in the hours after a meal or snack. Experts agree that it’s much harder to bring high blood glucose back down than to control blood glucose levels with sufficient insulin in the first place.

Glycemic Index: The glycemic index of foods as well as the fiber and fat content dramatically affect how quickly or slowly blood glucose level rises. (The glycemic index ranks foods based on how quickly they raise a person’s blood glucose.) One tip since most people’s blood sugar rises most quickly in the morning is to eat low glycemic foods at breakfast like yogurt or a bowl of oatmeal with a piece of fruit rather than foods with a higher glycemic index such as some cold cereals, pancakes, or muffins.

In general, foods and combinations of foods that have a low glycemic index and high fiber content will raise blood glucose more slowly. Conversely, foods with a high fat content tend to cause a delayed rise in blood glucose. The extent to which the glycemic index or fat content of a meal speeds or slows the rise in blood glucose following a meal varies from person to person. 

Meticulously timing your rapid-acting insulin dose and carefully calculating your dose according to the carbohydrate you will eat is usually best for blood glucose control, but it may not always be possible. There are times when you know exactly when and how much you will eat and times when you don’t. The following  tips may help you adjust for the realities of daily life:

High blood glucose before a meal. If your blood glucose is high before a meal, use how much your blood glucose level falls in response to one unit of insulin to calculate a dose of rapid-acting insulin to cover the high, then wait until that insulin begins to lower your blood glucose before you eat. 

Claudia Shwide-Slavin, a dietitian and certified diabetes educator in private practice in New York City, advises the following: “If your blood glucose level is between 140 mg/dl and 180 mg/dl, take the rapid-acting insulin and wait half an hour before eating. If it’s between 180 mg/dl and 200 mg/dl, wait 45 minutes. If it’s higher than 200 mg/dl, wait at least an hour.”  If a person is hungry or must eat at a specific time, Shwide-Slavin recommends limiting the amount of carbohydrate at the meal by eating mainly protein and nonstarchy vegetables.

Low blood glucose before a meal. If your blood glucose is low before a meal (below about 80 mg/dl), “Wait to take your insulin,” says Shwide-Slavin. “Let the food have 15 minutes to raise your blood glucose before taking your insulin.”

So, a few few more helpful hints to put your management “in the zone.” 

 

 

Learning more about timing insulin

I know a lot about diabetes and working with my insulin. But recently a friend sent me an article, “Rapid-Acting Insulin, Timing It Just Right”, written by well-noted certified diabetes educator and registered dietician, Hope Warshaw. It helped confirm some of what I know and helped clarify some of what I didn’t know about timing insulin with your meals. Here are some of the article’s highlights.

Warshaw points out that even when you think you’re doing everything right with your diabetes care regimen, your blood glucose levels can seem hard to control. One potential source of difficulty is how you time your injections of rapid-acting insulin with respect to meals.

Most diabetes experts recommend taking meal-time insulins (Humalog, Novolog and Apidra) within 15 minutes of starting a meal. This advice is based on the belief that rapid-acting insulin is absorbed quickly and begins lowering blood glucose quickly. However, this may not be true for everyone. 

Howard Wolpert, M.D., editor of the book Smart Pumping and Senior Physician and Director of the Insulin Pump Program at Joslin Diabetes Center, cautions against blind-faith acceptance of insulin action curves or standard advice about when insulin works, noting that insulin can show “a lot of variability…between individuals and even within the same person from day to day.” The time ranges given for an insulin to reach its peak action are averages, so they may not fit everyone or every situation. You may find through blood glucose monitoring and experience that rapid-acting insulin typically reaches peak effectiveness within 45–90 minutes or possibly sooner or later. In general, people with normal stomach emptying can expect some glucose from the carbohydrate they’ve eaten to start raising their blood glucose level within minutes of starting to eat. Blood glucose level tends to peak about one to two hours after the start of a meal and gradually drops over the next three hours.

If rapid-acting insulin always started working almost immediately and peaked one to two hours later, injecting it anytime within 15 minutes of starting to eat would work well. But newer observations suggest that rapid-acting insulin doesn’t get absorbed and start working that quickly in all people. John Walsh, P.A., C.D.E., coauthor of the book Using Insulin, for example, believes the maximum blood-glucose-lowering effect of rapid-acting insulin may occur much closer to two hours after an injection rather than 45–90 minutes. If this is the case, the optimal time to take rapid-acting insulin is 10 to 15 minutes before eating rather than with the first bite or 15 minutes after starting a meal. Walsh’s belief is based on research suggesting that insulin may be measurable in the bloodstream before it begins actively lowering blood glucose.

