Thursday, June 30, 2011

Exercising Post Breakfast

While there has been some press lately on how exercising before versus after a meal may affect calories burned and weight management, people with diabetes have additional considerations.  For me, I have generally avoided exercising soon after a meal simply because I'd rather not deal with the conundrum of either taking my normal bolus and crashing from the insulin once it becomes super-active during exercise or underbolusing and then going high early on.  This was especially noticeable with running, and I tried to never have more than 1 U of insulin floating around when I went out the door.  For races or other times when I want to have a meal beforehand, I try to bolus & eat about 3 hours prior to starting to exercise.  Then, I am able to take a full bolus that is pretty much gone by the time I start.

But today, for various, uninteresting reasons, I wanted to eat before my 1-hour easy ride.  So I thought I would experiment a little.  I took my full bolus and ate my normal breakfast.  But when I took my bolus I also shut my pump off for an hour.  Hmm, maybe it was 90 minutes.  At any rate, by the time I started my ride, my pump had been off for 45 to 60 minutes; although I had a full bolus still peaking.  My BG was somewhere in the low 100s and rose up a bit; I checked about 40 minutes in and it was starting to fall, so I ate a 20g gel.  By the time I finished, I was 160; I took a correction bolus and settled in nicely in the low 100s.

I still prefer to exercise with just a snack versus a whole meal, but it was nice to figure out a way to sneak in a ride post meal in case I need to do that again.  I think if it had been a much harder ride, I may have had a bit of trouble.  Also, since I don't normally shut my pump off (or even modify basal rates) during exercise, I have some room to play with my basal rates.  I guess, in the past, I have used this method if I had to take a correction bolus close to exercising; although usually I just take a smaller correction than I might have otherwise done.

Saturday, June 25, 2011

ISCorp Downer Classic

We are off to Madison early in the morning, but I thought I'd update quickly on my blood glucose victory in today's race.  Yesterday, I came down a bit low after breakfast, and then turned my basal rate down to +15% (vs +30%), and ate a gel on the line, and finished around 300.  Today I tried the same thing but was able to head off the low with a granola bar and a few Dex 4 tabs, and then left my basal rates at +30%.  I hesitated but decided to go ahead with the gel again, about 10 minutes before the race start.  This race was a fun course, with a sharp turn at corner 2 but two long straightaways which helped me to move around more.  I spent some time at the front and also too much time in the wind again, but was felt more comfortable overall adjusting to stuff in the pack and was able to test out my sprint at the end.  Following our 30-minute race, I checked the Dexcom and saw 110 with a steady arrow.  I had gone up a bit from my pre-race 140 but settled down during the course of the race.  Victory!  So for the record, today I had my basals up 30% all morning (1 hour before breakfast onwards) and changed my carb ratio from 1:15 to 1:11 and my correction factors by 10 points.  I rode around a lot more today and hence had a couple bad lows in the evening.  I also did an easy ride yesterday late afternoon, so perhaps that also had an effect.

I stuck around to watch the rest of my team race in the P1/2/3 race in the afternoon, and enjoyed cycling a bit along Lake Michigan.  The atmosphere at the race today was downright festive, with lots of local people filling the, sidewalks.

Friday, June 24, 2011

Fond du Lac at Tour of America's Dairyland

On day 2 of my diabetes revamp, I seemed to have a bit too much insulin on board.  I had a horrible high that kept me up for an hour overnight--I think it was related to the infusion site--but had settled down nicely by breakfast.  Eating the same meal as yesterday, I rose up but came down a bit low, 58 right before I planned to warm up for the race in Fond du Lac.  (My theory is that since we had such a relaxed conversation on our long drive before the race, I was less nervous than usual. Maybe??)  I ate a granola bar plus a handful of Dex 4 glucose tabs, and turned my pump down so it was only +15% over normal.  My BG was 166 the last time I checked, and was just barely starting to fall again; unfortunately, my CGM stopped working on the line of the race, and since I was feeling sort of lowish, I decided to eat a gel just in case.  The race started and I went to the front and stayed with the pack.  I have been working on staying in the pack, towards the front, without doing a crazy amount of work.  (My average watts in these races have been high which is mostly reflective of me staying in the wind too much.)  I felt like there were some improvements and that my comfort level was much greater.   I could feel that racing feeling coming back at last.  I enjoyed racing with Erin Ball, my teammate on Team Type 1, and was happy to see her right in the mix; plus she went for a prime and nearly got it. Very cool! It has also been great racing with my friend Katie Styer from the Early Bird Women's team, which I was part of for 2 years--she is a very positive person to have around and she helped rein me in from the wind a few times.  After the race, my BG was up to 300 but came down to 224 after 15 minutes of easy riding.  Overall, I felt better even though my BG ended up a bit high.  We have two more races to go--tomorrow in Milwaukee and Sunday in Madison, where I am looking forward to meeting up with some great friends and supporters of Team Type 1. Yay!

