Symlin-ing Again

I decided a few weeks ago to try Symlin yet again. Despite some lasting fears induced by a couple scary episodes of severe Symlin-induced lows, I felt like perhaps now might be a better time to really test it. My training schedule is a bit more mellow, and with no big races coming up, I am a more willing to do some experimentation which might result in me having to cut short some workouts. I have been taking Symlin for a few weeks and built up to my current dose of 5 units, which I take at each meal. Initially, I took a regular bolus with the Symlin but have found that, for me, it works better if I do a dual-wave bolus with 30-70% of the insulin upfront and the rest extended over an hour. Otherwise, I was getting low within the hour, having a hard time pulling out, and then shooting up over the following hour. So far, I am happy with the results although I definitely have to make bigger reductions in my basal rates before exercising. Of course, with diabetes, it can be pretty tough to pick out what is causing what, so I won't make any big conclusions yet (especially since my basal rates are in a state of flux since the Ironman, then my recovery and now getting back into training). I am still feeling some nausea but that seems to be lessening; also, I have felt more sated after meals although sometimes I wonder if I am just experiencing nausea. It's a feeling somewhere between feeling satisfied and feeling pukey. I do still worry whether this is safe to take since it's relatively new.

Note: I am not a doctor and this is not medical advice. Consult your doctor for help with Symlin.

Riding along Ridgecrest in Triabetes gear

Here's a picture from the race on Saturday, which the race photographers sold for a reasonable $4.50. (Hello triathlon photographers! How do you justify your ridiculous prices? Ironman Wisconsin high res images are currently $35 each whereas photos for this race were $15 for high-res and a reasonable $4.50 for a lower-res version. I know it's an Ironman but come on...)

As you can see, September is a pretty dry month in California. I was reflecting on how green San Francisco is year-round and had to admit that I guess I am okay with all the fog after all, and that I suppose it is better than getting rained on all the time. I just love wearing my Triabets jersey, which reminds me... Is there anyone out there that would be interested in purchasing a bike jersey if they were made available? Just wondering.

Mt. Tam Hill Climb

Here's a picture (from here) of Sister #3 out of the "Seven Sisters" that make up Ridgecrest Blvd. (See this post for more pictures from Ridgecrest.) At the Mt. Tam Hill Climb bike race this morning, I encountered these fine Sisters after a few quick miles on Highway 1 and a long climb up Fairfax-Bolinas Road. This was my first "real" bike race, I suppose, although I did several of the Low Key Hill Climbs last year. This definitely had less of a low key feel about it!

When I arrived at Stinson Beach, I saw many people warming up on trainers and one guy was on his rollers. This race was open to riders spanning the general public to USAC Cat. 1/pro racers. I noted that there were actually a couple tri bikes there but was still glad I spent the time this morning to clean up my road bike for this race. I didn't want to make it too obvious that I was a newbie, and my road bike has better gearing for this sort of climb. Because the "public" category had been filled, I had signed up as a USAC Cat 4 woman, which I guess is where I belong anyway as a beginner. I reflected how at ease I am with the triathlon race scene compared with this morning. The race number was supposed to be pinned on the left, which I gathered from the people asking "left side?" at the registration table. After a fellow first-timer helped me to pin on my number, another new friend came and said, "Hmm, I think your number is upside-down." Woops! We got that straightened out and I made my way to the start area.

My blood sugar had been low-ish since breakfast and was 65 about 20 minutes before the race; I think my breakfast bolus was too high and I was still feeling the effects, even though it had been 3 hours. I did skip the Symlin this morning. Also, I had reduced my basal by 40% for 1.5 hours beginning one hour before the race, and had eaten a banana (unbolused). At the race start, I had eaten some more goodies (half a cookie and a mini-brownie--bike races definitely have tastier food than triathlons!) and about 5 minutes before the race, checked in with a BG of 75. I assumed the food plus anxiety would kick in soon and keep my BG's afloat. At least, this was my hope. Without a swim and run, I would be going close to all-out on this 12.5 mile race.

I was a bit anxious and tucked in the back of the pack after the race began. There were about 15 other women in our group and we had a lead car clearing the road for us. I have to say, those first few flat miles were exhilarating and just a little terrifying, as I paid careful attention to stay with the pack while watching the road for hazards and making sure I didn't cause any accidents. This part felt easy physically because I had a nice draft and the road was more or less flat. I wondered if the lead riders were dogging it but concluded that I was just benefitting from the draft. Our group of ladies was pretty mellow and once the order of riders was settled, nobody tried to pass on Highway 1.

