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.

What I Wish People Knew About Diabetes

Part of the joy of attending events such as a JDRF ride or a triathlon with Triabetes is being surrounded by people who really "get it" with respect to having type 1 diabetes and trying to live a full and active life.  I have also been fortunate to have many close friends and family members without diabetes who have taken time to learn and have been patient as I rambled on about my experiences managing my diabetes.  In my mind, I carry a little corner of worry--or perhaps "attention" is a better word, depending on the circumstances--about my blood sugar and insulin levels and how they are changing, and how they might be affected by anything else happening.  For example, I may be running, watching my blood sugar falling and thinking, "Hmm, can I beat this or am I going to have to eat something before I finish up in 15 minutes?"  Or maybe on a long bike ride I may see my blood sugar rising and wonder whether that half-of-a-unit will be enough or should I risk having to eat more later or getting a low blood sugar because I treated it more aggressively.  Being able to share these moments with a friend who understands, or is willing to learn how to understand, eases my worry.  Knowing that there is at least one other person nearby who understands what it might mean for me to see "42" on my meter helps me to feel so much less vulnerable.  When I was in a crash at a criterium in February, 2009, the medical staff person (thank you Katherine H!) for the race came over and said that she was a nurse and experienced with diabetes; a wave of relief passed through me.  "My blood sugar was 250 before the race and now my pump is broken! I'm on Humalog!" She knew exactly why I was worried and was able to find my meter for me and communicate my concerns to the EMTs.  This was a tremendous comfort to me during a truly frightening and painful experience.

What do I wish people knew about diabetes? Honestly, there is so much to learn and so many other diseases and medical conditions that people may need to focus on in their own lives, that I wouldn't expect anyone to become an expert on diabetes unless it were required of them or else they had a particular interest.  I would hope that people are aware of the signs & symptoms of both type 1 and type 2 diabetes, since delaying a proper diagnosis can lead to a great deal of unnecessary suffering.  Also, there is a type of diabetes called "1.5" or LADA, which presents more like type 2 but which is actually a slow-onset version of type 1 (and is often misdiagnosed).  I wish more people appreciated the dramatic effect of exercise and diet on their metabolism and worked to prevent the onset of type 2 as much as possible.  Diabetes is no joke.  Still, I think it is unhelpful to make assumptions about either type 1 or type 2 diabetes unless one has already gained some actual fact-based knowledge on the topics, and met quite a number of people who actually have type 1 or type 2 diabetes.

But if you happen to be a friend of a person with diabetes (and I will focus on type 1, since that is my area of expertise, so to speak), and want to be someone who "gets it," here are a few starting points:

1)  Type 1 diabetes does not have a cure, although there are a lot of exciting lines of research.  I am 100% uninterested in anyone claiming to have an "unknown" or "magic" cure.  Really, once it is found, I am sure it will not be a secret for long.  I will take insulin until a cure is found.  Although changing my diet and exercising will affect the way I manage diabetes, it does not cure me of it.  Type 1 diabetes is caused by an auto-immune process that seems to be triggered by something environmental.  The exact cause is unknown.  Although it is more common in kids and young adults, it can occur at any age.

2)  Insulin is a hormone made in the pancreas by the beta cells.  In type 1 diabetes, the beta cells get destroyed and the insulin must be replaced through injections (via an insulin pump, syringes, or pens).  Insulin is required 24 hours per day, even when fasting.  I take a background rate of insulin ("basal rate") to cover basic metabolic needs, and take a "bolus" (like an injection) when I eat anything with carbohydrates.  High fat and/or protein foods also require insulin over longer time period.  Food gets converted into glucose (in varying proportions) which eventually enters the bloodstream, causing a rise in the blood glucose level.  Insulin lowers the glucose concentration in the blood by facilitating transport into fat and muscle cells.  

4)  Although the normal blood glucose for someone without diabetes is typically 70-90 mg/dL and temporarily a bit higher after a meal, my blood sugar can be anywhere.  If you ask me what my "normal" blood sugar is, I might give you a blank stare.  I try to keep it above 70 and otherwise as low as possible given the situation; I guess my target is around 110.  When I am exercising I will usually keep it a bit higher, since it can fall very quickly.  I have had readings below 20 and above 600, otherwise known as "LO" and "HI" on the blood glucose meter.  It can fall and rise really fast; but sometimes it can take forever to budge.  Low blood sugar makes me feel really weak and also scared, if it is quite low.  I am still able to communicate (this is not universal) but I may speak slower and act a little dazed.  I really hate having low blood sugar.  High blood sugar can make me sleepy and/or moody and it sometimes feels like a mild stomach flu.  I get thirsty and can become dehydrated more easily.  Sometimes my arms will cramp.  Things that lower my blood glucose include: insulin, exercise, not enough food.  Things that can raise my blood glucose include: food, stress & anxiety, exercise, too little insulin.  These are not the complete lists.  On my pump, I have different basal rates for the different times of day.  I also take a certain amount of insulin in response to the amount of carbohydrates in a meal and another amount to correct for a high blood sugar.

5)  Exercise can lower or raise my blood sugar in the moment.  In the long run, the increased insulin sensitivity due to exercise makes it easier for me to alter my blood sugar and allows me to take less insulin overall.  During exercise, I am exquisitely sensitive to insulin.  For example, I may take 3 units for 45 grams of carbohydrate normally; but when exercising, I might just take 0.5 unit.  Frequently, I may not even take any insulin at all, other than my ongoing basal rate.  Stopping for too long to eat in the middle of an exercise session can make it difficult, because then I will either need to bolus for the food or will watch my blood sugar start to climb.  If I take a normal bolus, and then start exercising again, all the insulin in my body becomes supercharged and my blood sugar may come crashing down.  Then I have to eat more, which is really annoying to me, or I will have to stop, which is even more frustrating.  I could compromise and take a partial bolus and this is often what I do.  But there is a bit of uncertainty about how much to take and then all I get to think about for the next couple hours is whether my blood sugar is going to crash.  This is why I may get eager to get going again; really, I can relax!