Thursday, June 23, 2011

Sheboygan BGs--Update on My Insulin Tweaks

Dexcom readings around Sheboygan crit

(Update on BGs after major insulin adjustments described in my last post.)  

After a bit of a low BG before going to bed last night, I shut off my pump for an hour, which allowed my BGs to creep up to around 200.  The increased basal rates were a bit too much from about midnight until I woke up, as evidenced by a steady but slow drop between those times; but fortunately I landed in a nice spot this morning, right around 100.  I lowered the early morning basal by 0.1 U/hr so hopefully tonight will be better.

For the rest of the day, things have worked out pretty well.  The first bump on the Dexcom shown here is my breakfast spike, which came down after about a 20 minute warmup.  I saw "86" with a slight downward trend about an hour before the race start, and still had my basals cranked up, so ate a granola bar.  I warmed up a little longer and then headed for the car once it started raining about 40 minutes before the start.  My last BG check before the race showed about 135 and the Dexcom showed a flat trend at 120.  Finally things seemed to be where I wanted them!  I was a little anxious, actually, about having a normal BG, and popped a couple Dex 4 glucose tabs just in case.

The rain began in a complete downpour and I was soaked just waiting on the line. The field quickly became strung out and I was somewhere in the middle (I think), tucking in behind people when I could.  One of the biggest puddles on the course was right in the corner, but I actually enjoyed plowing through the water--at least it wasn't cold!  After the race, I was elated to learn that my teammate, Becca Schepps, had won the race!  I knew she was strong enough and had the tactical skills to do it, so was glad that it worked out! Very exciting.

Once I had changed out of my sopping clothes, I checked my BG and came in at 115, although I felt more like 60.  If the race had been much longer, I think I would have gone low (perhaps)? I think that I might either bring my race basal down a little, or eat a little more before if I find myself in the same position tomorrow.  I'd rather be up a little at the finish just to be on the safe side. I bolused a huge amount (compared to normal) for lunch and then corrected for the high (seen as the excursion above the line) and have been satisfied with how things are continuing to work out.

Although this game never ends, I am glad to have tamped down some of the constant highs and BG spikes.  Tomorrow we race in Fond du Lac, and I am hoping for similarly good BGs but a race without rain!

Wednesday, June 22, 2011

Adjusting Type 1 Diabetes to Racing Tour of America's Dairyland

Often when I travel, it seems like I need to increase my insulin basal rates; but racing this week in Wisconsin has required a surprisingly large adjustment.  Leading up to the start of the series for me, I had my basal rates on increased, "taper" mode, which is what I try to remember to use when I have a rest week in my training, or am tapering my training before a race.  (With a decreased training load, I will need more insulin.)  After arriving in Wisconsin for my first race (Friday),  I turned on my "race day" basal rate profile.  This profile has an approximate 30% increase an hour before my planned breakfast and throughout my races, which are all 30-40 minutes in length, beginning sometime between 11:20 and 11:50 AM.  At other times, the basal rate profile uses my normal rates.  At my race Sunday in Waukesha, my BG started around 190 and ended up around 300 forty minutes later.  I don't necessarily expect to have a flat line (BG-wise) during a race, so my goal is to start lower so that I don't finish the race quite so high.

Aside from the race-related BG spikes, I have had overall higher BGs, frustratingly resistant to multiple corrections.  Leaving my race day basal rate profile on constantly was still not bringing my BGs down so yesterday afternoon I just decided to increase my basal rates by another 30% or so.  Overnight, things were a bit better and this morning, I programmed a new basal rate profile that is 30% higher than my already high, "taper" profile.  I looked back and saw that, instead of my typical total daily insulin dose of 20-32 units, I was needing more than 40 units for consecutive days, which is very much outside the norm for me.  Since I had been staying high after meals and my corrections were not working well, I also reprogrammed my carb ratios from 15 g/U to 11 g/U and lowered all of my correction factors by 10 mg/dL/U.