Once we started climbing up Fairfax-Bolinas Rd., people quickly separated. I stayed with a few riders for a bit and then fell back a little. My heart was pounding like crazy, partly from being so hyped about the race but also from the climbing, and I felt like perhaps I should back off a little. I guessed my time would be over an hour and wanted to keep something for those Seven Sisters. Fairfax-Bolinas Road is a little-traveled, windy road that intersects the main route for the Alpine Dam Loop when it connects with Ridgecrest. I had been up this road once for the Race Across Marin in 2006, but had forgotten how long it was! It seemed to go forever, constantly winding up, sometimes exposed with views of the hills and the ocean below and other times shaded in the redwoods. I could see the fog still clinging to Stinson Beach and the ocean with bright blue skies everywhere else.

As I was nearing the top of Fairfax-Bolinas, I heard the Dexcom CGM beeping in my back pocket. I ignored it. I didn't even want to take the time to pull it out and I assumed that my BG was rising--my typical reaction to climbing or intense cycling efforts. I remembered that my basal was lowered and decided that I felt good, that I had eaten enough, and that I would not be able to sustain a 185 heart rate with a low BG! There were a few people there cheering as I started out on Ridgecrest--"only 7 more rises!" I was actually relieved to hit this part of the course, since there is only one "sister" that is truly steep, and I would get some breaks after each climb. My heart rate was high but my spark was fading a bit. Determined to keep track of each hill number, I counted but lost track around the 4th or 5th sister as usual. But I made it to the finish, eventually, in around 71 minutes. I was last in our division but I guess this only gives me motivation to keep at it.

I pulled out the Dexcom and was surprised to see that it was beeping because I was at 86, below my alarm level of 90. "Hmm, this must be wrong," I thought. The BG meter read 82. I checked again. 82. I was really surprised. I guess in retrospect it does make sense because, although I often include intervals of high intensity in my cycling class and on some long rides, I don't generally keep this up continuously for an hour or more. I was glad I had cut back the basal and felt a little bit of diabetic smugness for hitting the nail on the head (this time).

I hope to do some more road racing in the future. This may be dangerous for my bank account though, since I'm not sure how much life is left in my dear red road bike. Anybody want to buy me a new one? :) (Here's a beauty, for starters...)

Study shows continuous glucose monitoring significantly improves pregnancy outcomes

An article published yesterday in the British Journal of Medicine found that using CGM technology significantly improved several pregnancy outcomes including decreased maternal HbA1c in the 3rd trimester from 6.4 to 5.8% and reduced occurrence of macrosomia in the baby. For more details, read ScienceDaily or the original article at BJM.

Ironman Wisconsin Diabetes Race Report

The day after the race, I quickly wrote up a race summary for Dr. Matt, who was in Snowmass, CO, busy, running his 3rd Diabetes Training Camp for 2008. The summary focuses mostly on the race itself and my diabetes management during the race. I thought I would include it here for anyone who might be interested. At the bottom, I've written a brief explanation of some of the diabetes lingo that I use here, for those who are less familiar with all this stuff! Photos are courtesy of Blair Ryan.

**

Here's a brief lowdown on the diabetes stuff (mostly) from the race yesterday. But first, it was an amazing experience. We had nearly perfect weather and the Triabetes support crew was amazing. And trying to look good for the camera kept my pace up a little. ha! Well, until the end anyway...

I ate breakfast (60 g breakfast, oatmeal/banana/PB/milk) around 4:15, 45 minutes later than planned but 2:45 before the race. This didn't give me as much time to deal with pre-race highs and I was high and rising. I bolused 0.5 when I was still on the rise at 380. It had come down to around 320 by 6:40 so I ate about 10 g GU before hopping in the water. My basal from 5-8:30 was 0.9 and then it went up to 1.6 until 10 AM (at which point it was 0.7). The swim started at 7:00 AM. On the 2nd lap, I became worried about going low and was feeling tired, so I flipped over and ate a GU sea-otter style and immediately started feeling better with the next stroke I took--it was probably psychological because I think I was holding back on the effort a little to avoid going low. I started cramping in my calves the last half mile of the swim and it was painful and slowed me down. I think getting out of the water after the 1st lap at IMCDA helps in this regard. But I was able to finish in 1:46, a few minutes slower than IMCDA.

