Tuesday, December 08, 2009

Ironman Arizona Diabetes Details

I thought I would give a description of diabetes-related details for Ironman Arizona for those who may be interested. This is not necessarily the best approach for anyone else or even myself, but is what I have been trying as of late. My strategy in training for past long triathlon events has been to do a lot of record-keeping, especially around key workouts that simulate aspects of the race. This time, for whatever reason, I didn't have the time or energy to be as diligent about that. Also, I was trying to cut back on calories during workouts, so it was a little harder to compare with race day. And furthermore, I really wasn't able to do any long runs so it was hard to simulate the conditions for the marathon.

On Saturday, I pre-programmed my pump for the race the next day, based on my predicted times for each leg of the triathlon. Typically for a race, I will program an increased basal rate before my planned breakfast time in order to help counter my tendency to run high on race morning. For an Ironman, this is typically about 4 hours before the race start. About an hour before the swim start I might drop it a little from normal; I don't need to drop it much because my basal rate is pretty much set to keep me stable during morning exercise. I'll keep it slightly lowered during the first hour of the swim, and then raise it quite a bit about 30-45 minutes before I get out. The reason I do this is because I consistently have a spike in my BG at the start of the bike. I have had races where, within one hour of starting the bike, my BG has gone from upper 100s to over 400, even with eating very little to no calories. I believe this is due to the high level of excitement (and therefore increased adrenalin) that naturally occurs in the transition between the swim and the bike. I'll keep my basal rate raised (say from my normal 0.6 to 0.7 units/hour to 1.0 or more) for the first hour or two of the bike, and then drop it down to a level that has worked for me in training on the bike, given my planned calorie intake. An hour or so before the run, I'll drop it down lower, to a level that has worked during training runs, especially those that had followed a long bike ride. I may also eat a little extra in the last hour of the bike. During the run, I often have to do some trouble-shooting it seems, but try to settle into a good level as soon as possible. After the race and overnight, I set my basal rates back to normal or to slightly reduced levels.

For me, this strategy has worked well, especially if I have done a lot of testing during training to get really comfortable for what rates work well for me. I try to get familiar with the actual numbers, rather than just a percent increase or decrease. Still, it is hard to predict how my body might react to the increased stress and duration of exercise on race day, especially after a week of tapering. I tend to err on the side of letting my BG ride a little higher rather than increase my chances of having a low BG, which is really painful during an Ironman. Although, having high BGs during a race is no picnic either.

Regarding bolusing, I will take my normal breakfast bolus 3.5 hours before the race start to give myself time to correct for post-meal highs, and to give the bolus time to taper off before starting the swim. I am still learning how much I can bolus during an event without crashing later. Correcting for highs on the bike seems easier, and I have more recently learned that I can manage with a couple units of insulin on board without my blood sugar crashing. I get really nervous taking big boluses, even to correct for severely high BG, during exercise. I just hate so much having low BG during a race. It really destroys me, physically and mentally. Although I have also learned that I seem to recover okay if I am patient when I have a low.

Record of my diabetes management during IMAZ 2009
(Thanks to Kevin for his Excel logbook, which can be found here.)

At 3:30 AM, 3.5 hours before the race start, I bolused 4.5 units for my 65-g carb breakfast. About 1.5 hours later, my BG was good at 165, but then started to climb before the start. I was surprised to see it rising up through the 200s and then spike at 303. I skipped my pre-race gel/Gatorade and decided to correct with 0.3 U before getting in the water for the swim start at 7 AM. During the first half of the swim, I felt good, but started to get hungry about an hour in; after some internal debate I ate a gel, which gave me confidence, and finished the swim at 182. I started the bike around 9 AM and was really hungry right away. I ate a few bites a few miles in and before checking my BG again, trusting that my basal rate of 1 U/hr since 8:30 had been enough. Unfortunately, I popped up to 349, so went ahead and bolused 1.4 units. This gradually brought me down to the 180s and then 130s about an hour before the run. I started the marathon at 139 and promptly dropped to 53 in the first 2-3 miles. It took me some time to recover from this and I was shocked at how high I had set my basal rate! What was I thinking? Anyway, I temporarily shut off the pump for 30 minutes and set my basal rate at 0.2 U/hr. This seemed to work for a while but then I had an unexpected, enormous spike in my BG; I think this was the beginning of the third loop. I wondered if the pain was stressing me, causing the high BG? Or probably the slow pace was requiring fewer calories? Did that chicken broth have a lot of calories in it? I took about 2 units but this high was stubborn, and I had to take another unit of insulin. I was over 400 for about an hour. Yuck. I drank lots of water, took some salt tabs to replace depleted electrolytes from the high. I eventually came down and then relied on the cola to keep me from bottoming out. I didn't check right after finishing, but had come up to 242 about 45 minutes after. I bolused for the pizza I ate and went to bed a little hungry, and woke up with a BG of 63 early the next morning. But otherwise, I didn't have any issues with low BG following the race.

