Anyone still here? Control IQ and exercise (part 1)

Hi. It's been awhile. Do people still read blogs? (I think I know the answer.) A lot has happened since I last wrote here, but I thought I would drop in to say that I am currently using a Tandem tslim:X2 pump with the Dexcom G6 CGM and the Tandem Control IQ ("CIQ") algorithm. I have been playing around a lot with the exercise mode and cycling and am finally getting something to work well. It took a lot of trial and error, and I got some really great help from some Facebook groups; but otherwise I felt like I was on my own figuring this out. Hopefully others can skip ahead past some of the stuff I tried. (Mostly, using my regular profiles in exercise mode did not work well for me for any exercise over an hour.)

I generally bike a minimum of 90 minutes nearly every day and have been on rides recently up to about 7 hours. The intensity varies quite a bit since I am sometimes working on intervals, often climbing and also often descending back down those climbs. My goal is to use the exercise mode with no lows or near lows, no serious or prolonged highs, and the ability to fuel my exercise rather than my blood sugar.

**Note! I am not a doctor! While I feel confident adjusting my pump settings, and my endocrinologist has basically said, "Why are you asking me? You know how to figure it out," please do not interpret this post as medical or insulin dosing advice. Check in with your doctor, please.**

The short story is that I created a cycling profile with sensitivity factors 2.5 to 3.5 times my normal settings, increasing every hour or two over a period of about 6 hours. So, for example, instead of 1:55, I am using 1:170 for the first hour. My basal rates stay about the same initially, since I tend to spike during the first hour, and then taper every hour or two. I can then allow the CIQ algorithm to automatically adjust basals and give correction boluses without messing around with it too much, but also eat when I need to. Initially I was taking a small 0.05 unit bolus to prevent CIQ from auto-bolusing, but this is hard to remember to do for longer rides, and I do want to be able to prevent highs as well. I turn on the profile and exercise mode right before I head out, because I also eat a small snack (about 11 g carbs) and tend to go high in the first hour.

I have modified my on-bike food to include foods with a bit of protein and fat, but still pack a ton of gels to bring me out of lows should I encounter them. FWIW if I ever get a hunger pang during a ride, it almost always is a precursor to falling BGs.

A recent ride beginning 6 AM and ending around 11. I ate about 100 cals/hour. Ride included 3 50-minute mountain climbs.

Twenty-Five Years

Twenty-five years ago, today, I was pulled from my gym class in my freshman year of high school for a trip to the hospital that would quickly result in a diagnosis of type 1 diabetes.  I had recently turned 14 and had been noticing some of the signs.  I even joked with my best friend Libby that I "must have diabetes or something" because of my unquenchable thirst and frequent trips to the bathroom.  One night after a pizza party, I stepped on the scale and noticed that I weighed less than before dinner.  In youthful optimism and a sign of some probably unhealthy thinking about body image, I was excited about the weight loss and had bought a bunch of new school clothes for my too-skinny body.  My dad, who was diagnosed with type 1 diabetes as an adult, had tested my blood glucose the night before.  Somehow my parents shielded me from the worry that must have hit them hard at the high reading; or perhaps they were hoping against hope that it was somehow a fluke.  When I asked the nurse at the hospital, "Do I have diabetes?" she looked at me in some surprise and said something to the effect of "Yes, of course."  Oh.

I received the necessary education and tools and had the support of my dad and the rest of my family and my pediatrician to get my blood sugars better regulated.  I recall not being able to read at first as my eyes adjusted to the normal blood sugars, and asking my 9th grade English teacher (Mrs. Bills) if I could eat a snack during her class.  One time, I told a surprisingly gullible friend that my blood glucose meter lancet was a brain scanner: "you just run it over your head like this." In what I view as a positive point of reflection, I do not recall diabetes playing a major role in my life during the rest of high school.  Perhaps I had a longer honeymoon period?  Or the super-rigid schedule I lived by helped keep things smoother?  I view this time as the easiest period I have had in my life with diabetes.  I joined the cross country team, participated in band and orchestra, continued piano lessons and did well at my academics.  But my diabetes regimen did mean that I never slept in on weekends, and had to arrange special accommodations if I ever wanted to eat dinner at a party that started later than my regular meal time.  And at that time, I absolutely never ate candy or desserts except for perhaps angel food cake on my birthday or to treat a low blood sugar.  I remember saying, "When I am cured, I will eat a doughnut."

I was fortunate to be surrounded by family and friends who did not once question my ability to do whatever I set out to do, whether that was to study hard for school, ride my bike around town or join the cross country team.  I imagine there were some harder moments that I have since forgotten; but overall, I felt like I was doing okay with life.  In the more than 20 years since that time, I have had my ups and downs with diabetes, and it has made for some good stories and some very magical moments.  While having diabetes has certainly made life more difficult in many ways, I am grateful especially for the wonderful people I have met as a result, and the many insights I have been given into my own body. Also I believe that in many ways I may be healthier because of the early focus diabetes brought on my health; for one, I realized right away the positive impact exercise had on my diabetes management, and was more dedicated and consistent with it as a result.  This was actually a gift that I have carried with me throughout my life so far.  Here's hoping to at least another two big twenty-five year milestones down the road.  And I'd like to extend a heartfelt "thank you" to the many friends and family members who have been a source of strength and support to me over these past 25 years.

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!

Lost Bones Reunited! (Hopefully)

Ten weeks after my bike crash in February 2009, I wrote with optimism that my left clavicle fracture was beginning to heal.  And for the most part, the pain subsided over time.  Later in 2009, I was able to complete the 206-mile cycling race, Lotoja, and also Ironman Arizona; although, there were lingering issues with my back strength and upper arm strength, especially on my left side.  Also, I still experienced a sort of searing pain, like the pain a tearing muscle might inflict, in my upper left arm with certain reaching movements.  The pain became worse after I fractured my right clavicle in May 2010 and had to rely on my left arm while that healed.  From the medical imaging, it became clear that the left clavicle fracture had never healed; and after months of PT and ruling out shoulder joint problems (cortisone injection, MR arthrogram, etc.), the orthopedic surgeon determined that the most likely cause of my continued searing upper arm pain was this "non-union" fracture.  Surgery was scheduled for October 24, 2011, approaching 3 years after the original injury.

The surgical plan was to scrape off the substantial hypertrophic (i.e., overgrown) bone growth at the bone edges and to use that material as a sort of grout between the fractured bone ends.  The bone would be properly realigned and then secured with a plate and several screws.  Aside from some pretty unpleasant complications from the general anesthesia and pain meds, the surgery and immediate recovery went smoothly.  The surgeon was unable to remove all of the hypertrophic growth from underneath the clavicle because of the proximity to major blood vessels; but otherwise, things went as planned.  Currently, there is some skin tenderness on the surface of the plate, and it is still too soon to know whether the pain is resolved.  But so far I feel hopeful that it will be better than before.  If the plate bugs me, there is an option to have it removed once the bone has completely healed.

Six weeks post injury; hypertrophy of bone has not occurred yet. (Xray March 16, 2009)

About six weeks post surgery. There is one longer screw to insert into the hypertrophic bone that couldn't be removed.  A healed fracture from 2009 is visible in the 3rd rib down, (Xray 12/6/2011)

What I didn't anticipate about this is that, although planned, the surgery was essentially the same as re-fracturing the clavicle and required a recovery period just as long.  So, I am yet again facing another period of regaining fitness lost to injury.  Of course, I am grateful that I was able to have the repair and the pain was substantially less (not even comparable, really) to the original injury.

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.

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 streets....er, sidewalks.

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!

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!

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

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!