Coming out of the water my BG was 83--a little on the low side so I ate prob. 60 g carbs in transition. In retrospect, my BG was probably in a great place if I didn't eat but I had that big basal going and I panicked. (I really hate low BGs during a race.) About a mile into the bike I lost my water bottle in a place that was difficult to turn around and made a decision to continue. I begged some water off a volunteer along the route but didn't get another water bottle until about 45 min into the ride. I was probably dehydrated from the high BG's earlier and should have stopped somewhere for water, although I didn't have many options there. I considered briefly grabbing one of the bottles on the side of the road after a particularly bumpy stretch, and was eyeing all the volunteers for spare water. My heart rate was high which is pretty typical for me on the beginning of the bike. I did note that when I got some water at the 1st aid station, my heart rate came down fairly quickly; I'm not sure if it was due to getting the water into my body or just finally relaxing. My BGs shot up to something around 350 after 1 to 1.5 hours on the bike. I was pretty surprised, but then again not so much; I guess I shouldn't have eaten so much in T1. I just went ahead and bolused 1 U and waited a bit before eating more. Eventually it came down and then I was struggling to keep my BG up towards the end of the ride even though I spent the last 2 hours at 0.25 U/hr basal. At about 65 miles into the bike, my calves started cramping again and it was painful. I had been drinking a lot of water/Perpetuum/Gatorade, had taken a lot of salt in, and couldn't figure out what to do. Fortunately, at one of these moments, the camera crew came by and I thought, "Well I can't just be a baby and stop pedaling here." So I just tried to pedal through it. That actually worked pretty well to work out the cramps, and I discovered that if I worked at a harder gear with a lower cadence, I would cramp less frequently. But I was a little disappointed that I couldn't really put the pedal to the metal since otherwise I felt good. I finished up the the ride in 7:05, which is about 7 minutes slower than my CDA time. I wanted to go faster, because I felt stronger than before CDA, but the cramping really slowed me down. I suspect that the high BG/no water situation had something to do with it as well as the cramping on the swim. I was worried that I would cramp on the run but that didn't seem to be a big problem (except for when I drank cola instead of Gatorade--I noticed that also happened in CDA).

My BGs were a little on the low side (low 100s/90s) at the end of the bike and I think I shut down my pump for a half hour at the beginning of the run. I felt well-hydrated. My BG's were in the 90-100 range and I lowered my basal to 0.125. I was eating a GU every 40 minutes, and pretzels and Gatorade at almost all aid stations. (Granted maybe it was only 2-3 pretzels.) I shut down my pump another couple of times because I couldn't get my BGs up. I was eating probably 200-250 calories per hour, maybe more. I ate what I could. I had a couple episodes of low BGs--measured at 60s, 70s and dropping fast--but noticed that I didn't feel great (GI ickiness) when I shut down my pump. At the last turnaround around mile 18 my BG was pretty low and I felt on the verge of emotional breakdown so allowed myself to walk for a few minutes. I ate about 50 g carbs and then saw my BG rising. I was happy to see it rising steadily upwards until it hit 200, at which point I started to wonder if my pump was disconnected. I had a couple miles to go so nudged it with 0.2 U just in case there was a problem. I was sort of bummed that I couldn't run faster but happy I made it through. I felt pretty low energy-wise for a lot of the run, although I had some better moments here and there. I tried to pick it up when I could, and was happy to keep running through the end. When I was walking due to the 2nd low BG episode, a woman said, "Don't worry--there is plenty of time to finish." I started running after a few minutes and she wished me good luck.

I did notice a couple times the sort of fatigue come on that I experienced on the run in CDA 07 and on the bike in CDA 08. I am more alert to the initial symptoms (basically low BG feelings when the BG is normal--especially slight dizziness) and backed off right away when I felt this way on the 2nd loop of the bike. After I finished the race, I felt the same way and it might have something to do with blood pressure perhaps. My blood pressure was 100-110 (can't remember) over 50; I drank 3 cups of broth and it came to 110/60. Who knows I guess.

