Saturday, May 31, 2008

123.6 Miles

Today we rode from San Francisco, around Tiburon, to Nicasio and towards the lighthouse at Point Reyes and back. The weather was cool and cloudy at first but sunshine broke through for the second half of the ride. I initially felt weak from low BG's last night and especially this morning before the ride, but I felt stronger after about an hour. I used the basal rates shown in the chart and decreased them throughout the ride. I was consistently eating about 300 calories per hour with a slight increase towards the end of the ride. Most interesting to me was how steady my BG was right around 80-100 despite the changing basal rates. And for the second half of the ride, the Dexcom was completely flat. It didn't seem to matter whether I ate something small (chocolate GU at 20 g) or big (40 g of honey fruit snacks). It was almost as if my body wanted to stay right there! But there is a more likely explanation, of course. Initially, when my basal rates were a bit higher (0.7-0.9) I was rising a bit after each snack and then falling again. But when my basal rate was lower at 0.5 for the second half, I stayed pretty steady after eating. So it appears that the glucose entering my blood from the gut was leaving at about the exact same rate there.

The basal rates were a touch too high initially and need some adjusting; however, I want to make sure I don't start off high, since it seems to make things much more difficult to manage overall.

The ride was a great confidence-booster for Ironman Coeur d'Alene, which is approaching quickly!

Friday, May 30, 2008

Post-Exercise Highs and Lows

Today's workouts were great but the rest of the day was a little rocky--how easily my body reverts back to its high-in-the-morning/crash-in-the-afternoon pattern. I woke up a touch on the low side, ate some Luna Moons and started my 4000-yard swim. I decided beforehand that I would test halfway through, since I was trying out a new basal rate of 1 U/hr. After 2000 yards of warmup, some drills and long sets, my BG was 137; I ate a GU (which I also intend to do at IMCDA) and finished off with 4 sets of 500 yards. I came out of the water at 184 and was stable over the next 15 minutes. Previously my BG would start climbing immediately after I stopped. I started running about 20 minutes later, and ate 20g about 20 minutes into the run when my BG had fallen to 129. I was happy to see that this was stable through the rest of my run and for 15 minutes following the run. When I finished the run, I bolused and waited a few minutes before eating a Stinger (honey) energy bar (about 25 g), and then I bolused immediately for breakfast using my 1U:9g carb ratio (same as yesterday). As is apparent from the chart, though, the results were very different.

My workouts ended about an hour later today than yesterday, once my basal rate had already moved from 1 to 0.4 U/hr, which leads me to wonder if the high was mostly caused by the reduced basal rate following exercise. Yesterday my basal rate was still at 1 U/hr for the whole hour following exercise. But I did bolus almost 10 units immediately following the exercise. Wouldn't that be enough to substitute for a 1 U/hr basal if I didn't eat more than my recovery bar (25g) for a full hour?

I believe I was low throughout the afternoon today compared to yesterday due to the increased duration of the workouts. My basal rate was pretty low at 0.25 U/hr; still, once I can see that I am running low, I could immediately set a temporary reduction rather than slogging through lows for 5 hours.

Having stable BG's during exercise was the big victory for today and I hope that I can make some progress on the high/low problem following exercise. At least my numbers today were on the chart, and the period of high BG was only about 3 hours.

Thursday, May 29, 2008

Thorlo Socks Rule

Have you tried Thorlo socks? I am not trying to turn my blog into anything even remotely commercial but I just am sincerely grateful for Thorlo's support of the Triabetes project. As part of their sponsorship, they shipped us each a nice package of Thorlo socks of our choice. At first I thought, "These socks are thicker than what I wear and I might not like them." But I was wrong! They have the right amount of thickness (a little more cushioning on the bottom yet still thinner on the top) for the styles that I got, and they are very comfortable for those long (or short) runs. They have definitely become my preferred running sock. I also have word that the people who own the company sincerely care about feet and wouldn't want to sell you a sock that might compromise your foot health. When I ordered a fun pair of ultra-thin socks for skiing (to fit my boots), they were concerned and double-checked that I really wanted them, since they might be a little rough on my feet. Thanks for the socks, thanks for supporting Triabetes, and thanks for caring so much about feet!