6)  I plan my insulin and meals around my exercise.  If there is a big change in schedule, this can make it more difficult.  I may have changed my insulin dosages in anticipation of a race or workout start time.  If there is a big change, then I will need to compensate for that.  This could require me to eat 2-3 extra GUs to get through a run (boo!) or could result in a super high blood sugar for the first hour of a bike race.  I realize changes happen and try to be flexible. 

7)  Please don't ditch me if I have to stop to test my blood sugar.  I usually try to test when people are stopped for some other reason.  I don't get bothered by most things, but getting left behind on a ride because I needed 45 seconds to check my blood sugar makes me want to cry.  Fortunately this rarely happens anyway, and having a continuous glucose meter means I just have to pull it out and take a look.

8)  If you find yourself surrounded by some PWD (people with diabetes), just throw out the question, "What's the fastest way to raise a low blood sugar?" and you will keep the conversation going for at least 10 minutes.  In general, simple carbs without fat or protein absorb quickest and are best for treating low blood sugar.  How much I need to eat depends on how much insulin I have in my system, how fast I may still be dropping (i.e., how fast my blood glucose is dropping), if I am exercising or planning to exercise, if I ate something else already, etc.  I try to carry enough sugar to feed 100 hypoglycemic PWD but if a friend happens to carry a spare GU, that certainly could come in handy.  Foods that help me bring up a low blood sugar include: glucose tablets, Skittles, Smarties, juice, milk, energy gels (like GU), soda, honey (but eat carefully--I seriously choked once eating honey too fast during a low), corn syrup, etc.  Foods I wouldn't target but could bring up my blood sugar more slowly include: bread, fruit such as apples/bananas, candy with a lot of fat, granola bars, crackers, cake.  Foods that won't help include: pure protein (steak, chicken, cheese, eggs, etc.), nuts, non-starchy vegetables, lard (hey just seeing if anyone is actually reading this).

Well, I could go on but anyone reading this probably either knows this stuff already or is now completely overloaded.  Perhaps most importantly, what I would like people to know is that I and most people with diabetes are always willing to answer questions, as much as you are interested.  Personally, I don't expect people to know too much about the particulars, just as I don't know the ins and outs of most other chronic diseases.  So if a friend says, "Hey does insulin cause your blood sugar to go up or down?" I am not thinking, "What a dufus!"  I am sincerely glad to explain it because your just asking about it makes me feel more supported.  And I believe that PWD have insights gained through their unique window on their own metabolism that can be enlightening to anyone, with or without diabetes.  Finally, I believe that as the incidence of diabetes continues to increase, PWD who have observed the dramatic changes in metabolism related to insulin, exercise and diet are in a unique position to support efforts to prevent type 2 and to help people improve their management of both type 1 and type 2 diabetes.

(See other blog posts addressing this diabetes blog day topic.

I was supposed to just name 6 things but I got a little carried away. Oops.)

Velodrome Crash: the Long Story

I had been interested in racing the track for a while, but didn't have the confidence to try it out.  After a clinic last December, another 2-day clinic about a month ago, and then a great workout session the night before, I felt comfortable racing at the Hellyer Velodrome's “Get Ready for Summer” races on Saturday, May 29, 2010.  We would have our own women's category 4 field, rather than race with the guys.  The first race was a tempo race, with points given each lap for the 12 laps.  I think I came in first or maybe second for a couple laps, and I ended up placing third overall.  Our next race was a 12-lap scratch race, which is like a criterium in that the winner is determined by who finishes the whole thing first.

I'm #519 in red. photo by Steve Woo

Throughout the race, I felt like people were squeezing the group somewhat down track (i.e., towards the inside); for me to move around I would go up and around and advance.  I realized partway through that I did not feel comfortable advancing my position, and settled somewhere towards the back, looking for a good opportunity.  With three laps to go, I was in the sprinter's lane (the innermost lane on the track) behind a line of riders.  We were approaching turn three.  I have a few seconds of memory lapse here but the next thing I recall is riding on the apron pavement towards the warmup circle (in the infield area) and seeing someone down immediately in front of me.  I had nowhere to go.  It was a déjà vu moment from last year as I flew over my handlebars and hit the ground.  Stars flashed and I came to a stop, sitting up.  I assessed the situation and immediately felt relief--no great pain.  Maybe I wasn't that hurt.  But moving a little, I was certain my right collarbone was broken.  I felt angry, mostly, and was pretty quiet.  I noticed some blood trickling down my face and people were coming over.  It was very sunny, bright and hot sitting there on the black asphalt.

People began helping me while we waited for the ambulance.  The initial numbing shock started to wear off and I could feel the pain increasing, mostly in my shoulder.  Since I couldn't lie down, and I had hit my head, a friend stabilized my neck while I sat.  It was quite a while, so thank you, Evan. I felt bleeding in my pelvic area and thought for sure there must be blood gushing.  Once the paramedics arrived, I heard the words "dislocated" and "deformed" with regard to my shoulder, and was not amused.  The thought of someone pulling my arm to put it back in place was horrifying.  They were good about not forcing a certain position and got me on the spine board (yeah, here we go again) and into the ambulance.  I asked for morphine since last year I didn't get pain medication quickly enough.  The paramedic continued asking me questions and I felt sleepy but he didn't want me sleeping, I guess.  I felt like I was still bleeding in my pelvic area and mentioned it again.  But the bleeding was internal; the paramedic put an ice pack there and also one on my shoulder, which brought some relief.  I was most impressed that he was able to start an IV while the ambulance was moving without jabbing me all over.