It has seemed a bit paradoxical that during an 10-day race series (with 8 races), I would need so much more insulin.  But, perhaps it makes sense.  Although I am racing almost daily, the races are short & intense.  My blood sugar always goes up during 30-40 min crits, which are high-adrenalin events.  The common thought is that, with high intensity activities, adrenalin is released, causing the liver to release glucose from glycogen stores; for someone with diabetes, the lack of a normal insulin response can easily leave the blood sugar high.  Furthermore, the short duration of these crits means that my overall exercise volume is much lower.  And to compound that, we spend most of the rest of race days resting or doing light activity, which is in contrast to a more typical day of traveling (by foot or bike) to and from work, working a full day, etc.

So far, during our rest day today, I have only had a couple brief excursions over 200, which is a huge improvement over the past few days.  It is always nerve-wracking to take so much more insulin, but it seems to be working well so far.  But really--since when did I have to take 1.4 units for an apple?  We will resume racing tomorrow and continue through Sunday if all goes well, and I fully expect that I will have to make more adjustments.  Diabetes is always a work-in-progress!

Total daily rapid-acting insulin using Omnipod
June 12--end of 18-hr training week; June 13--begin taper; 
June 17--daily racing begins; June 20--no race

Tuesday, June 21, 2011

Mid-tour in America's Dairyland with the Team Type 1 Women

I am starting to lose track of time after multiple days of racing here in Wisconsin. Today is Tuesday I think?  So far our team has raced in Shorewood, Thiensville, Grafton, Waukesha, and Milwaukee; we have upcoming races in Sheboygan (Thurs), Fond du Lac (Fri), Milwaukee (Sat) and finally Madison (Sun).  We also had the pleasure of riding in the American Diabetes Association Tour de Cure in Grafton before our race there, and spent another day sharing our experiences with exercise and diabetes with local health care providers.  We have been taking turns writing up reports, which are posted at the Team Type 1 website here.  If you are in the area, we would love to have you come out for a race!  Please come find us and say hello.  We have women racing in both women's races, typically starting at 11:20 AM (Women's Category 3/4) and 3 PM (Women's Pro 1/2/3).  The daily schedule is located at the Tour of America's Dairyland website here.

So far, I have learned an incredible amount both during the races but also in our frequent discussions together off the bike, and have had a lot of fun getting to know my teammates.  What an incredible and fun group of women!  We are very fortunate to have Kori Seehafer--with her enthusiasm and expertise--directing us each day; managing the logistics of 7 people racing day after day, as well as directing tactics and strategies, AND racing each day is a big undertaking!

It's surprising how much energy even a 30-40 minute race takes after several days, so I will write up more when I have had a chance to rest up a bit.  But I will say that I am looking forward to the rest of the series and to racing with my teammates at future events.

Also, I wanted to say thank you to Sanofi-aventis for sponsoring our team, which makes this all possible.  I am truly grateful to be able to help spread the message of the importance of exercise in the management of diabetes, and that we can reach for our goals regardless of having type 1 diabetes.  Sanofi-aventis is not only helping to bring athletes with type 1 diabetes to the top levels of the sport but is also helping us share this message with the diabetes community and beyond!

Saturday, April 09, 2011

My Latest Strategy for Managing Type 1 Diabetes During Road Cycling Races

After a lot of trial and error, I have finally been having some good success managing my blood sugar during intense cycling efforts such as at criteriums, circuit races and time trials.  This is very exciting to me because at some points last year, I was at my wit's end with race-related blood sugars severely high enough to not only hurt my performance but also to raise my A1c slightly.

In general terms, I pre-program my pump basal rate to increase by 30%, beginning an hour before I plan to eat breakfast, and I time my breakfast to be no closer than 3 hours before the race start.  So, for example, I started my 30% increase at 5 AM this morning and ate breakfast at about 5:50, in anticipation of my 9:00 AM time trial (TT) start time.  I ate a normal breakfast and took my full bolus plus a small correction for a 164 BG.  (I actually bolused about 15 minutes before I ate, at 5:35 AM. In general I like to take a meal bolus as far away from my race as practical, while not eating so early that I'm hungry again before I race.)  I pre-programmed my basal rate to be +30% throughout the duration of my race.  I prefer using increased basal rates versus extra boluses because, in the case that I give too much insulin, correcting for the former is much easier.