A Great BG Day

After a month of trial-and-error, I had one of my best BG days in memory. Here it is. Yay! Note the 1 U/hr basal rate in the morning compared with 0.25 U/hr in the afternoon. It took a month off the pump for me to accept that I really needed this much insulin in the morning. I'll have a chance to put this plan to the real test this weekend with a 120-mile ride and 19-mile run. Then begins the 3-week taper before Ironman Coeur d'Alene.

I am using the basal rates as shown below, with a 1U:40mg/dL correction factor for high blood glucose, 1U:9g carb ratio for bolusing, and 4-hour insulin-on-board time window on the pump. Previously, I was using 1:85 correction factor, 1U:10-15g carb ratio, and 2.5-hour IOB time window, so this is quite a change. I am trying to really test out these parameters by careful programming of my boluses and so far, so good. And I expect to make adjustments as I try this out longer. I try not to expect perfection, but isn't that a nice string of 80-120's there at the end of the day?

Thank you, Matt Corcoran (of Diabetes Training Camp), for working with me to figure this out.

Wednesday, May 28, 2008

I Sort of Missed You, Pump

After about a month of using Levemir 2-3 times per day, I am back on the pump. Trying to figure out how to take enough to prevent highs without crashing was tough. I found that about 3-5 hours after a dose that was too high, I would drop at a remarkably constant and steady rate. It was sort of cool to see such a straight, downward-sloping line on the Dexcom, but not if it was 1 AM and I was waking up with another BG of 39 and knew that after I blew the diet by eating 200 calories in GU, I would wake up in another 4 hours with low BG again. Still, I was impressed at how much steadier Levemir is than NPH, which was the long-acting insulin I used when first diagnosed.

The Levemir regimen we finished with was 6 units between 5 and 6:30 AM, 3 units between 1-2:30 PM and 2 units before bed. This worked fairly well although by the morning, my BG would start to rise. Increasing the evening dose to 3 units led to unpleasant lows. I had similar issues with the morning dose.

Although I am not continuing with Levemir for now, I definitely think it was helpful to take a break from the pump and to figure things out with a long-acting insulin. I have a much better understanding of my insulin needs throughout the day and during exercise and hope to be able to transfer this knowledge over to a more effective use of the pump. One of the biggest discoveries was that, if I want to eat anything during exercise, I need a lot more insulin than I had been taking, and definitely more than I would need at rest.

The mental freedom of being on a long-acting insulin was nice, though. There is some comfort in being "good to go" for many hours and not needing to be connected to anything (although I was using the pump for boluses and also the Dexcom).

Saturday, May 24, 2008

Workout Report

By the way I do these for my own future reference or in the off chance that it might help someone else! Today we swam 1.2 miles in the Bel Marin Keys, which was fantastic and highly recommended. Following that, we rode about 93 miles through Marin, somehow having a mostly flat(ish) ride. Well, flatter ride might be more correct. Anyway, I remember being in my aerobars a lot which says something. I tried using the pump/Levemir combo that was suggested by Sarah F. on the Insulinfactor list. Also I took a lot more insulin for my breakfast (almost 1 U Humalog per 10 g instead of 15 g carbs). I still shot up a bit on the bike but held steady until we took a 20-minute break midway and then I got a flat a short time later. I need to keep moving when I am eating 250-300 calories per hour! Next time I might keep my low basal rate going on the pump a few more hours. I also have to be fairly aggressive with bolusing right after or even a little before I finish a workout like this. I think my body is still churning out the juice (aka glycogen) and doesn't realize I've stopped! Well, and that huge burrito didn't help matters. My BG has cruised on down to a nice 133 now by the way. I think it's still cruising on down...

Thursday, May 22, 2008

Windy Headlands Ride

I enjoyed a cruise through the Marin Headlands on this clear and windy morning. Coming down Conzelman, which is a narrow and winding road, I pondered my fate should a strong gust blow me over the edge into the surf below. Actually, it was less windy there than I expected. Climbing the hills has become much easier since I had my bike re-fit and my seat was raised a few inches(!). I think my seat had been creeping down. Anyway, it was a beautiful morning for a ride, which offset my frustration with my disappointing blood sugars. As my friend Peter put it, hey, maybe I have diabetes!