I arrived at the Regional Medical Center San Jose, the closest trauma center, and things got busy.  I was very happy to see two good friends, Rita and Amy, waiting there for me.  The ER staff did some Xrays and other exams and cut off my favorite bib shorts and team jersey.  It wasn't until we were there for some time that they noticed a puncture wound on my shoulder, and soon discovered that the clavicle fracture was open, meaning that it had broken through the skin.  This has been my nightmare and the ultimate in bad injuries! Ahhh!  The surgeon came in and numbed it, thinking he could perhaps set it in the ER.  I felt and heard him tapping on the bone (ugh!) but at least it didn't hurt.  It became clear that surgery would be required.  Later I learned that the clavicle had fractured, completely shredding the ligaments attached to the scapula below, and piercing through the trapezius muscle and out through the skin.  Somehow it had also retracted back in a bit; so there wasn’t a huge piece of bone sticking out, at least.

 Waiting for the results to come in, I was still 

unaware of the compound fracture.

I was scheduled for surgery as soon as possible, the next morning.  They admitted me from the ER and put me on morphine to help with the pain.  I was nervous about the surgery but was comforted by the company of good friends.  They wheeled me to the OR where the surgeon explained his plan to repair the torn ligaments and to stabilize the fracture using a surgical device called a "tight rope."  Also, the anesthesiologist and I discussed diabetes management; he was interested in my Dexcom CGM, which he kept with him during the surgery. The next thing I remember was waking up with severe pain in my shoulder.  I was in a daze the rest of the day and would briefly see my friend Rita every now and then when I woke up.  Thanks for staying with me all day.  After some physical therapy to get me moving a little the next day, Monday, I was ready to go home.  I wanted to get back to San Francisco; if I needed further medical care, I preferred to go to my regular doctor.  Also, it was so hot in that hospital that I was constantly sweating and uncomfortable.  My friend June from my bike team stopped by after the Memorial Day Crit and graciously offered to wait for me to be discharged and to drive me home.  I was still a bit dizzy and unstable walking around but the medical staff seemed to feel it was okay to leave.  I noticed some pain in my right calf that I hadn't felt before.

 Before surgery

 After surgery: the two metal "buttons" connect the clavicle and 
corocoid process via "rope" and constitute the "tight rope."

I was glad to be home and was comforted by my having my roommate Radhika there.  Sleeping was still difficult and I woke up that night around 1:30 AM, a bit uncomfortable, but fell asleep again.  I had some weird dreams including one where I was outside in a storm at my parents' home in Utah, watching lightning strike uncomfortably close.  I thought that I might get struck and then a thick bolt, covered with burning embers, struck my parents' house, causing it to burst into flames.  Then the lightning came my way, striking me and throwing me down into a dark pit, where I was burned up.  Lovely!  I'm so lucky! I woke up at that point to severe pain in my right side.  It was around 4:30 AM and I was disappointed I hadn't slept more.  I thought I must have jammed my arm into my side or something--that the pain was just from sleeping in a bad position.  After standing up and walking around a bit, the pain started to subside.  Still, when I would try to lie down again, the pain would return.  Last year, the rib and L2 fracture diagnoses took about a week to come in, so I assumed I had just broken a rib that was somehow missed on Xray.  Or maybe somehow my side was slightly injured and my sleeping position further injured it.  I did sleep again for a bit and after that, I couldn't find any comfortable position.  I noticed that the pain in my side was completely eclipsing my collarbone pain.

A good cycling friend (and nurse!), Cheryl, came that morning to help me and stayed for quite some time; I was so grateful for her company and help.  I was feeling anxious about being home alone with this pain and was still somewhat lightheaded and unstable at times.  I was so happy to finally be able to shower and was put at ease to have her there. Throughout the day, the pain would get worse and then subside again.  My doctor felt like the trauma center most likely did not miss a rib fracture and helped me to get a new prescription for pain medication.  In the afternoon, a case worker from my health plan called; she was in the process of transferring my medical records from the trauma center, including my radiology images.  She asked how I was doing and I told her about the pain, that it was a "10 out of 10" when I tried to breathe deeply.  Basically, I could not breathe normally at all. It felt just like a broken rib. She recommended that if it did not improve with the vicodin, that I head to the ER.  I took another vicodin and the pain did improve somewhat.  But by about 4 PM when my friend Colleen arrived to visit, I felt like it was time to go in.  I was mostly worried that my shallow breathing would cause my blood oxygen levels to drop and that that might put any brain injury (if I had one) at greater risk.  I was still pretty sure I had a rib fracture--the pain felt very sharp and was consistent with where I fell.

Colleen braved the insanely steep ER driveway in her stick shift car and dropped me off.  I was becoming somewhat hysterical because I felt like something was really wrong but I hadn't been able to find an answer.  I had tried to get in touch with someone--anyone--to review my Xrays from the trauma center.  I knew I would not be able to sleep with this pain.  And I was becoming short of breath and very uncomfortable breathing.  I was seen very quickly (for an ER) and they started doing tests.  Let me tell you--if you have to be in an ER, Colleen is someone you want with you.  She had an uncanny way of making me laugh and relax and I was grateful for her company.  They did the chest Xrays and didn't find any broken ribs, and also started some blood work.  At the last moment, the attending doctor said he would run the D-dimer test to check for blood clots in my lungs.  He said that, due to my recent trauma and surgery, the test would likely come back as elevated, and that they would need to do a CT angiogram of my chest in that case.  He seemed to feel that it was unlikely that I would have clots, but that they would check it out anyway.

