Down (and maybe done) with Symlin

I may be giving up on Symlin. It seems that it has caused me more problems than the modest benefits it claims to give. At least, I am currently blaming Symlin for my increasing problems with hypoglycemia lately. Since I have begun training for my Ironman race, my insulin needs have gone down by about 30-40%, and my insulin sensitivity has gone up signifianctly. (My carb-to-insulin ratio went from 10-12g carbs: 1.0U inuslin to 17g:1.0 U and my correction factor from 1 U insulin for 60 mg/dL to 1 U for 95-100 mg/dL blood glucose.) I am exercising upwards of 14 hours per week, which means that I exercise in the morning and evening at least 3 days per week, and have a long ride and a long run on 2 other days. On the days that I exercise in the morning, it doesn't make sense to take Symlin except for lunch, possibly. And after a 4-hour bike ride, Symlin will not be helpful to me--I don't see large BG excursions, typically, after a meal on a day like that.

Of course, I may just be blaming Symlin for a severe low BG that spoiled my lunch-time run today. The first 40 minutes I was cruising along at a sub-8 minute per mile pace when--wham!--the low BG knocked me out. I had that spacey, "Uh oh" feeling and, after eating two gels (50 g of sugary goo), I still felt like I had to stop completely. I wouldn't have minded as terribly except that we had a freakish outburst of hail and there I was, standing under a big tree in the Golden Gate Park, unpacking my Ultra from the 2 too-small Ziploc bags, trying to dry off my finger to test. 41. Would it go up in 30 seconds? yep. 42. I finally got it up to 52 in about 10 minutes and decided to jog slowly. "Uh oh." I stopped and retested: 47. I downed another gel and waited another 10 minutes before deciding I might as well try to walk. At breakfast five hours earlier, I had taken my Symlin; as I stood there with my hands stinging in the wet cold, I recalled another very scary experience after taking Symlin, when I was unable to get my BG above 50 for a couple hours (and had to have IV dextrose administered). Unlike the previous experience, I had no nausea today; still, using Symlin burdens me with the fear that I won't be able to quickly recover from my low BG's. And I just don't need that.

Nocturnal Hypoglycemia Unawareness...Another Argument for CGM

A study published today shows that type 1 diabetics often miss episodes of hypoglycemia during sleep; this finding may or may not come as a surprise to most type 1's. I used to assume that low BG's always, or at least usually, woke me up. At least, I had woken up plenty of times with that heavy, weak feeling and rushed for the nearest dose of sugar. But when I started wearing the DexCom, and waking up to the low BG alarm far more than expected, I realized my assumption was wrong. Confirming my own observations, an article published today in PLoS (Public Library of Science) Medicine suggests that nocturnal hypoglycemia unawareness may be a much more common problem than previously assumed. In the article, "Defective Awakening Response to Nocturnal Hypoglycemia in Patients with Type 1 Diabetes Mellitus," Schultes, Jauch-Chara et al., compare the response to hypoglycemia (2.2 mmol/L plasma or 35 mg/dL whole blood) induced in 16 type 1's and 16 controls during stage 2 of sleep. Only 1 out of 16 diabetics woke up, in comparison to 10 out of 16 controls (6.2% vs 62%), which was significant statistically. In all research subjects who woke up, a significant increase in epinephrine blood concentration was seen, on average, 7.5 minutes prior to waking. (Epinephrine is a one of the "fight-or-flight" hormones that is released in response to stress.) The type 1's showed a weakened or absent epinephrine response. The article also discusses other counterregulatory hormones, such as glucagon, which was higher in the controls than in the type 1's.

Again, I was really surprised how many times that low BG alarm has gone off during the night with my DexCom, especially after a big day of exercise or a change in my normal routine. I remember one night after a particularly long bike ride when I repeated three cycles of waking to the DexCom alarm, eating, and falling asleep again. Whether I would have woken up eventually can't be determined from that experience; but since the DexCom woke me up each time, I definitely would have had a more severe low BG without it.

I had stopped using the DexCom because I ran out of sensors and didn't want to fork over $175 for another 5-pack. But maybe this will encourage me to do so. And I definitely plan on quoting this study in my letter to my insurance for CGM coverage.

I originally read about this story on ScienceDaily's medical headlines: "Patients With Type 1 Diabetes Don't Wake In Response To Hypoglycemia." They wrote a good summary of the study. Another easily understandable summary is on the front page of the original article.

JDRF Ride to Cure Diabetes

Go to my JDRF site to donate...

So after who-knows how many hours of training and competing for various running, cycling, and triathlon events, I decided that I ought to put some of those hours towards a good cause. I was trying to figure out how I could combine my Ironman training efforts with fund-raising for JDRF; in the end, though, I decided that it would be best to do the fund-raising through one of JDRF's official rides.

Early this morning, I signed up for the September 2007 ride in Whitefish, Montana. I will be covering the 100-mile, very hilly route! My goal is to raise at least $5000 for the ride; $4000 is the minimum, but I hope to raise even more than that.

The Juvenile Diabetes Research Foundation is one of the most efficient charities out there and was featured in Forbes magazine back in 3/2005 (unfortunately, no longer available for free viewing online) as one of their top-rated charities. More than 80% of funds raised go directly to research to find a cure for type 1 diabetes. People with type 2 also have benefited and will undoubtedly benefit in the future from JDRF-sponsored research. But, the primary focus is to cure type 1. Additionally, the JDRF is supporting research to develop an artificial pancreas, which would combine CGM (continuous glucose monitoring) and pump therapies in a closed-loop system. This would allow type 1's to ease up on the constant vigilance they must have with the disease, and would lead to improved A1c's and, thus, reduced complications (as shown in the DCCT).