 

Some other factors that may cause insulin action to differ from the action curve given in product literature or to vary from person to person include thickness of the subcutaneous fatty layer at an injection site, temperature, blood flow, exercise, and dose size. (The choice of injection site—abdomen, thigh, arm, buttock—does not seem to affect the absorption rate of rapid-acting insulin as it does for slower-acting insulins.) Injecting into areas that have more subcutaneous fat tends to slow insulin absorption. Widened blood vessels (caused by higher temperatures or exercise) allow insulin to be absorbed more quickly; constricted blood vessels (caused by colder temperatures or smoking) can cause slower absorption. Large doses of insulin may also be absorbed somewhat more slowly than smaller doses.

Thank you Ms. Warshaw. Since this is a lengthy article there’ll be more from Hope’s article over the next few posts.

A hospital where patient experience is paramount

Need a snack? Fruit-only

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The Botanical Garden

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Me and the CEO, Mr. Liak

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Kind reminders to be healthy

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 Can you imagine a hospital where floors are carpeted so you feel calm, soothed and protected? Where doors open silently so as not to jar your jangled nerves? Where vending machines are only filled with fresh fruit and the healthier the meal in the cafeteria the less it costs? How about elevator doors covered in exotic floral motifs and a Diabetes Center where you never wait more than ten minutes to be seen?

I could never have imagined these things but instead I saw them with my own eyes here in Singapore at the Alexandra Hospital. The hospital sits amid a lush and beautiful botanical garden that volunteer employees care for and each floor of the hospital has a view of greenery. In this tropical paradise even medicinal herbs are flowering in the gardens.

This hospital is the vision and result of its CEO, Mr. Liak, and his passionate staff. It is their mission to create a place of healing where people are helped to make healthy choices, even if it’s just taking the stairs instead of the elevator.  No wonder stairways are easily accessible throughout the hospital, not hidden behind impenetrable or locked doors, and they are marked by big wooden red hearts that say, “Please give your heart a lift, use the stairs.”

I had the pleasure to meet Mr. Liak and discuss the state of healthcare in Singapore and the U.S. and the work I am doing bringing a more positive attitude to managing diabetes. Mr. Liak spent three hours with me and my husband, who has worked with him in the past, generously sharing what some would call a contrarian view: give diabetes patients a year of treatment and education and if they improve and own their management, encourage them to be peer-mentors wherein they can give back, help other patients and help the hospital provide its services to more patients. If they don’t take responsibility for their care after a year, patients are free to seek help elsewhere and leave space for new patients at Alexandra Hospital.

To say the least it makes one think. In the U.S. the health care system does not particularly motivate patients to become self-reliant and responsible for their care, and we know this is paramount managing diabetes. In fact, I have heard upon occasion a critical tone from my own endocrinologist’s office when I come in for a yearly visit rather than every three months. But why do I need to come four times a year? I am a well-educated patient managing my diabetes daily and getting the necessary tests as appropriate. I can easily discuss my test results with my doctor over the phone and make any necessary adjustments. I am doing what medical professionals say they want patients to be capable of doing, managing my own diabetes!

After chatting about societal influences on health care and patient behavior, I gave Mr. Liak five copies of my book, The ABCs Of Loving Yourself With Diabetes. His face lit up, he loved it. He said this is what we need, a more cheerful and optimistic attitude about managing diabetes. And with that he toured my husband and I through the hospital halls including what resembled a “war room” filled with storyboards, flow charts and feedback circles reflecting plans for the new, expanded hospital they are building. At every touch-point in the new hospital the patient will be accommodated, from a simple registration process to remote controls where patients can control the light and air temperature of their room. Where room furniture is being built with drawers and countertops that allow patients to put more than one thing in and on them. And who is in the hospital bed photo testing all the equipment? None other than Mr. Liak himself.

Our tour stopped at the Diabetes Centre where I was introduced to the staff and two copies of my book were handed to the Diabetes Centre Director and diabetes nurse. Talk began of translating my book into the Malaysian language, Malay. Thank goodness my head had not grown so large that I could not still get it through the door to the cafeteria where our tour ended. And over a bowl of vegetables and tofu Mr. Liak told me it was a dream of his to employ someone such as myself to consult with his professional staff and help inspire and encourage other patients. Can you imagine? In Singapore, you don’t have to, it’s on the drawing boards.

Leaving Alexandra Hospital I thought if I ever need to be in the hospital maybe I would consider, if time permitted, hopping a flight to Singapore. Meanwhile, I’m happy to do what I can to help the staff and patients here. And now that I’ve finished this post, do what most people who are not in the hospital do in Singapore, shop. 