It was fantastic seeing everyone along the course and I was especially happy to see my partner in crime (or so I would like to think) Michelle after some hill somewhere and Ray and the camera crews and anyone in one of the blue IronFan T's. The IronKid crew on the run course was also fantastic and it was great to see Marissa and the rest cheering enthusiastically each time I passed by. Racing with 11 other type 1 athletes was such a pleasure for me; I had a big boost when I saw anyone on the course and it was such a comfort knowing that so many people "in the know" about diabetes were out there. And having that table for the swim was so incredibly helpful. It took a lot of stress out of the morning for me. I am pretty sore today and have a really weird bruise on my ankle but otherwise am doing okay. I had BGs >400 overnight and they are up again so I had better see what is going on.

**

"Basal what?"
For those who are less familiar with diabetes terms, here's a primer. BG refers to blood glucose, which increases with food intake (especially carbs) and stress, and decreases with insulin and, often, exercise. Sometimes exercise can cause the BG to increase, and many other variables affect the rise & fall of BG. Insulin takes the glucose from the blood and helps to shuttle it into fat & muscle cells. Insulin must always be present and can be delivered through injection or insulin pump. I use an insulin pump, which delivers a "basal rate" of insulin throughout the day. I program this depending on my activity level; basal rates also change throughout the day. For me they are highest in the morning and lowest in the afternoon. When I eat a meal, or need to correct a high BG, I take a "bolus" which is basically like an injection except it's done with a pump. The Dexcom is a continuous glucose meter (CGM) which measures the glucose concentration beneath the skin every 5 minutes. It is calibrated to a BG meter and can give useful information on BG trending and values (as long as it has calibrated successfully).

Triabetes Journey

How do I sum up my race in Wisconsin a little over a week ago? I could detail my BGs throughout the day and the diabetes-related decisions that I made. Or I could talk about how I picked up my pace a little every time I saw a red or blue Triabetes IronFan T-shirt out on the course. Or maybe I could talk about my amazing teammates, both the 11 others racing and the honorary diabetic (aka Michelle) keeping BG meters at the ready and cheering herself hoarse. Perhaps the real story is in the 12 months leading up to the race?

Being part of Triabetes this year was a gift. All those years of people asking "Are you still running?" as I played the never-ending game of what-will-this-do-to-my-BG finally, finally, paid off in my readiness to join this group of amazing people. Since being diagnosed I have tried to continue to live life as I would have otherwise, and have been blessed with extraordinary friends and family who supported me along the way. Still at times managing diabetes is difficult and frustrating. In some way, I have received acknowledgment from somewhere--maybe just myself--that, yes, it is hard but it is also worth it. As I crossed the finish line in Madison, Ray asked me that question, "Was it worth it?" My response was, "Ask me in an hour," as I experienced a huge emotional and physical relief to be done with the race, followed by "Yes, of course it was." This Ironman was a lot more painful for me, with cramping on the swim and bike, and a low-BG-head feeling for most of the run. It was hard. But the reward to me and, I hope, the many more who participated or will see the documentary, is great. Yes, it is hard. Yes, there are highs and lows. But, in the end, it is worth it all.

Triabetes Update

A full race report is in the works but I wanted to take a moment to thank everyone for making last weekend such a powerful experience. I did finish in 14:23 (30 minutes slower than IMCDA 08 but 20 minutes faster than IMCDA 07) and was happy to cross the finish line running. It wasn't a perfect race for me and I felt hampered in my pace on the bike and the run. So I guess I have not conquered this yet. But as one of the other Triabetics, John Moore, also mentioned, at some point during the day, the finishing time became irrelevant. Triabetes became much more than that. Thank you to Michelle Alswager for having this dream and setting it in motion. It has changed my life. Thank you for sacrificing your race to ensure that things went smoothly for all of us. Also my deep thanks go to the camera crew--Ray & Nella and Mike H. and everyone else--who were out there doing their own Ironman filiming session. Also thank you to InsulinDependence, Diabetes Training Camp, and LifeScan and the rest of our dedicated sponsors. You all made this possible. Finally a sincere thank-you to all of the many IronFans, following along in person or online, and the IronKids out there on the course. Your support was felt by all and appreciated greatly.