Well, the D-dimer test came back elevated. I asked, "How elevated is it?" and he responded that it is either elevated or not.  Oh.  I was hoping it would be like having a blood sugar of 150--a little high but not an emergency.  I was prepped for yet another CT exam and had the nasty, hot contrast injected as I held my breath.  The tech asked if I worked in radiology--I guess because I held still so well?  This is something I instruct people to do all the time so I guess I take it seriously when someone asks me to do it!  Back in the room, I waited with Colleen for the results.  I said, "I doubt it will show anything," and was not overly worried.  I didn't really know how serious blood clots were but they sounded bad.  After some time, a different doctor came to tell me the results.  She seemed serious when she said I had three small clots in my lungs.  I don't remember what else she told me but came to understand over the next hour that they would put me on heparin right away and that I would be admitted for treatment.  The nurse was having a difficult time getting the IV tubing set up and I was getting increasingly agitated as the doctor tried to explain again what was going on.  I asked if I would be okay and the only answer I got was, "It's good you came in."  Ugh.  They finally got the IV sorted out and injected a huge bolus of heparin.  My confidence was sort of shot with that particular nurse and I just hoped she was giving me the right amount.  Colleen was there and after the chaos calmed down, I started to relax a little.  Over the next hour or two, I could feel the pain lessening in my side with the heparin starting to work.  The IV heparin drip would continue for another day or so.

 I think the blood clot is that dark spot in the left wedge-like vessel. Get that?

I was moved to the telemonitoring floor where they would be watching my EKG constantly at the nursing station (in case I suddenly keeled over, I guess).  I was hooked up to the IV, the EKG leads/box, my insulin pump and had my Dexcom CGM handy.  Oh, and of course I had to keep my iPhone by my side.  It was impossible to move anywhere without dropping something.  I still can't find the clip for my pump so I have been carrying it everywhere.  I tried to see how low I could get my heart rate and was sort of disappointed it wouldn't go below 45.  I think I can get it to 42 when I am really rested.  I was hoping a 45 would set off some bradycardia alarm but alas, they were not concerned.  They frequently checked my blood pressure and temperature and regularly drew blood for lab tests.  Unfortunately, my veins were not happy and they had about a 30% success rate of finding one.  Most of the bruises have just disappeared.  They gave me pain medication when I asked, and I should have asked more frequently.   I was quickly breaking out in a rash all over due to some allergy and they decided it was probably from the morphine and/or vicodin.  I was not happy with the way vicodin was making my head feel, anyway, so we stopped the narcotics around noon on Wednesday.  Later, my doctor determined that the allergy was due to the IV cephalexin (antibiotic) I had post-op.

All throughout the day Wednesday, I had a stream of visitors who really kept my spirits up (and kept me distracted from worrying).  Those visits, flowers, calls and other help really meant so much to me.  Thank you, thank you.

I had an ultrasound exam to check for blood clots in my legs (negative) and a brain CT to check for possible brain injury, since a blood thinner could cause significant complications in that case.  I continued to feel sluggish in thinking and speaking, and since I work with people with brain disease and trauma, I know the signs all too well.  I was so worried.  At one point, the nurse said something that made me really scared and I called my mom and asked her to bump up her flight to that evening, instead of the next morning.  I think the comment, "I've had a patient die here from this," was not helpful.  I guess I wanted to know how serious it was; I think I would do better with statistics than a horror story, though.  After that, the doctor's suggestion that my prognosis was good didn't really stick well.

Thursday morning, I received the news that my brain CT was clear. I was feeling a little more clear-headed and was greatly relieved by these results.  The nurses had started me on a twice daily regimen of Lovenox shots on Wednesday, as well as coumadin.  The coumadin (i.e., warfarin) is a drug that interferes with blood clotting, and is the drug I will be taking for six months while the clots dissolve.  It takes a while to build up, so in the meantime, they wanted me on Lovenox as a backup.  Lovenox is a form of heparin that also works to block clotting.  The needles are huge and leave bruises that don't want to go away.  Since I was comfortable giving myself injections, I was sent home Thursday.  Thank you to Alissa for helping my mom with the flowers and for taking me home.

 Flowers from the hospital stays.

My INR, a measure of clotting time, was 1.5 when I left the hospital; they want me to be at 2-3 for the duration of my treatment.  I continued taking the Lovenox shots until the next Monday.  Since then, my INR levels have been 2.7, 2.3, 1.7, 1.4 and then 2.6.  I will continue going in for blood work a couple times a week until things stabilize better.  I have learned that the INR is affected by foods, exercise, sickness, stress, etc., which sure sounds like another fun drug that I get to take all the time (i.e., insulin).  But fortunately, there is a clinic with pharmacists who read my results and call me, telling me how much to take for the next few days.  I am looking forward to going in for blood work less often, since I'm getting weary of being poked in my arms.

As of now, the pain is gone except for my back and shoulder and occasional headaches.  The clavicle is healing well and I can already drive.  The road rash has mostly healed.  If it weren't for the blood clots, I could imagine being out on the road again in another week.  I am still easily fatigued, though, and don't want to ride until I am 100% confident of my upper body stability.  Although racing is completely out of the question, I have been told it is okay to ride my bike while taking coumadin, as long as I am extra careful.  But since I am always careful, I'm not sure what this will mean for me.  I was glad to connect with a few other athletes who have had blood clots and continued training to some degree while on coumadin.  Compared to last year, I am physically less injured.  But the clots present a different challenge that from here on out, seems more mental.  It has been hard.