Leonard says learn to love the plateau

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Learn to love the practice

 

I guess I’m into absorbing new ideas these days as my last two posts are about books I’ve read. There’s an interesting idea expressed in George Leonard’s paper and e-book, Mastery – The Keys to Success and Long-Term Fulfillment. Leonard is a social scientist and Aikido master and I’m intrigued by his call for us to get lost in the ‘practice’ and make peace with riding the plateau.

Early in life we are pushed to “do” to “get” and focus on what comes next rather than where we are. We are urged as children to study hard so that we’ll get good grades. We are told to get good grades so that we’ll graduate from high school and get into college. We are told to graduate from high school and get into college so that we’ll get a good job. We are told to get a good job so that we can buy a house and a car. Again and again we are told to do one thing only so that we can get something else, be somewhere else. We spend our lives doing stuff so tomorrow will be better. But where does that leave us today? Sort of checked out from our lives.

See any parallels with diabetes? We are told to control our blood sugar so we don’t get complications, exercise so we’ll lose weight, lose weight so we become less insulin resistant. Of course we need to do all those things, but what if we were also taught at the same time to be one with the doing, enjoy the doing, don’t put all your eggs into the arrival; like a Zen master, see value and pleasure in the practice, get lost in it so that you are in the flow, totally in the moment. If you do that, not only will you be more present in your life but you will be creating the best chance for the positive outcomes we all want, and we may even notice and enjoy the journey.

When you’re ‘in the practice’ you’ll actually taste your food, maybe for the first time in a very long time. You’ll begin to enjoy the nutty flavor of whole grains by paying attention while you eat them, you’ll notice the natural sweetness in peaches and berries. When you exercise from the practice, you’ll feel your body’s strength and agility, its growing power, you’ll notice the endorphin-rush and Serotonin uptake, you’ll feel happy. Controlling your blood sugar when you are in the practice will imbue you with confidence, you will notice your growing capability, you will actually tune in to feeling proud. When we are so focused on the long, far away and abstract goals of living longer, staying healthy and avoiding complications, we are missing the moment, dismissing the pleasure in the moment and the opportunity for peace and pride in the every day practice.

“The real juice in life,” Leonard says in his book, “is to be found not so much in the product of our efforts as in the process itself, and how it feels to be alive.” We are taught in countless ways to value the end product, the prize, the blue ribbon or Olympic medal at the end of an endeavor, that climactic moment, not the pleasure of the moments that lead up to a medal, and then the next medal you might hang on your wall.

If our life is focused on mastery instead of wins, most of it Leonard says will be spent on a plateau–that long stretch of diligent effort with no seeming progress, for there are numerous inherent plateaus on the journey: learning, musing, germinating, reflecting, taking baby steps with only little bursts and puffs of what society deems as celebratory, noteworthy movement forward in-between. How much better if we were taught to love the plateau. If you honor the practice says Leonard you will enjoy the plateaus, “if not, a large part of your journey will be spent in restless, distracted, ultimately self-destructive attempts to escape the plateau to move faster and farther,” hither and thither missing the moment. I hope I pass you on your plateau as I sail by on mine and we are present enough in the moment to wave hello.

 

Are your systems helping or hurting you?

In my last post I touched briefly on the importance of the systems in your life to support your diabetes management.

Systems-talk is generally heard relative to companies seeking ways to improve  processes in order to increase profits and save time and waste. But doesn’t it make perfect sense that the same holds true for managing diabetes? Our systems either make us successful with less cost in time and energy, or foil us. Back to the company analogy, no matter how dedicated employees may be, if they’re working within a system that doesn’t support their intentions and efforts, they won’t accomplish their aim. Similarly, no matter how good your intentions, if your systems do not support your best efforts, success will evade you.

What does this really mean? We all have some kind of system we work within for the daily or weekly tasks we perform regarding our diabetes management. For instance, you have a system for feeding yourself – it may be skipping breakfast, eating a yogurt for lunch, then a candy bar in the mid-afternoon, and having dinner at fast food drive-ins half the week and pulling frozen entrees out of your freezer the other half. This system doesn’t support having your best health, let alone a desire to lose 10 pounds. A better system would be having a healthy breakfast, a larger healthy lunch and skipping the candy bar, and, going to the supermarket once a week to bring home nourishing foods. You might cook a week’s worth of dinners on the weekend, freeze them, and one day a week greet the loud speaker at Burger King, McDonalds, KFC or your fast food joint of preference.

