At the recent ISPAD meeting in Montreal, there was a notion canvassed at one of the satellite symposia - “time in happiness”. It was the first time I had heard of it, but it appears that, as with most things, I am late to the party. This idea was actually put forward over a year ago by Kamil Armaki, a well-known patient advocate from the UK. It is an apt and powerful idea, but of course, it begs the question, “What is happiness?”
Now there is a question philosophers have been picking over for the ages! So many definitions.
On a biological level, happiness is the dance between dopamine and the amygdala in an escalating race of increasingly sought-after pleasure. In the book Homo Deus, Yuval Noah Harari expands the definition, prosecuting the case that happiness is when expectation and reality align with our body’s biochemistry—a tough ask of synchrony for anyone. Happiness is then perhaps easier to define by what it is not.
A somewhat glum summation by The World Happiness Report defines happiness as the absence of misery leading to despair. This report has identified poor mental illness as a key cause of misery and a lack of societal benevolence as a key cause of despair.
We know that a life with diabetes can be associated with disordered biochemistry, mental health challenges and stigmatization or a perceived lack of benevolence. Setting aside the rather grim comparisons of characters in Victor Hugo’s Les Misérables, one thing is fairly clear. It is hard to be happy about having diabetes. So maybe a focus on “time in happiness” is clinical sandbagging and setting people up to fail.
I gave a talk 15 years ago about the Hvidoere Group’s findings of the importance of dogmatically pursuing clinical targets. In my dispatch of the counter-argument of not having targets, I pithily (in my humble assessment) quoted the Cheshire Cat from Lewis Carroll’s Alice in Wonderland, “If you don't know where you're going, any road will get you there”. This quote was greeted stonily by a loaded question from a younger version of the Chairperson from the afore-mentioned Montreal symposium. “What happens when the dogged pursuit of an unachievable HbA1C leads to a poor quality of life?” When you are in mid-career and full of Lewis Carroll, chutzpah and hubris, such questions are easily batted away. From memory, my response was along the lines of “Well, nothing will impact quality of life more than premature micro- and macrovascular disease”. Boom! Case closed, no more questions from the floor. Only…. 15 years later, I am still wondering about that question. My glib reply did not reflect the lived reality of people with diabetes and somewhat missed the point.
The cruel truth is that adolescent years appear to contribute more to lifetime risk of complications than any other decade. So, at a time when having diabetes is arguably most challenging, mental health risks are most significant, and the world is perceived to be at its least benevolent, the optimization of glucose levels is most important. This brutal irony again belies the quixotic pursuit of ephemeral “happiness” when living with diabetes. Particularly in the age group we look after.
If not happiness, then what? The ancient Greek philosophers described a less transient notion of happiness, that of eudaimonia. This more stable and profound sense of joy is achieved by living a life that is in alignment with one’s values, built on foundations of positive relationships, autonomy, competence and virtuous action. “Good spirit” or human flourishing. Socrates, Plato and Aristotle regarded eudaimonia as the ultimate goal of a good life. Longer-term fulfillment is emphasized over momentary pleasure or hedonia. When you think about it, such a philosophy aligns with the burden and tasks of diabetes—playing the long game to achieve the best life outcomes and drawing on the important people around you and the best of your own self to flourish.
George Bernard Shaw could have been thinking of diabetes when he wrote, “Life is not meant to be easy, my child; but take courage: it can be delightful”. However, for those of us frustrated by the rollercoaster of hope of a ‘cure’, succour might be better found in the more contemporary literary canon. To wit, the Rolling Stones’ You Can’t Always Get What You Want—penned by savants Keith Richards and Mick Jagger. Famous as an homage to the 1960’s, it captures sequential feelings of optimism, disillusion, and resigned pragmatism. Does that feel familiar?
So, here comes my pitch for 2026. At the risk of ‘concept-appropriation’ and ‘doctor-splaining’ how to live with diabetes, my challenge for this year’s contemplation is as follows. Let’s expand notions of “time in happiness”- maybe seen as a pursuit of ephemeral pleasure or hedonia, and reframe the discussion to include “time in eudaimonia”. Let’s tweak things and shift the emphasis from happiness to flourishing.
Best to all,
Fergus Cameron