I am so grateful to the many friends and family who stepped in to help me out, and for your continued support.  It would have been impossibly difficult without you.  Thank you.

Relaxing outside at Crissy Field.

Here are some additional pictures.  My mom tells me I should warn you that they could make some people queasy.  But I don't think they are so horrible.

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.

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.

Swim
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!

Bike
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!

Run
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)

Ironman Arizona...Here It Comes

This year has been one with many unexpected challenges, and I have never gone into a race with this much uncertainty. Because of a nagging IT band injury, I haven't been able to train as much as I would normally have done, especially with regards to running. As a result, I spent more time swimming; not only has this helped me to improve my stroke, but also I have come to enjoy swimming much more. Although my swim time probably won't be faster than last year, I am happy to be back to my pre-crash state (more or less). Because I have basically spent this whole year rehabbing, I do not want to set myself back in a major way. While some pain is to be expected in an Ironman, I am hoping I can know the line between enduring to the finish and risking permanent harm. At Lotoja in September, the left side of my back and shoulder became quite weak and my IT band really started to hurt after 150 miles or so. It might have been wise to stop at that point. Lately, I've been able to ride without pain most of the time and run without pain for about an hour. I feel that I should be okay on the bike, and we'll just have to see about the run. I know that seeing many friendly faces will buoy me along the way, and that I am not the only one who has faced extra challenges training this year.

But, more importantly, I am looking forward to once again being in the community of amazing people involved with Triabetes, from last year and this year. And maybe some new people will discover us and join us for future adventures. I can't wait to see the documentary and to meet up with my Triabuddy Elisa, and to visit with Ray & Nella (her parents). Their dedication in filming and producing this documentary is unrivaled and I know I share the gratitude of many for their efforts. Saturday is a celebration and Sunday will be a time to enjoy having so many friends and family members on the course while I enjoy my little "catered workout" in Arizona.

What Is Inspiration? My Triabuddy Elisa

The Triabuddies program of Triabetes has given me cause to reflect often over the past couple of years on what it means to be a positive influence. Each team captain is mentoring a young person with type 1 diabetes; this group of Triabuddies will go on a sailing trip together next week, and will meet us all race weekend in Tempe to share the Ironman experience. My joy in swimming, cycling and running is my primary motivation for doing the sport of triathlon. Secondly, I see the positive effect the training has not only on my health but also on my strength to carry on with my daily life. I expect myself to exercise regularly as much as I expect myself to eat, sleep and go to work. So, sometimes, I struggle with the notion that what we as athletes with diabetes do serves as an inspiration for others. It seems presumptuous. But with continued reflection, I remember key people from my younger years who stepped in with confidence in my possibilities and the subtle direction they have had on my life. Visiting a research lab with my mom’s friend, Shirley, added to my belief that it was a normal thing for a woman to be a scientist. My high school running coaches gave me the gift of a lifetime love of running by pushing me just enough, and never doubting my ability to run with diabetes. Many similar experiences have added up over the years, helping me to operate with the assumption that most personal roadblocks can be overcome with the right approach and enough work. (Okay, I am more cynical at times and of course I get discouraged but I do try to get back to this.)

So I guess what I hope to show my Triabuddy, Elisa, is something she already seems to grasp—that diabetes doesn’t have to stop her from living her dreams. In fact, I have sometimes wondered, “How can I help Elisa? She seems to already fully understand this.” I was impressed with my Triabuddy, Marissa, from last year, in the same way. These kids have innate determination and encouraging parents who give them confidence that they can succeed. But perhaps I can be one positive influence she can remember if she ever wonders if diabetes might be a reason to let a goal slip away. And maybe what I can offer Elisa is an understanding of diabetes—that, yes, you should go for your dreams, but when you have frustrating moments, I understand that, too. Just because you can “give it a shot” doesn’t mean that it is always easy. But you just keep going.

People who have been positive influences in my life have also made efforts to build relationships with me. This year, I have had the opportunity to visit occasionally with Elisa and enjoyed very much a recent phone interview with her. Her descriptions of her life unrelated to diabetes were refreshing, and reminded me of how I have tried to live with diabetes; sure, it’s there, and it requires my attention, but it is not the focus of my life. For other kids and parents out there, here is a summary of my interview with Elisa, a smart and athletic, nearly-11-year-old girl in fifth grade, who happens to have type 1 diabetes.

In school, Elisa recently enjoyed learning how to create circuits with batteries, wires and miniature light bulbs, and discovered how to make a bulb burn brighter by reconfiguring the circuit. (Can you do that?) Also, she enjoyed designing an island with her team of classmates. They named it “Birthday Island,” complete with Party Hat Forest and Ribbon River. In math class she is learning about lattices, which sounds pretty advanced to me. (I had to do a wikipedia search on that one.) A couple of her favorite musicians are Selena Gomez and Taylor Swift. Although she won’t be pinned down quite yet, her answer to the adult’s favorite question, “What do you want to do when you grow up?” was photography, which she enjoys, especially if it includes animals. Her favorite animals are lions and tigers.

Elisa recognizes kindness in others, and kind people—friends, family, and people she “doesn’t even know”—are the ones she admires most. If given the chance to meet a historical figure, she might choose Sacagawea. Some of the games she enjoys are Club Penguin, Pop Tropica, and videos on YouTube. She enjoys playing mid-field on the soccer team and prefers freestyle and breaststroke during swim season. Another favorite game is 4-square. (Yes! I’m glad some things are still around.) Not surprisingly, Elisa “would rather play than to watch.”