Next time, I would keep my increased early morning basal rate until 6:30 AM, rather than 6; or perhaps I would raise it from 0.8 to 0.9 (above my normal of about 0.55 that time of day). For me, it's easier to treat a too-high basal rate than a bolus over-correction. About 30-45 minutes before the swim finish, I would increase my basal rate even higher--maybe to 1.5-2 U/hr--and would keep it there for about an hour on the bike. Or else, I could take a couple units as an extended bolus in T1, which would have the same effect but would be timed a little more precisely with my race. I used to use this method but felt like it was less to think about to pre-program my basal rates. Also, I think it works better for me to have increased insulin on board before I get out of the water. For the run, I could have lowered my basal rate earlier before getting off the bike, and should have lowered it more. It was essentially the same as it would normally be at that time of day, if not higher! I had based this on a level I've used for long training runs in the past but at a different time of day and not after a long ride. I need to keep my wits about me and realize that, if my pace is really slow, I am probably not burning as many calories per hour, so probably will need more insulin. I think my strategy next time might be to drop my basal to something like 0.2 units/hour before the run start and then increase it a little to 0.25 or after an hour or so of running.

I'd like to believe that I can figure it out once and for all and then have perfect insulin and BG levels at every race! But I think, for me, it is more realistic to expect a certain amount of fiddling. There are so many variables, new and old, to consider on race day. I definitely feel that, after several years of experience, I can anticipate a lot of the tricky spots during a race; and, even when things don't go perfectly (which is always the case for me, it seems), I have less fear and anxiety over it all.

(Stolen from an earlier post of mine...)
"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.

Sunday, December 06, 2009

Triabetes and Ironman Arizona 2009, Part 2

Date: November 22, 2009, 7 AM
Race: Ironman Arizona, Tempe, Arizona (2.4 mi swim, 112 bike, 26.2 run)
Weather: cool, ~50 at the start to mid-70s during the day to cool again by the end.
Teammates present: 15 teammates from Triabetes, a bunch of guys & gals from Team Pacific Bicycle and a whole host of Triabetes friends & family
Goals: to keep focused on finishing and enjoying celebrating the day; to stay comfortable during the swim and bike and to allow myself time as needed in transition; to manage IT band injury so I could finish without causing long-term consequences.

Some races are about shooting for a new personal record (PR) or placing well; others are about making it to the starting line and doing one's best to finish. This race would be the latter.

Before the Start

Since I arrived with fellow teammate Sean at 5 AM, two hours before the start, I had plenty of time to make final preparations. I pumped up my tires, dropped off the special needs bags (which they give back to you midway through the bike and run), and cycled through the portapotty line a couple of times. I felt relaxed and ready to go--it really helps that they have you drop off all your gear the day before. Also, I planned to take a simpler approach to the bike and run this year, and would rely more on the aid stations for my fluids and nutrition. In past races, I have used Perpetuum on the bike, but this time I would just try Gatorade, water, and mix of solid food supplemented with gels etc. as needed. I would shoot for about 200 to 250 calories per hour while on the bike. For the run, I would carry plenty of fast-acting carbs with me, but also knew I could use the PowerGels and other food they were offering if I ran low. I had an extra infusion set inserted and primed the day before, but also had a spare on my bike and in my run special needs bag. I had a meter for the swim start, and another that I would stick in my jersey pocket on the bike and run. I had also thrown in a spare meter in my run transition bag.

After pulling on my wetsuit, I randomly found a few other Triabetes people; we made our way to the start with the slowly moving crowds. Sarah Jane and Sarah W. had set up a table near the start where we could leave our diabetes gear, and I was able to check my blood glucose (BG) one more time before hopping in the water. Although a bit on the cold side at 62 degrees, the water felt okay compared to swimming in the San Francisco Bay, and I was hoping that the fresh water would be kinder on my neck, since I yet again forgotten to put Body Glide on beforehand. I've seen some pretty bad wetsuit neckline welts before and wondered how long those took to heal. Oh well, it was too late; I just hoped for the best.

