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

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

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

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

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

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

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

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