Having been on injections for years, Elisa took the brave step of starting on the Omnipod insulin pump in the summer of 2009. Regarding the change she said, “It is different…because you don’t have to take a shot whenever you are high [hyperglycemic] or have a snack. And you don’t have to change it for three days. It’s comfortable to me because I can barely feel it.” She feels like it is easy to bolus and knows how to use many of the pump’s programming features. She reports that her blood sugars have been very steady on the pump and that she likes it “way better than having to get shots.” Although she was scared at first that it might hurt, and says that sometimes it does hurt, she would advise others her age who were thinking about it that “it’s not a problem. You’ll get so used to it that it will feel like you don’t have to do anything anymore.” Her parents help her by telling her how many carbs are in her lunch, but overall she is able to be much more independent on the pump. I asked whether her friends knew about it and she replied, “They keep forgetting, and ask every week, ‘What is that thing?’” She has one friend who seems to remember, so she directs the others to her.

Next week, Elisa will embark on her own Ironman adventure of sorts as she joins the other Triabuddies for a sailing trip in California. She is excited for sailing but it will be a new challenge to be away from her home, dealing with highs and lows without her parents nearby. Her new friends in the Triabuddies program, as well as the staff, will be there to help her. I am proud of her for taking on this challenge and hope she can gain new confidence in her ability to manage diabetes while enjoying the sailing experience.

And of course, I was curious what Elisa thought about triathlons. Her reply was, “They’re difficult,” especially the long run (i.e., marathon) at the end. Someone, please take Elisa to a sprint triathlon! Her favorite part would be crossing the finish line.

In the end, I’m not sure who is inspiring whom with regards to the Tribuddies program. Without a doubt, knowing Elisa will be cheering me on during Ironman Arizona has kept me going this year throughout many physical and personal challenges. I can say with certainty that I would not be pulling on my wetsuit a week from Sunday without Elisa’s implicit support. Making it to the start line will be my biggest victory this time around. I will do my best during the race and however I finish, I look forward to celebrating our mutual growth and success this year and to sharing many more experiences in the years to come.

As a final note, if you are able to support Elisa on her Triabuddy trip, donations of any amount are still needed and welcomed here.

Blood Sugar Wrangling

For those who don't live with diabetes, here are some reminders:
basal rate = background insulin, usually fast-acting, delivered 24/7 by an insulin pump
bolus = equivalent of an injection of insulin, usually rapid-acting
CGM = continuous glucose monitor, which gives glucose readings every 1 to 5 minutes
BG = blood glucose, measured by a BG meter; aka "blood sugar." Normal is 70 to ~120 depending on various conditions. BG is affected by insulin concentration, stress, exercise, food, illness,...
insulin = hormone that facilitates movement of BG from blood to cells; fast-acting insulin starts working fairly quickly, peaks in about an hour or so, and sticks around for 3-4+ hours (for me). Exercise makes insulin much, much more potent.

The other night, I woke up around 1 AM feeling weak and hungry, as if I had low blood sugar. I checked and it was okay at 100. Not sure if my BG was rising or falling, since I am not, sadly, using a CGM right now, I ate half of a gel--about 10-15 g carbs--and went back to sleep. When I checked again before starting a morning swim, I was startled to see 279 on the meter. If anything, I have been waking up low in the morning recently since I significantly increased my basal rates. I was about to hop in the pool and figured leaving my basal rate at 100%, instead of reducing by 20-30%, plus skipping a pre-exercise snack, would help knock it down. Although I might typically give a little insulin to get things started, I decided to forgo it because of my elevated basal rate. I started my swim with a big set of 50's and felt thirsty and lethargic. I kept going, realizing that some days are better than others for a variety of reasons; still, I was having to work really hard to make intervals that were manageable the week before. After 45 minutes, I checked my BG, which had risen to a sticky 316. Ugh! No wonder I felt horrible. I gave a 1.2-unit bolus, drank some more water, and got back in the pool. A little disconcerted, I checked again about 20 minutes later and saw that I had already fallen to 262, and following my swim I had settled down to 122. There were many moments during the first half of this swim where I wanted to call it a day. While I am obviously a big fan of exercise, I do it for health benefits and for my enjoyment; it is not required to be an act of heroics! But sometimes, it sort of feels that way. Once I could see that my blood sugar was falling, I felt comfortable from past experience that things would improve. Throughout the day, I still felt off, and wonder if my probable prolonged overnight high BG had taken a toll.

My blood sugars were pretty oscillatory for the day and I had a late lunch/snack around 4 PM, requiring about 6 units of insulin, which is a lot considering my daily insulin is anywhere from 20 to 35 units. I was supposed to run after work, but had not been looking forward to it during the day. With my IT band troubles as of late, I haven't been able to really enjoy running, with each run ending in pain and frustration. Maybe I subconsciously ate late so I could use a massive bolus-on-board as an excuse? It's possible. For some reason, though, taking a lot of insulin made me feel a little better and I started to think that maybe I would run after all. So, about 45 minutes before I started running, I knocked my basal rate down by 90%, meaning I was basically taking little to no insulin. I didn't really think this would work, but had plenty of back-up GU handy. At 6:30, I started my run; I decided to run on the track in case I had to bail early. My BG was at about 120 and I decided I would just run and see how it fared. I just didn't want to eat more calories if I could help it. About 30 minutes into it, I had that sudden realization, "I'm low." I was at 74 and ate one gel and kept going. My blood sugar came back up nicely and I was able to finish my 50-minute run without any BG or IT band catastrophes.