Tuesday, May 20, 2008

Century #4 (I guess)

Are we up to number 4 already? Sitting in the living room with the heat on, it is hard to believe that all I wanted on Saturday was ice water on my head! This weekend we rode 111 miles starting in Calistoga and looping around the Vineman course, finishing with a 30-mile out-and-back bit on Silverado Trail Road. The weather was hot and rumor has it that temp's were above 100 degrees in the afternoon.

I took my 5U of Levemir at 5:50 and also 5U Humalog for breakfast plus a correction for a high caused by treating an overnight low. We started the ride around 9 AM and after about an hour of riding, I had dropped a little over a pound despite drinking nearly a full bottle of Vitalyte and another of water. My BG's started to fall but then climbed up again before starting their slow, bumpy decline throughout the rest of the ride. From the Dexcom plot, one can estimate a negative slope of about 60 mg/dL/hour between 1 and 5 PM. I was eating and drinking during this time so it seems like my basal insulin was too high; perhaps I could take an initial bolus to offset the early highs and reduce the basal to prevent the steadily dropping BG's later on.

We weighed ourselves again about 50 miles in and at 92 miles. After 50 miles, my weight was down by about 2.4 pounds. We were at our midway break, and took some time to refuel and rehydrate. By the time I resumed riding, I was about 1 pound down. Soon after that point, the temperatures really started climbing, and I felt pretty bad between miles 65 and 80 (when I had a flat and, incidentally, had a few moments to rest in the shade). I was afraid of running out of water between stops but guess I had been drinking enough because my weight was up one pound by mile 92. I really struggled through the last 10, and especially 5 miles. More than anything, I wanted to stop. I was just so hot and uncomfortable! But eventually I pulled myself back into town. I was feeling a little dizzy and spaced out, although my BG's were fine. I think something may have been going with my electrolytes, but that is a topic for another day.

Here's the Dexcom data. I had disconnected my pump and ate without bolusing right away after the ride; hence you see the post-exercise spike. I tried to refuel as well as possible that evening since I had a 20-mile run planned for the next morning at 6 AM.

Sunday, May 11, 2008

How's Your Humalog?

Has anyone noticed a recent change in the way your Humalog is being absorbed? Or has anyone had a change in the way your Humalog is absorbed over some period of time? Of course there are a million explanations for anything in diabetes but Humalog just doesn't seem to be working for me the way it used to--it takes a very long time to start acting (at least an hour usually) and seems to accumulate and then hit me later on in the day (by pump or by injection). I assume it's just me but I've had one other friend report the same thing in the past few weeks. I've used Lilly insulin since day 1 and it has been great but I am considering switching over to Novolog or Apidra. I've tried to rule out all of the usual suspects (pump problems, stress etc.) It could also be that I'm paying a lot closer attention so am more finicky about getting rid of those highs.

Saturday, May 10, 2008

Century #3

I enjoyed a hilly ride through Marin and southern Sonoma Counties today for our 3rd century ride in about 5 weeks. We started off the morning with a quick 45 minute swim and then drove quickly up to Marin for the 107-mile ride. I guess we should have done a quick run at the end to make the day complete. Um, yeah, maybe not... The picture shows the diabetes data. Once I recovered from my initial free-fall, the BG's stabilized and I was happy with the Levemir. After being on the pump since 1993, it's been interesting trying some of the newer long-acting insulins.

Thursday, May 08, 2008

Wildflower Note

There will be more to come on Wildflower but as a quick update, the race went well. I ended up going with Levemir and was happy with the outcome. From last year I took 3 minutes off my swim, about 10 minutes off my bike, and 9 minutes off my run. That adds up to 22 minutes but somehow I spent forever in transition and had a time of only 17 minutes faster. (I did forget to put my timing chip back on after the swim and forgot it yet again before the run and had to go back to get it right before I left the transition area. Argh!) It was great to meet up with Bill and Peter and some good friends from my San Francisco tri team. We scored a prime location for camping and enjoyed clear starry nights.