Trust me, you have a system for everything. Take refilling your meds. It may be you open your pill bottle and you notice it’s empty, you grumble or shriek and then go to the pharmacy or call your doctor. Here’s another system that might be less stressful: when a new bottle of pills come into the house, if it’s for a 90-day supply for instance, write on a calendar 75 days from that day, “Reorder meds.”

Think about how diabetes fits into your day, or doesn’t? Is it the last thing you always seem to contend with? If so, your systems are not very efficient or supportive for managing your diabetes. How about your emotional system? Do you let loved ones help you in some way or shoo them away? Do you do enough of what you love to replenish your energy and positivity? If not, can you schedule that into your week?

The good news is you designed your systems, consciously or unconsciously, and can change them with a keen eye, some creative thinking and practiceLook specifically at what you’re having trouble with and then look at the system behind it. For example, if you forget to take your pill before lunch because you’re always stressed at work, or running into a meeting, how can you remedy this? Can you put a note where you’ll always see it just before lunch? Dan you keep an extra pill in your wallet if you carry your wallet or  purse into meetings? f you’ve been trying hard and not doing terribly well, don’t blame yourself, blame your system and then revise it.

My Systems

My system for taking my blood sugar approximately 5xday includes keeping my meter always in the same place, on my kitchen counter, my test strips always in my meter case, my lancing device  always on my kitchen counter. I work at home and this works for me. If I’m out of the house, I take my smallest meter with me so I can always test.

My system for eating is to buy mostly fresh vegetables, fruits, chicken and fish and do most of my own cooking. Every morning I make a bowl of steel cut oatmeal. Almost every lunch I have a spinach salad with an assortment of veggies, beans and some feta cheese. I mostly steam vegetables and broil or saute meats and fish for dinner. I eat beans in replacement of higher carbs, for instance, rice, pasta, potatoes. The few freezer products I use don’t have any added butter, cream, etc. I use vegetables a lot as foods to fill up on, and crunch on, when I need something crunchy. I like nuts for this too, and yes, I have to be careful not to sit down with the whole jar. I notice when I run out of healthy foods, I begin to reach for less healthy foods (my husband’s stock of crackers, licorice, etc) so part of my system is to always try as I can, keep an adequate supply of healthy foods in the house. I make sure I have 85% dark chocolate in the house and cocoa powder so when I need a sweet I can satisfy my sweet tooth and not go crazy. If I don’t do this, I’ll eat everything in my house and still feel unsatisfied.

My system for exercise is to every morning take a one hour walk around my local park typically from 9:30-10:30 A.M. Just after checking my email and before getting into any major project. If I miss my walk because I have an appointment, I try to fit it into the late afternoon. If my appointment is in the city, I’ll walk 40 or 60 blocks when I get out of my appointment to a subway station so I fit my walk in that way.

My system for emotional health includes doing lots of things I really enjoy that make me feel purposeful, and I get the rich reward of serotonin, the feel good brain chemicals from helping others. I spend time with friends who nourish me. I love reading and movies and indulge in both. When times are tough, I reach out to my partner who always listens and then see how much good I still have in my life. If all else fails I do something guaranteed to bring a smile, look at the pictures in my wedding album, call a dear friend across the country or just leave my house and go somewhere else from where life looks different.

I’m only telling you about my systems to give you an idea of how systems work. Admittedly, I have a lot of lattitude working for myself and working at home. I don’t want you to compare what you to what I do. I want you to look at your systems and your life and see if your systems support your best efforts and if not what can you do to improve them?

Here are some questions to stimulate your systems-thinking:

Q: Where are my supplies? Are they handy? As I said my meter is always on my kitchen counter making it easy to find and grab, no searching that might lead me to say, “oh what the heck, I’ll test later.”

Q: Am I always running out of my meds or test strips? Why? Can I guesstimate when it would be time to order more and work out a system for this? Is my husband or wife always at me about this and so do I put off reordering my meds just to bug him or her? Can I remedy this by having a heart to heart talk with my loved one and then do better for myself?

Q: How can I avoid all the tempting foods always at work from parties and meetings? Can I keep a healthier replacement treat at my desk, or give myself a reward when I pass up temptation like a movie or little trinket?

Q: I only seem to be getting to the gym a third of the time I’d planned because work or family obligations get in the way. Can my family help pick up some of the load by taking over some simple chores?

Looking at your systems, start with the assumption that it’s possible to refine them. And remember, to improve you can’t do what you’ve always done and expect different results. Sounds like common sense, but many people will often spend their energy trying harder in a failing system than change their system.