I lost everyone by then and just swam toward the start line, which was probably about 200 yards away. I had barely gotten somewhat close when the gun went off; we were underway! I started somewhere in the middle, trying to avoid the right side, where I imagined the more aggressive swimmers would be. Anyway, it was your typical Ironman swim start mayhem for a while but I could tell that we were going at a decent speed, and tried to stay in the pack. With about 2500 people starting, it was a big crowd! Partway down, I just didn't feel like dealing with it and inched out a little. Then the sun came up directly ahead and I couldn't see anything and just sighted off the other swimmers. I hate it when I look over and realize there is NO ONE to my side. I would move left, back to the pack to get some draft and then find myself to the right again. We passed beneath some bridges that I thought were near the turnaround, but I couldn't see the landmarks I had picked out earlier. But suddenly I was at the big red buoy; for the first time ever in a race, I thought, "Wow, it's already time to turn around!" I think having so many swimmers packed together in a somewhat narrow lake made for a stronger current than you might have at Ironman Coeur d'Alene or Wisconsin. Also, the turnaround buoy is not quite halfway through the course. I wondered if I might PR on the swim.

Swimming back, I felt really hungry and debated whether I should stop for a gel. I wasn't sure if I was low or just hungry since I had skipped my pre-race GU (gel), but decided to go ahead just to be safe. Also, if I even suspect that I have low BG, I tend to slow down; and usually when I am swimming, if I think I'm low, I am. But not always. For me, though, feeling hunger pangs is a pretty good indication of falling BG while exercising. I did feel better after the GU, although kicking on my back while eating seemed to disturb my calves and I started to cramp up. I tried to flex my feet and relax my calves, but they totally seized up. Owww! As I floated on my back, trying to relax the cramps, a woman in a kayak asked if I needed help. Hmm, I had sort of prided myself on not needing to stop during an IM swim, but this sounded like a good idea. Another woman who was closer slid up next to me on a surfboard and I grabbed it while trying to stretch out my calves. It took a few minutes but finally they relaxed, and I was able to swim the last half-mile without a problem. The Triabetes table had miraculously moved to the swim exit; I was very grateful for help with a post-swim BG check, which would give me a few extra minutes to make necessary adjustments. Also, it appeared that my neck was not chafed. Yeah!

the swim exit on a calmer day

I ran to get my transition bag, and slipped into the tent to get on my bike gear. I had opted to wear the Triabetes tri shorts and top for the whole race, rather than changing into separate bike and run clothes, so didn't really have that much to do. The volunteers rubbed me down with sunblock, which sort of globbed up on my wet skin. Clearly I wasn't in too much of a hurry, because I stopped in the portapotty to rub it in, probably wiping most of it off! (Yeah I had some weird sunburns the next day.) Eventually, I made it out of T1 and was on the bike. The Kestrel felt light under my feet as I made my way up the ramp, forgetting the rule about not passing anyone there. I saw some Triabetes fans wearing their blue shirts and I was happy!

My plan for the bike was to pace conservatively so that I could finish this leg without a flare-up of my IT band knee pain. I kept telling myself, "Don't be greedy!" meaning that it was NOT okay to just say, "Forget about the run! I'm going to hammer on the bike!" I have done this before! With such a flat course, I suspected that I might PR while keeping a steady but comfortable pace. Because I only had one water bottle cage on my bike, I planned to drink one bottle of water between each aid station, and would grab some Gatorade at the beginning of each, drink what I could and toss it at the last trash drop. With aid stations every 10 miles, I figured I would be passing one every 30-40 minutes, which would be fine. Actually, I suspected I might drink more, knowing that I had one bottle that should be mostly empty by the next stop. Also, I felt that by forcing myself to slow down a little for the aid stations, I would keep the pace under control better. My goal was to finish, remember? I tried to keep this in mind.

The course was 3 loops and nearly flat. Well, there was a mostly big-chain-rideable uphill on the way out and then the reverse slight downhill on the way back. There was a small short hill near the turnaround just long enough to stretch my legs out a bit. On the first loop out we had a pretty strong headwind, which took me by surprise since there had been NO wind whatsoever the days leading up! But the way down was super fast and fun and wow, that Kestrel is a bullet. I was so happy to see my mom and aunt along the sidelines on the way back, and got a big lift from the Triabetes crowds (as well as other friendly cheerers) at the turnaround for the start of lap two. I was enjoying this and felt strong and comfortable.