In retrospect, it would have worked better to take a little insulin before my swim, and check partway through. If I needed to eat at that point, I could have. Also, during my run, I felt like it was likely that I would drop, so it might have been better to eat before I got started, rather than waiting until I was low. (Well, in the first place, it would have been better to not take 6 units of insulin that close to exercise.) In both cases, I was motivated by trying to avoid eating extra calories. I had to eat the calories anyway for the run, and getting my BG down sooner during my swim would have led to a more productive, healthier workout. And I was definitely hungry in the pool, so being able to eat a gel might have helped me swim stronger.

In the end, I was happy that I was able to get through both workouts, although the mental struggle in getting through them (and even starting them) was tough. I do love exercise, but that doesn't mean I love every workout. Anyway, Ironman Arizona is coming up quickly and at this point, each workout is key and will make a difference in how I feel race day. I am hoping that a little pain now will make race day a little less painful; I'd like to keep my focus on the wonderful experience of racing with my Triabetes team and watching out for my Triabuddy Elisa and other friends and family along the course!

Note: We're still short of our fundraising goal for the Triabetes documentary. Please click on the widget to the right or go here to donate a few bucks if you can. You can donate anonymously if you want by putting in an anonymous name on the first page. Note that Crazy Sea Lion has done just that.

Race Report: Lotoja 2009

Event: Lotoja (206-mi race from Logan, Utah, to Jackson, Wyoming)
Date: 9/12/2009
Weather: cool, pleasant in the morning; a little warm/hot midday and cooling considerably by the finish; moderate winds during first 2/3 of the ride during open stretches
Teammates present: raced with 4 other friends on our team, the "Part-time Models": Jane Bergeson, Rita Ogden, Erika Feinauer, and Kristan Warnick. Jerseys were donated by Jane's sister from Contender Bicycles. SAG by Contender plus some team friends/family.
Other teams present: various, mostly local teams
Category raced: women cat 4 in a mixed race with women cat 1/2/3
Goal: stay with the pack until at least Preston and finish the race before the 8:15 PM cutoff.

(Note: making it through this whole post is an endurance event, perhaps to reflect the nature of Lotoja...I'm not sure my mom will even get through it this time.)

For 2009, I had the goal of doing mostly cycling--focusing on bike races and longer endurance events--until late summer, when I would transition to full Ironman training. With this in mind, I signed up for Lotoja with several other friends, as soon as I was relatively confident I would be able to get back on the bike. Lotoja is a 206-mile bike race (or ride) from Logan, Utah (~4500'), to Jackson, Wyoming (~6500'), with about 10,000' elevation gain. The event has USAC race as well as fun ride categories; although our intention was to ride together in the fun ride group, we ended up in the women's cat 4 race. I think I was the only one initially happy about that. My training included doing the Death Ride in July, the Santa Cruz Mountain Challenge Century (highly recommended!), and a string of triathlons and bike road races. My longest training ride for Lotoja was the Death Ride--129 miles, but done back in July. I felt strong on the bike leading up to Lotoja, but wondered if my body, especially my back, would hold up for such a long ride.

Compressing 206 miles into a 3-inch picture leaves out a few details.

We were treated with pleasantly cool, clear weather the morning of the race. Making one of the largest teams, the five of us lined up on the front with about 35 other women. Perhaps our matching Contender jerseys got us a little more respect? At precisely 6:58 AM, we were off, winding our way out of Logan and onto some country roads. The pace was manageable and I was comfortable staying toward the front during this mostly flat stretch. After 5-10 miles the pack narrowed and someone managed to organize a rotating paceline with the front 20 or so riders. I found myself moving up to the front in the left line and watched the women in front rotate clockwise in a continuous motion. It was a beautiful sight, moving smoothly and efficiently! I found it tricky to accurately gauge the speed of the line moving back but one of the women gave me a tip of just slowing by about 1/2 to 1 MPH once I moved over. The paceline was moving pretty quickly but I didn't have to work too much. But of course, I found myself in front when we hit one of the few short uphill sections. I didn't want to be the one to slow down the group, so worked hard to keep the pace going. Well, I looked back and there were just a few of us off the front. Duh! Anyway, I felt comfortable in the pack and reflected several times how relaxed I felt. Because we were riding the first 34 miles of a 206-mile race, there was no need to be too assertive, and there were no attacks. Soon enough, we were at the first feedzone in Preston, Idaho, where we met up with our SAG team.

I tested my blood sugar and was pretty horrified to see "435" staring back at me. Twenty minutes before the race, I had been 120 and had eaten 1 gel for a little boost. By the race start I was 177 and felt that, once things got going, I would drop a little. I did not consume any carbs those first 34 miles, but the effort was greatly reduced by being in the pack. This is the part of bike racing that seems so hard to manage--the effort is not necessarily predictable. Or perhaps it is, but I am not good at predicting it. Still, 430 from one gel? I bolused a couple units, drank lots of water, and rejoined the race. It took what seemed like forever to get my BG below 300, and I had to bolus another couple units. I don't like taking boluses >1 unit when I am exercising but needed to be more aggressive here.