Monday, May 05, 2008

Race Report: Wildflower Long Course 2008

My friend Jill and I both noticed how unusually calm we felt before the swim start at this year's Wildflower. It was her first time doing the Long Course, and my second, but I felt relaxed (although my pre-race BG would indicate otherwise). Since our target races were still a couple months away, and we didn't really taper (by doing a 92-mile ride and a 16-mile run the weekend before), the pressure was not too high for this race. The weather looked good, with clear skies, decent winds and warm to hot temperatures. Given the possibilities, we were in for a good day.

Matt and I had figured out a strategy for using Levemir instead of my pump for basal insulin, and I had my pump hooked up with zero basal rate for any boluses I might need along the way. We had only had a few days to work out the Levemir dosing, and I had never tried it in any long workouts. Given my recent problems, though, I felt it was worth a try. But you should have seen the arsenal of GU's I had on both the bike and run! People were wondering why anyone would carry so much food.

I took my 6 units of Levemir at 6 AM and ate my breakfast--a chocolate brownie PureFit bar (yum!) plus a banana. I took a nice 3 unit injection + 0.5 unit bolus (just to make sure the pump cannula was filled prior to the race) in anticipation of eating a bit more, but decided to wait. As I saw my BG shoot up to 423, I was glad I hadn't eaten any more. I had practiced this breakfast the day before and my BG had stayed in a great range. These pre-race "anxiety spikes" really get to me. My BG slowly came down but I wanted to eat a bit before the swim (GU + some Vitalyte) and nudged it a little with 0.3 units. I came out of the water around 180, and started the bike. I waited until I was confident I wasn't going to shoot into the 300's, and began my nutrition plan of 250-300 calories per hour in Perpetuum, Luna Moons, and GU.

The first 15 or so miles are fairly hilly, and then it levels out to long, mild grades for another 20 or so miles. About 40 miles in there is a steep and long climb, fabulous descent, and then some mild rollers and a couple hills before the last mile downhill. The wildflowers were, indeed, still in bloom for the race, and it was a beautiful ride. I ate my food as planned and felt strong for most of the ride. Compared to last year, when my BG spiked above 400 in the first hour of the ride, I was happy to see readings in the 200-250 range. I thought about nudging it downward with a small bolus but wanted to see how it would play out during the run.

I started to feel pretty sick during part of the ride and was pretty miserable for the first 5 miles of the run due to my favorite kind of cramps (that only a woman can appreciate). I backed off the pace and concentrated on my hydration during those initial miles and started to feel better once I hit the trail portion of the race. The run course is one of my favorites--it starts on the road but a significant portion is on well-maintained trails along the lake, through trees or through open fields. I felt stronger as I went on and was able to keep my BGs afloat on 3 GU's and a swig of Gatorade at nearly every water stop. I would also take a couple waters--one to drink and one to dump on my head. Towards the end of the run, I was surprised to see my BG creeping up into the 200's. I'm not sure if that was an insulin issue or if I was taking in more carb's than necessary. I also had been increasing the intensity, which can cause an increase in BG, at least in a non-depleted state.

My unexpected mishap for the race was forgetting to put my timing chip back on after the swim. Yeah, I know it is not necessary to take it off after the swim but I was having a tough time with my wetsuit! I realized it was off about 5 miles into the ride and there was no way I was going back for it. I was almost to the run start timing mat when I realized that, yet again, I had forgotten my timing chip. This time I did go back--I had been so happy with my quick transition! I was a little worried whether I would get an official finishing time but that worked out. My bike time on my bike computer was 3:26, which did not include a 5-minute bathroom break. I was happy with my finishing time of 6:46 compared to last year's time of 7:03.

In the Dexcom plot below, you can see my breakfast + anxiety spike climbing after 5 AM. There is a gradual drop-off and then a steeper decline during the swim, which started at 9:15 AM. On the bike, the glucose levels climb a bit and then there is a gradual decline at the beginning and another increase at the end of the run. I was happy with the outcome, especially since this was a big experiment with the Levemir. Next time I'll try to get those levels down into the 150-200 range perhaps.