My attitude towards diabetes is one of optimism, that diabetes will not stop me from reaching my goals. Still, I have seen first-hand, in my life and others' lives, the struggles that this disease brings. And, although I try not to dwell on fears this disease can bring, the thoughts do sometimes flicker across my mind. I wonder how parents with small children can possibly manage the innumerable variables that seem to thwart optimal control. I wonder when my fingertips will heal from the 10+ fingersticks per day. I wonder how my uncle is doing after donating a kidney to my dad, and am continually grateful for the gift he gave. I worry about my dad's eyes. I wonder if complications are silently attacking me, weakening my nerves or pestering my own kidneys. I wonder what it would be like to do a race without fear that my blood sugar could bottom out unexpectedly.

My hope is that through research efforts funded by the JDRF, no one will wonder these things anymore.

If you would like to donate and feel you have the means to do so, please go to my JDRF page at http://ride.jdrf.org/rider.cfm?id=7134. I'll continue to give periodic updates here on my training.

Oh, and did I mention that donations are 100% tax-deductible?

Amgen Tour of California Starts Sunday

The 2nd annual Amgen Tour of California starts this weekend here in San Francisco, and it looks like it will be an exciting race. Some top riders that you may have heard about from the Tour de France, such as David Zabriskie, George Hincapie, Levi Leipheimer, Ivan Basso, and Robbie McEwen, among many others, will all be here. This morning, I heard an interview on NPR with Levi Leipheimer, who is from Santa Rosa, CA, where one of the first stages will be held. He sounds like a good chap, so I will be rooting for him!

In search of bike shoes

After many fruitless hours in search of new bike shoes, I have come to the conclusion that there really must be drastically fewer women cyclists than men. Although running shoe manufacturers realized years ago that the feet and running mechanics differ between men and women, bike shoe manufacturers--or at least retailers--seem to be ignorant of this information. Or else, they just don't care. I battled San Francisco, Valentine's Day, rush-hour traffic in the Mission to go to Performance Bikes, only to find that they had only one "women's specific" road shoe. Saying "women's specific" is just a not-so-clever attempt at implying that all of the men's shoes would be perfectly fine for women. Argh! I've tried all 3 Sports Basements in the Bay Area and can't find the right shoe there, easy. Does it have to be so hard? I am losing my infinite patience. Someone suggested I try Lombardi Sports, but by the look of their website (only 4 or 5 shoes even listed), I am not so hopeful.

I just took a moment to find the local dealer for SIDI shoes, which, for San Francisco, is City Cycle. Their website looks promising, and I know that they are one of the most popular and well-respected places to get a bike fitting. So I will check them out tomorrow. Wish me good luck!

Two Sites I Support

Here are two somewhat (okay definitely) political sites I support:

stopglobalwarming.org

and

sefora.org

Although their missions have strong political implications, I think they both seek to accomplish their goals through rigorous scientific research rather than someone's or some organization's personal dogma.

The first is a site connected to Al Gore's campaign to raise awareness and action related to global warming. I also put one of their logos on the side of my page.

The other is for the organization, Scientist and Engineers for America. Their stated mission is to "influence targeted elections at all levels of government to renew respect for evidence-based debate and decision-making in politics."

Check them out.

Training Update: Month 2

This is just a quick update to say that the Ironman training is going well. I am swimming, biking, and running each 3 times per week, and also including some strength training through a local fitness club's Boot Camp program. (The name "Boot Camp" is to invoke something hard! It is a mix of strength training, plyometrics, calisthenics and stretching.) I am trying to get more sleep and to eat enough, but not too much. Most of the time, I feel good. I ran the Kaiser Permanente Half-Marathon last weekend and finished in a time of 1:54, which is slower than my PR last year of 1:42 but fine given my goals for the race. (I was supposed to hold back a little more than I did but I did show some restraint!) I need to really focus on getting more quality sleep. This means I should probably spend less time online! I use trainingpeaks.com to log my training, and nutridiary.com to log my food. My diabetes is going well, generally, except for a few really nasty lows (one requiring IV D-50 in the ER for the first time in my life) that I am attributing to Symlin and increased insulin sensitivity from all of the exercise. My average on my meter is 176, which could be better, and was actually better a few days ago... I guess those super-low BGs are not being averaged in anymore! Too bad. My insulin to carb ratio is 1 unit for 17 grams and I use a correction factor of 1 unit for 80-100 mg/dL blood glucose. I am taking about 22-23 units Humalog per day with about 9 units of that being my basal insulin. I am eating on average 2200-2400 calories per day and have lost about 8 pounds. I'd like to drop another 10-15 by the end of March.

Southwest Returns to SFO

No longer will I have to beg, borrow or steal (okay, so I don't really steal) to get a ride to OAK for my preferred airline, Southwest. Today, SWA announced that they will be resuming service to SFO this fall, after discontinuing in 2001. To get to Oakland, it required a 1-hour-plus shuttle ride, an hour car-to-BART or foot-to-bus-to-Muni-to-BART trip, or a guilt-ridden ride from a friend willing to brave rush hour traffic on the Bay Bridge. (Who knows how long this last option would be?) Okay, maybe it wasn't all that bad (due to one very kind "friend" in particular), but SFO will be much easier! It's about 15-20 minutes by car and there are no bridges involved. I am very happy to hear this news. United Airlines, on the other hand, will probably not be as happy to hear this news.