Just starting the bike. (Photo courtesy of Blair Ryan)

The next loop up, there was also some headwind, but on the turnaround there was also headwind. What?? Where did that beautiful tailwind go? Still, it was downhill and I had my goofy aero helmet on, which I actually love after all these years of mocking them, so it wasn't too bad. I stopped for my special needs bag and munched on some food and took a stop at the bathroom and was on my way again. I reminded myself that it was okay to not go crazy and rush through everything. I felt pretty good for the rest of the ride despite one serious flare-up of IT band pain. My physical therapist (PT) told me to swing my knee a little wider if this happened and lo! and behold! it worked. The pain was completely gone after a few minutes. I was happily surprised. Riding in the aero position was not entirely comfortable for me but I hadn't prepared much that way so I wasn't too surprised. I was probably in my aero position for about 50-55% of the time, when it should have been closer to 90-95% given the course.

Even though it was a good ride for me (and a PR of 40 minutes), I was happy to finish up and get off the bike! Immediately after handing a volunteer my bike, my knee started hurting. I walked slowly towards the transition bags as the volunteers pointed me up the hill towards my number. Well, I guess I just had one leg left. A marathon. Maybe if I took my time in transition, my knee would chill out and I could at least get through half the run still running. I finished the bike sometime around 3:30 PM, so would have over 8 1/2 hours to get through 26.2 miles. I felt like I could do this but I really didn't want to be out there that long!

Eventually, after procrastinating as much as I could, I crossed the timing mat to start the run. My plan was to start off at a really conservative pace and just hope I could maintain that for the whole marathon. My knee was hurting a little for the first few miles, but I was relatively comfortably maintaining an 11-12 min/mile pace, which was my target. Around mile 3, I started feeling really spacy and checked my BG, which was in the 50s. I reprogrammed my basal rate, shut off the pump for 30 min, and loaded up on carbs. I decided to wait to start running again until I got above 80. I think Seb passed me here and it was good to see a fellow Triabetes teammate. My BG finally came up and I resumed my slow run. I was happy to see my mom and aunt, who were exactly where they said they would be, at the top of one of the short hills. "This is going to be a long run," I said. I was glad to note that they had some chairs to sit in!

Around mile 5, I decided to walk a little to give my knee a break, which seemed to help. On the second loop, by mile 8, the pain had increased and I was limping quite a bit. Some volunteers tried to help at an aid station by massaging my calf and knee area, but it got even worse after that, and my pace dropped off closer to 14-15 min/mile. I don't know if it was the massage; it probably would have gotten worse anyway. I kept recalculating how long this would take. Four MPH and 18 miles to go? I didn't want to think about it. I had asked my PT before the race whether the pain was something that should alert me to stop. I really wanted to finish; but more important to me was the ability to continue exercising after the race. He said that it could be a few weeks for the recovery, but that it shouldn't cause long-term problems. This was a relief to me as I continued, and although it was painful, I kept the pace below a level that would have caused burning pain. This would have been a show-stopper, whether or not I wanted to continue.

After an eternity I finished the second lap. The Triabetes tent area was amazing and it was so special to run through there. Thanks to my teammate Reid's sons for giving me the extra cheers as I passed through. Thinking about that last lap was a bit discouraging, because my pace was now somewhere between 3-4 MPH and I kept thinking, "I can't believe I am going to be out here for more than 2 hours!" But dang! I still wanted to finish this thing. I felt that physically I could get through it. Mentally, though, it was a struggle. At least, on this last lap, I knew I would be passing through each spot for the last time.

I was really happy to see a few faces from last year out there, including Aaron Perry, who was giving big cheers out in the boonies of the run course (yeah!) and Dave Shack, who was close to the Triabetes tent area. I commented to Dave how I had thought many times of his "power-walking in biking shorts" comment that made it to the documentary. Dave had made it through with a lot of walking and massive blisters on the bottoms of his feet! I guess I could muddle through another 5 miles. (But, still, ugh!!!) Thanks, too, to Ray Ibsen of Andiamo who walked with me a bit, his camera in hand. (Ray, you must have a really strong right arm.) A week of traveling had caught up with Elisa, so she had gone to bed; but she was still in my mind as I made my way around.

Crossing one of the bridges, Reid and Sean caught up with me, and we walked together for a while. It was so nice to be together, and I was happy to see that they were doing well. Soon enough, Denise came motoring on through like the Energizer bunny, and Reid and Sean decided to pick it up for the end. I tried to run a little here and there; it didn't seem to really help my pace all that much. But the end was in sight. After hearing Mike Reiley announcing other finishers for hours, it would soon be my turn. I discovered I had a little juice left and picked it up (relatively speaking!) for mile 25, and then dropped my pace by about 3 min/mile for mile 26. The crowds had all moved to the finish line, except for Nate Heintzman and teammate Jerry Nairn, a happy sight in the solitude of that last mile.