Once onsite, I got all my stuff ready, rode about a mile to registration and back, and got ready to start my warmup on the trainer.  By this time (8:15 AM) my BG was hovering around 100 so I ate 34 g carbs (clif kid twisted fruit ropes, which seem relatively easy on the BG); since I was about to warmup, I expected that effort to keep me from rising too much, as well.  I only had time for about 30 minutes of warmup, and checked in with a BG of 89 ten minutes before my race start time.  I ate one clif shot energy gel and could see my BG was starting to rise, so tucked another gel under my shorts and went to the line.  (I also had 2-3 gels in my jersey pocket because, well, you never know.)  My instinct, when I see a BG of 90 that close to a race is to overreact and eat too much; it has been hard for me to learn to trust that the adrenalin will really kick in (especially with a +30% increase in my basal rate).

Since I have been using the Dexcom 7+, I rarely bring my blood glucose testing kit with me on rides of less than a few hours; and it really is very impractical to test during a cycling race.  My confidence in the Dexcom CGM technology has grown tremendously compared to the first STS sensor years ago.  (I think anyone who used that remains a bit cautious; but I am quite impressed with the current version.)  For races, I set all of the alarms on to sound plus vibrate; I also set the low alarm at 100, the high alarm at 200, and the rising/falling alarm at 2 mg/dL/min.  Sometimes I can feel the CGM vibrate but usually I hear the 2 or 3 tones that tell me whether I am high or on the rise, or low or falling, respectively.  (I really wish the low and high alarms were fully customizable; actually I wish the number of alarms was also customizable and that there were more sounds to choose from.  I really want to know when my BG is below 120 or I may have some other arbitrary target.  Actually, what would be even better is if it were displayed on my bike computer screen. Can the Dexcom transmit ANT+ please?)  Anyway, for today's race I could hear that I was rising; although at the time I assumed I was high since the alarms are the same.  The CGM graph showed that my BG rose throughout the race but peaked at around 180, which I'm pretty happy with.  It was still on the rise until after I finished racing.

I've used this approach for the past couple races now, and I am slowly beginning to trust it; although I realize there may yet be a better strategy.  In some ways, it is similar to the challenges I had during T1 (transition between the swim and bike) in half- and full-ironman distance triathlons.  Believing that a 400 BG after a significant swim plus hour on the bike is due to my own hormonal response, and not some fault in the insulin delivery or some other wacky unknown, took some experience.  And believing that I could really increase my basal rate during the swim (or end of the swim) took some trial and error as I gradually increased my confidence that I wouldn't go low.  If insulin didn't cause low blood sugar, this would all be so much easier, no?

Oh, and for today's race, I came in 4th place for the women's 4 field.  Race reports that may describe more of the race details can be found on the Team Type 1 website.

Wednesday, March 30, 2011

Total Daily Insulin Versus Cycling Time

Thanks to my super-fantastic coach and team director Kori, I have been logging my workouts since she started working with me late last year.  From my insulin pump, I can also pull off my total daily insulin amounts (or "TDD" for total daily dose) since the beginning of time, give or take.  I thought it might be fun to just plot out my TDD as a function of my cycling time, even though the results are probably as shocking as showing that washing hands reduces the spread of colds.  Anyway, I decided to just do a very simple linear regression of the data between January and March, 2011.  This model ignores variables such as what other exercise I did that day (I often walk about 40 minutes per day), whether I ate more or less than normal, my weight, how old my infusion set was, etc.  In short, the only variable I am considering is time on the bike.  But there still is a clear trend that shows with increasing time on the bike, I took less insulin.

An Overly Simplistic Model But Still Sort of Interesting

For those who like details, the slope was -0.046 U/min, the y-intercept was 35.3 U and correlation coefficient was -0.65.  If I included only March, rather than January through March, the correlation coefficient was -0.68.  The mean TDD for January was 32 U and was 30 U for March.  Total cycling time was only 90 minutes more in March although the intensity was higher.  My weight was about 5 pounds less in March.  Again, one of the most important and obvious variables affecting TDD is calorie intake, which is not included here.  But still it was fun to plot this out since the data was readily available.   Maybe I will be better about logging total activity time, including other forms of exercise, for a period of time.  If I am super motivated, I might even track calories although I can only stand doing that once in a while.