There was a little climb out of Preston, with a fabulous descent, and then some flat/rolling sections. The pack either got out of the feedzone before us (likely) or splintered, but we found a few others to ride with. I think any notions of rejoining the pack were abandoned after our bathroom break, though. I was happy to continue with friends and just enjoy the day. Still, we would have to maintain an average pace of 16 MPH to finish in time. From the course description, this seemed doable. A few miles later, I dropped my chain off the small chain ring. I made a big mistake by telling everyone to keep going, because the chain was really jammed and it took me a few minutes to get rolling again. I was then riding alone and fighting the wind a bit; I didn't want to work too hard to get back, but I didn't want to ride alone either. I had another chain drop incident, this time off of my big chain ring. A guy nearby said, "You dropped your chain." "Yeah, I know," and I wondered if I could get it back on without moving it by hand. Inspired by a teammate's recent dropped chain victory at the Giro di San Francisco, I tried to move the chain by shifting to the small chain ring while pedaling very gingerly. It worked! The chain dropped to the small ring and I was able to shift it back up. I got a cheer from the guy nearby and was on my way again. (Thanks, Sarah!)

After a few more miles, I was happy to see Rita drifting back to pick me up. Soon enough, we started our first significant climb of the day: Mink Creek. The grade was not too steep and there were plenty of easier sections throughout this long climb. I still felt pretty fresh and enjoyed the scenery on the way up. I reached the neutral feedzone near the summit and waited for Rita to rejoin. There was a nice descent on the backside and then many flat miles on the approach to Montpelier. It was quite windy on this section and I was really hoping to find our front 3 riders, so pushed it here. At one point, I saw a group ahead and thought I saw our jerseys in there but alas, it was another group. I had been expecting a little more downhill from the elevation map but, really, it just felt flat. I was torn between trying to catch our group and slowing down to ride in with Rita.

Finally, I pulled into Montpelier and saw our crew. My parents had decided to drive up to cheer us on and I was very happy to see them there. After restocking and resting for a few minutes, we were off again; Jane was ahead but we had a group of 4 together again. There was another shorter climb and another great descent. We regrouped for the flattish stretch before the 3rd big climb of the day at Salt River Pass. We were at mile 110 or so and my high blood sugar woes were a thing of the past--I was hovering around 85-100, about 40-50 points lower than I like to be during a race. A BG below 100 can very quickly drop to a seriously low level for me, and I generally feel hypoglycemic at anything less than 110 during intense exercise. I felt pretty bad on this climb and had no motivation to push it for the Queen of the Mountain timed race. This was also the warmest section and very exposed to the sun. Mercifully, the climb was not too long. I have no memory of the ride into Afton, the next feedzone where we met up with our SAG crew.

Star Valley, Wyoming was a section well-suited to pacelining and I hoped we could keep our speed up here. (Here is a youtube clip.) Unfortunately, my ITB near my knee, which has bothered me since Barb's Race, acted up again and I also started feeling the effects of a long day on the saddle! I was feeling okay in the paceline but at one point, I just dropped off. I knew I should have said something but didn't even have the energy. I ate some more food and was grateful that Rita came back to see what was up. Pulling over, I checked my BG, which was around 80. After a short break, I felt a little rejuvenated but just didn't have a lot of energy, and didn't enjoy the pain. Around mile 150, I noticed that my left arm and shoulder were starting to feel tired and I was having a harder time keeping a normal posture. I felt good pulling on the downhill sections, where I could help with the pace, but was not feeling great otherwise.

Pulling into Alpine, I was relieved and dismayed to see that we had 47 miles to go. I knew we had to finish this in about 3 hours, which would have been no problem under other circumstances. This stretch goes up the canyon with spectacular views of the Snake River; with a mild grade and some rolling sections, maintaining 16 MPH average should have been easy. But facing another 3 hours on the bike was daunting. We picked up another rider here and there, and made our way. Thanks to Rita who took the flat/uphill sections, we eventually got through. I continued to do my best to pull on the downhills, which were never as long or steep as one would hope. I saw people rafting down the river, and told myself I needed to come back to visit again someday. It would be a fantastic ride if one started from Alpine!

We stopped at the last aid station around mile 175 and eventually made it to the turnoff from the highway. I was in pretty serious pain from my knee and saddle discomfort and never felt sure of how many miles we had left. After the longest 15 miles ever, we witnessed the gorgeous spectacle of the sunset over the Tetons, and saw a happy sign: "5 km." All races should be measured in kilometers! Those last 5 km fell away and we finished, a few minutes after 8 PM and before the finish line came down at 8:15. It was a relief to be off the bike and I was happy that all five of us had finished. I would not have been able to get through this without Rita especially, my other teammates and our wonderful SAG crew. Our official time was 13:04 for 206 miles.


Crossing the finish line at last!

Positives: I was happy that I felt good the first 110 miles, and that, for the most part, I felt good on the climbs. Feeling comfortable in the pack was a big step for me, and very enjoyable. It sort of turned the 200-miler into a 170-miler (sort of). I was glad I got my BG down, even though it seemed to take several hours. Having great support on the course made this a great experience, and I am proud of our whole team for finishing in time.

Needs improvement: I feel better when my BG's are in the right zone, which they weren't for most of this ride. Instead of overreacting to seeing 120 on my meter, and eating a gel, I should have trusted that my basal rates were in the right place. This was tricky because it seems that high altitude has an effect; but it's one I don't feel confident relying on yet. Also, when I was trying to increase my BG later in the race, I should have made a more drastic reduction of my basal rate, or forced myself to eat more. I am very happy that I finished, but I like to finish strong, which was not the case. I felt like I had the strength to ride better but was held back by recent and longer-term injuries. (Don't worry--I am very grateful that I had the opportunity to discover that 150 miles was the limit for my shoulder and back. But on the other hand, I look forward to the time when my left side catches back up to my right.)

Would I do it again? I think my statement at the end was, "This is a once-in-a-lifetime thing for me." But I think it is likely that my sign-up-for-race-itis will get the better of me on this one again.

This sort of sums up my feelings at the end.