Entering the finish area was maybe one of the best experiences I have had, ever. I saw so many people who are so dear to me, and others whom I hadn't met but who were sincerely cheering me on. I think this is a huge part of what makes these events so special. Not to be too sappy, but there is a genuine sense of caring, love and happiness and as my dad once said, it is a "celebration of humanity." Doing an Ironman is a self-inflicted challenge and some may wonder, "Why do it?" But what you do when you participate in an event like this is to teach yourself on a physical, emotional, and mental level that you are capable of pushing through something that may seem too difficult to bear. I tried to take it slow and just enjoy celebrating this finish, and immediately knew that it had been worth it all, not just that day but over the whole year and many years prior.

Thank you to everyone who participated in the weekend, both in Arizona and remotely in other locations. And thank you to my Triabuddy Elisa; I am totally serious when I say I wouldn't have made it to the start without her implicit support. Also I am very grateful to Kristin McGrath from Colorado Premiere Training; she enthusiastically and patiently coached me through my recovery and a complicated race schedule.

I hope to see Triabetes continue to grow so that more and more athletes with diabetes feel supported in their fitness goals, whether racing an Ironman or training for their first 5k run. For me, it has been a gift that makes it worth struggling with diabetes all these years. I am grateful to those who have supported Triabetes through volunteering, donations and sponsorships, making all of this possible. Thank you!

So happy. (Photo courtesy of Blair Ryan)

Saturday, December 05, 2009

Threatened by Driver of a Black Truck in Portola Valley

Today, I was out for my first ride since Ironman Arizona, and was enjoying a leisurely ride on the Peninsula. Heading back towards Woodside on Portola Road through Portola Valley, I rounded the corner and was heading down that smooth, gradual descent that just makes me happy to ride. There is a wide bike lane and although people often drive fast, traffic is usually light, and was today. I was approaching the intersection with Westridge when an older, dull green BMW, followed closely by a large, black pickup truck both passed me. The BMW's right-turn blinker was flashing. I also noticed some items in the bed of the black truck as it passed. There wasn't really time for the BMW driver to turn right but he proceeded anyway, and both the truck driver and I slowed a little as he turned. No big deal. The truck wasn't making any indication that he would be turning right, and I continued along downhill. It was impossible to believe he hadn't seen me, and we were already too close to the intersection for him to turn. When we were already both passing through the intersection, he screeched forward as he accelerated hard and then turned right, wheels squealing, onto the left side of Westridge, cutting in front of me. He continued to speed away quickly as I yelled some choice words; I noticed that the driver side window was up and figured he probably didn't hear me anyway. It was really close.

Momentarily I was just mad but then quickly became completely emotional and could hardly even ride--my legs were shaking on the pedals and I lost the spirit to go on. I saw a similar-looking black truck pass me again on Portola and wondered if it was the same one; it seemed entirely possible that the truck driver had not turned for any reason other than to threaten me. I pretty much coasted all the way to the turn-off to Woodside. I think it was just enough stress to open up some buried fears and emotions. I didn't have any flashbacks, but on a deep, maybe even subconscious, level I felt like I had come very close to serious injury, at least; furthermore, there was no doubt in my mind that this was a deliberate act on his part. Why would someone do that? Practical concerns kicked in because with the 15 minutes of easy riding I started to get really cold, and needed to pedal again. The emotional response eventually subsided and then I was just mad. I decided I would call the cops and report the guy. There was probably nothing that would come of it; but I figured this was probably not the first or last time this guy would do something like this. Anyway, it was all I could do. I stopped and made the quick phone call, and the police said they would send someone to check it out. They took it seriously, and noted all the details. I'm pretty sure that by that time, though, the truck was long gone. Mostly I just wanted to make a report so that it was on their record.

I don't know if this guy was mad at cyclists for some reason, but I was just riding along, alone, to the side of the road. I try to be courteous to drivers, especially near places like Woodside that see a lot of bike traffic on a regular basis. It doesn't really matter, though; this driver was using his truck as a way to physically threaten, and potentially harm me. I hope he takes a look at the news coming from So Cal and thinks a little more before trying this stunt again. I sort of doubt it would make a difference to him though.

Be careful out there.