Friday, March 25, 2011

Survey on Exercise and Motivation

I am working on a post about what motivates people to exercise.  If you'd like to contribute, please share your thoughts at this poll. Thanks!

Wednesday, February 09, 2011

Intensity and Blood Sugar

When I was diagnosed with type 1 diabetes, one of the guidelines I was given was that exercise would make my blood sugar drop.  Like most guidelines I received, this was an oversimplification.  During my years of daily running, I would go out the door without eating or taking any insulin, and often return with a slightly higher BG level.  I remember thinking, "'Guess I'm just weird."  And during track workouts, the response was even more perplexing.  After a few intervals at high intensity, my blood sugar would really start to climb.  I grew accustomed to this response and began taking some correction boluses or temporary basal rates to help temper the steep rise.  What I have learned since then, and which has hopefully become more common knowledge, is that high intensity physical efforts can increase the adrenalin and stimulate the liver to release more glucose into the bloodstream.  (Here is an article that explains the phenomenon and suggestions for how to manage it.  Also, fellow type 1 and exercise guru, Dr. Sheri Colberg-Ochs, has an excellent book devoted to the nuances of diabetes control and exercise.)

I think there is another reason that exercise does not always cause my blood sugar to drop, even when I am doing a more moderate-intensity workout: I have basically adjusted my basal rates to account for morning exercise, and I am consistent in exercising almost daily.  So, instead of constantly reducing my basal rate, I try to remember to increase it on my off days.  Of course, with anything diabetes-related, things don't always work out as planned--there are still days when I have to eat 3 gels to get through an hour of exercise!

When I first start a new exercise type, or increase volume and/or intensity of my current regimen, I will typically notice an increase in insulin sensitivity, as manifested by more frequent low blood sugar (unless I catch on early and adjust my basal rates).  This can be significant, especially initially; over a few weeks, the effect seems to be reduced, although I will still be more insulin sensitive than prior to the change in exercise (up to a point).  I remember, when I first started doing triathlon, I had a couple hours in the afternoon where I had to shut my pump off.  My body adapted to the changes and the effect did not last for more than a week or so; but still, I had an overall, significant decrease in my daily insulin dose that persisted.  I had been running 6 days/week for years so initially, at least, it was primarily the change in exercise type that was responsible for the effect.

When this effect diminishes and my insulin needs increase a little, I see it as a sign that my body is becoming more efficient at the exercise and that my fitness is improving.  Or maybe it's just time to take it up a notch again.

bike class at the beginning
I regularly attend a bike class that has efforts mainly in my upper power zones, equivalent in intensity to a track workout for running.  It takes a lot of focus to keep my intensity high because, basically, it hurts.  I have been watching my CGM during class to see what types of intervals cause my glucose levels to rise or fall.  Today's workout called for a five-minute warmup followed by isolated leg drills. We then moved into two five-minute high cadence intervals, following by two sets of six minutes at low cadence followed by a minute rest and then six minutes at high cadence.  These were all hard efforts and I tried to push it as hard as I could.  I came into the class right around 100 mg/dL and held off on eating anything. For the first half-hour, things remained steady.  I expected to see a rise after the two high cadence intervals, but it remained steady.  However, about 10 minutes later, there was a slight increase, which is the first bump you can see on the CGM display.  This came back down somewhat and I remained in a good zone throughout the class.  The high cadence intervals feel a lot harder to me; it takes much more determination to stay at 115 RPM for six minutes for me to do the equivalent Watts at 65 RPM.  For me to have the same heart rate at 65 RPM, I can increase my Watts by about 30.  This may explain my general observation that the high cadence intervals stimulate a greater blood sugar increase than the low cadence intervals.  Perhaps, today, the alternating high then low cadence intervals kept things more steady.  I need more data and translating this to the road may not be totally straightforward.  But I will add that the only bike race where I have had low blood sugar was the hill climb at Kern County Women's Stage Race.  (Of course, the hill climb being the second race of the day muddies the waters a little.)

Oh and now you can see, perhaps, why I want to have the power meter (and/or other fitness devices) and CGM all integrated.  I won't go off on another rant right now since I already took care of that here!