I am happy to report that, aside from some pretty painful stiffness for the couple days after the race, I am recovering well so far. I went out yesterday for a 90-minute ride along one of my favorite routes in Marin--Chileno Valley Road--and was proud to wear my Triabetes jersey. It was pretty fun, too, after 45 minutes on the bike, to be able to say, "That's enough," and turn back. I'm sure I'll be itching to do a long ride soon enough. My carb ratio has gone from 15:1 to 8:1 in just a week so it's time to get things hopping again!

Photo courtesy of Blair Ryan

How to follow Triabetes and here we go!

If you want to follow updates from the on-course fans tomorrow, you can do so at http://search.twitter.com/search?q=triabetes. By the way, you can also check to see if your text messages came through here.

I have my strategy for tomorrow mapped out as best as I can. I think in a couple years (or sooner) we will look at these methods the same way we look at pre-computer days! But using data from Coeur d'Alene, Vineman 70.3, workouts and just some intuition, I have a plan in place that at least I am comfortable with.

Visiting with everyone involved in this project today at the reception reminded me of why I signed up for this in the first place: I knew I would have the opportunity to meet and work with some of the finest people around. Thanks to all those who have helped to make this opportunity come to pass and my hope is that it will touch many more lives.

Okay, it's time for sleep.

Signing off,
Anne (#2079)

Final Preparations

With one day to go before the race, I am making my final plans, preparing transition bags and looking over my bike one more time. I have been more calm before this race, and plan to use my nutritional strategy from IM Coeur d'Alene. My blood sugars have settled a little but I am still anxious about the swim. NA Sports has allowed Michelle to set up a table where we can dump our diabetic gear before heading into the swim, and after getting our wetsuits peeled off. This will give me a little extra peace of mind, being able to check my blood sugar closer to the race start. And for some of the athletes, they will be disconnecting from their pumps at this point. Most people will be swimming/treading water for 15 minutes or so before the race, so I will need to take this into account.

The weather was rainy on Thursday, nice yesterday and should be nice today. Tomorrow there is a possibility of thunderstorms but I am hoping for the best. We have found one forecast that calls for decent weather, and that's the one I'm going with. At least, living in the Bay Area has prepared me for cool temperatures. I've been swimming in the lake a couple of times and the temperature is perfect; yesterday at the athlete meeting, they announced that it was 71 degrees. I can't complain about that! The course is beautiful as well and I was happy to see a lot more flat that I had been expecting. Driving it is a different experience than riding, but I was a little reassured after driving around the "lolly" part (vs. the "stick" part) of the "lollypop" course, as people describe it here.

It has been great to be reunited with the team members I had met and to meet those I hadn't, and to also visit with Ray, Nella, and Elisa. And this afternoon, the IronKids will be joining us for a reception after their canoe trip this week. I look forward to meeting up with Marissa and the other IronKids, and to having them on the course tomorrow.

Okay, enough procrastinating. I need to get my stuff ready. I added a twitter feed to this blog that may be updated tomorrow with additional information that you won't see on ironman.com. So if you use twitter, you can follow that feed if you'd like. You can also check triabetes.org or Michelle's blog at triabetesdocumentary.blogspot.com.

Ironman Wisconsin Count-Down

As I recover from a whirlwind work trip to Sapporo, Japan, I am already preparing to fly out to Madison for this weekend's big event. I am excited, and nervous, wondering how my last week of travel will affect my performance on Sunday. My blood sugars are slowly re-adjusting to the 16-hour time difference here and will be challenged by yet another 2-hour time change tomorrow. I am in taper mode and have bumped up the rates; still, I have noticed especially that my overnight basal rates are killing me with low BG and my afternoon BG's are too high. Get back with the program, body! We're not in Japan anymore! I am hopeful that this will not cause big problems, but I feel like making it through the swim on Sunday may be a bit of a guessing game, and that makes me nervous. Once I'm out of the water, I will be very relieved, especially if I can manage to keep my BG's <250 during the first couple hours of the ride. That would be a unique IM experience for me. I do have some careful records from before and during IMCDA and some more recent workout records to help guide me, and feel like my nutrition/hydration approach from IMCDA should also work well this time around.

For those interested, very cool Triabetes "IronFan" T-shirts are available from Michelle Alswager. Check out her blog for more details. We are also trying to put together some live tracking in addition to that available on ironman.live. Check out triabetes.org or the "Triabetes 2008" group on facebook for more information! (You can also join the facebook group if you'd like updates.)