Update!

Over the past 7-8 months, riding my bike daily has taken on a new meaning--mostly because I have been riding for two!  My husband and I found out in mid-January that we were expecting our first child together this September 21st.  I have to add, that September 21 (1988) is also the date I was diagnosed with diabetes.  I guess I needed to have a happier occasion to celebrate on this day (aside from the fact that it also my wonderful aunt-in-law Ceil's birthday on this date!).  It has been quite an adventure--I have written more about it on my previously super secret blog here.  Eventually I will wrap that blog into this one; I started it as a private blog when I wasn't ready to spill the beans quite yet, but still wanted to share with my family and to keep a journal of sorts.

I recently was in a bike accident that has put my riding on hold until after the baby is born, when surely I will have all the time and energy to get back out there, right? right?  Anyway, that's the plan; I may start out with the jogging stroller first.  If I had to say one thing I have learned being pregnant with type 1 diabetes, it is that I can actually keep my BGs in a much tighter range than I ever thought was possible.  And the second lesson would be that pregnancy does crazy things to a woman's metabolism!

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!

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.

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!

Research News Flash: Gleevec and Sutent

Thanks to Peter Nerothin and Kerri Morrone Sparling for the tip-off. An article published in the December 2, 2008 PNAS journal (with early release today) showed that 2 leukemia drugs--imatinib (Gleevec) and sunitinib (Sutent)--had potent effects in preventing and reversing new-onset diabetes in NOD mice. Of course it hasn't been shown to work in people yet, but this does seem like a very exciting development, in particular because Gleevec and Sutent are already FDA-approved drugs. Another exciting finding was that one course of treatment (albeit a 10-week course) had long-lasting effects, suggesting that the drugs had a modulatory effect on the immune system--not just a more temporary, suppressive one.

I went to an informative talk today on the cell/molecular biology of diabetes and routes to a cure, given by Jeff Bluestone and Steve Gitelman of UCSF. I missed the first part of it so perhaps they discussed it then, but it seems like perhaps they didn't want to spill the beans. Dr. Bluestone was quoted in related news stories and is one of the main authors.

I am optimistic about the state of research, but will make sure to keep stocked up on insulin and test strips for the foreseeable future.

Jen Alexander Swimming Northumberland Strait Today

Cheer on Jen Alexander as she swims the Northumberland Strait today. Her plan, according to a quick email this morning, is to swim from Prince Edward Island to New Brunswick and then to Nova Scotia. Wish her warm thoughts, calm water, and clear skies! You can follow along at her blog or track her real-time at her Britech site. Also give her cell phone a call if you have the number, and they will post your name on a board that she will see every now and then. Go Jen!

Rather, Don't Be an Underweight Type 1

I am glad to read a bit more on the study here. I was happy to read that this report states that there was no difference in mortality rates between normal weight and overweight subjects. Also, the study participants were all diagnosed between 1950 and 1980 so had been through many years of managing diabetes without many of the improved tools we have today. I also wonder what the quality of life and ease of control etc. was for people at different weights. Too bad I couldn't go to the conference and hear the talk myself. Did anyone else catch it?

An excerpt:

"'Although weight gain in adulthood is typically associated with increased mortality, this may not be the case for those with Type 1 diabetes,' said Trevor Orchard, professor of epidemiology at the University of Pittsburgh Graduate School of Public Health, in a release.

'Gaining a reasonable amount of weight may be a sign patients are getting enough insulin and appropriately controlling their disease, which may partly explain why those who gained weight over time had lower mortality rates.'

The study also found that those participants with a normal BMI of between 20 and 25 and those with a BMI in the overweight range (25 to 30) had no differences in mortality.

However, participants who had an underweight BMI of less than 20 were much more likely to die prematurely.

The researchers caution that gaining weight with Type 1 diabetes is not advised as a protective measure, but they feel the findings cast a new light on weight recommendations for people with the disease.

The study was presented Friday at the 68th Scientific Sessions of the American Diabetes Association in San Francisco."

Weight Gain May Be Beneficial in Type 1 Diabetes

The authors of this study presented at the ADA Scientific Sessions found that some weight gain in type 1 diabetes reduced mortality. I would like to check out this study to see if those who gained some weight had a better A1c, since keeping blood sugars lower increases episodes of hypoglycemia, and those little Junior Juices sure do add up. Here's an excerpt from the ScienceDaily.com report: "Gaining body fat may be a good thing, at least for people with type 1 diabetes, say researchers at the University of Pittsburgh Graduate School of Public Health. Their study, being presented at the 68th Scientific Sessions of the American Diabetes Association in San Francisco, followed 655 patients with type 1 diabetes for 20 years and found that patients who gained weight over time were less likely to die." I still want to get my weight down for personal competitive reasons (i.e., I can run and cycle faster at a lower weight), but perhaps I should not be overly concerned about it for health reasons. I guess it probably depends on what is causing the weight gain. Does anyone have the skinny on this study? :)