And one more thing: I think this stuff also applies to athletes without diabetes.  I am surprised that people haven't started using these tools to refine athletic performance.  Seriously, people pay big bucks to save 10 grams on their wheel, which is absolutely meaningless if you don't fuel properly and get sub-optimal blood sugar during a race.  It is really hard to nail down blood sugar levels unless you actually measure them.  (For example, I have bonked with normal blood sugar.)  And as luck would have it, there are plenty of tools to do so.  I would love to see some top athletes show their data during races, for example. Bueller? Bueller? Anyone?

Addendum: I'd like to add a reminder that exercise can of course cause a drop in blood glucose, which can become life-threatening if treatment (i.e., a carbohydrate source or glucagon) is not available.  I almost always have at least 50-75 g of fast-acting carbs with me, and more if I am exercising >1 hour or somewhere without quick access to a store etc. And I always bring along the CGM and/or BG meter.  (I rely on the CGM alone for workouts <2-3 hours, but will bring the meter as well if I'm going longer.)  Don't make fun of the bulging pockets on my jersey!

Wednesday, January 12, 2011

A Few Requests (Short of a Cure)

"I'm melting!"
When I was in college, two days before my first marathon, I capsized while sailing in the Charles River.  I blame my "date" who told me he sailed every summer growing up.  That seemed likely until he pulled the sail in tight, and didn't then release it when we were jibing in a strong wind.  End of story.  The boat house folks sent out a canoe for the sailboat but nothing for us.  After swimming to shore, I pulled out my pump, securely water-proofed in a few ziplocs, held it up and watched the water drain onto the ground. Oh no.  For my first marathon, I was back on injections for the first time in more than a year.  After then, I would have dreams where I was swimming or otherwise submersed in water and I would be holding the pump above the water, frantic that it might get wet. I felt like one of the witches in Oz.  Once I finally was able to switch to a waterproof pump, those dreams went away.  The development of water-proof insulin pumps is one of the advances that has made a significant, positive impact on my life--not just in getting rid of my pump-drowning dreams, but allowing me to stay connected during years of swimming and competing in triathlon.  And I'm no longer afraid of the rain.

But wait.  I have more requests.  Short of a cure, here are a few things on my diabetes wish list:

1) Blood insulin meter.  Let's say it's been 2 hours since my injection and I'm about to go exercise.  Wouldn't it be handy to just be able to know how much insulin is really still active?  Or how about when my blood sugar is 400 and I take a huge bolus to correct and two hours later I'm still at 400.  What happened to all that insulin?  Is it just hanging out, waiting to crush me later?  How could I know? Bolus up, maybe do a super bolus, and hope for the best!  Or be conservative and watch the BG hover up there for hours.  I imagine the metabolism of insulin varies a lot depending on many factors but no one really seems to discuss this much, probably because we (as patients) have no way to measure it.  And what about being able to pinpoint that the infusion site is bad vs I am coming down with a cold or maybe that day off from exercise is affecting me more than I expected.  So many variables! This could help significantly to cut down on the guesswork.

2) Stable glucagon in a pen delivery device.  One of those glucagon kits is $100 and can't really be used more than once according to enclosed instructions.  Sure it's easy to eat food and doesn't require an injection.  But seriously, I don't care about injections.  Those pen injectors are pretty slick.  What I want is good glucose control and to not have to eat 500 calories in a day to treat a low.  I don't want to go drink some soda after I overestimated the carbs in a filling meal.  I just don't want to HAVE to eat.  Especially after I just brushed my teeth for the 3rd time. Maybe it sounds petty to some people but I just wish I didn't have to make food and carbs such a focus of my life.  Let me introduce a little distance between food as nourishment and food as the thing that makes all my crappy feelings (i.e., hypoglycemia) go away.

3) Data integration with non-diabetes devices. FREE THE DATA!  Free it! Do it! Do it now!! Hey diabetes technology people!  Hey FDA! Design your devices so they are safe but let us capture the data in a way that we can use how we want!  I am not a moron!  This is perhaps the thing that drives me the most nuts.  There is absolutely no reason technology-wise that the continuous glucose meter data, for example, should be restricted from streaming to my iPhone or workout device. Arghhh! I have to stop writing about it because it is so incredibly frustrating.  I know there is a lot of work on this but there shouldn't have to be any.  Free the data and people will design apps.  FDA are you listening?!

Okay, those three things are probably enough for now.  If the list is too daunting, let's just get that cure all sorted out. Thanks!