Apr 21

Burning Carbs (I like chocolate)

By Cary diabetes No Comments »

I can almost guarantee I am the only person who stops at the newsstand to pickup a candy bar before going to the gym.

Pre-workout status: BG 150, Zero COB pre-test, Zero IOB, 45g carbs (candy bar)

My workout was a 4 mile run, 1.5 mile stair climb, 20 minutes of lifting to cool down.

For 45g of candy I would generally use 4.5u of insulin, or else my BG would rise by 270+ to 400+ within an hour.  However, considering I am using an extremely high basal rate for my current exercise regimen and metabolism my 150 BG would start coming down closer to 100 even without working out.  Therefore, I need a pretty big bump in carbs to attack this somewhat intense hour long workout.

Through this hour long workout, my body worked like it had almost 5u of insulin working on that candy bar.

If you see me in the gym walking to the locker room to change and I am eating a candy bar; believe it or not, I am not eating it because I like the taste of chocolate.

Apr 21

Feeding the Basal – A Follow Up

By Cary diabetes, exercise, lifestyle 2 Comments »

There is a downside to every huge upside — something you can prove in life, money and diabetes.  It’s called opportunity cost.  Diabetes is a math game.  A really annoying one where the rules always change.

I wrote about feeding the basal with enthusiasm.  However, I forgot to mention a very key downside that hit me recently.  Basically, I take more basal (currently Lantus) than I need to keep my BGsat 115 (my target, not my goal).  Therefore, if I do not eat, I will go low.  Not a problem with exercising (exacerbating the lower need of insulin), I eat and want to eat constantly.

Got home late last night at 8pm with a BG of 80, I proceeded to eat 90g, bolused correctly.  I continued to feel hungry, and therefore continued to eat (an unknown amount via blind eating for an hour plus).  Falling asleep with a BG under 100, I felt good.  However, bolusing for blind eating is tricky, especially so close to bed time – so I made a guess.  The guess was wrong — by a long shot.  I woke up very early and was very thirsty — the cue to know instantly I am running very high.

The worst part about being high is how difficult it can be to come down.  The usual ratios do not work. If you are 1u:60 points when you are 200-275, everything over 275 may take more insulin to bring down.  So from 275-350 you may need 1u:40 points, and anything above that may need 1u:30 points.  Basically, the higher you get, the harder it is to fall.  In my experience, I really hate to do this kind of math when realizing a high BG and just do a normal 1:60 correction.  However, in an hour I will see that I am not coming down fast enough.

Given the above situation, let’s say I was 400 and want to get down to 115.  I would need 1.6u to get me to 350 (1:30), 1.9u (1:40) to get to 275 and 2.6u (1:60) to get to 115.  For a total of about 6.1u — versus about 4.75 that I would take using my 1:60 baseline approach.  The difference?  1.35u or about 80 BG points.

Guess what happens when I used 1u:60 this morning instead of my more complicated formula?  I was 260 3.5hours after the correction.  Makes sense, since 80 points higher 3+ hours ago can easily translate into an additional 65 points over a few hours of higher BG.

Moral of the story
1. Watch what you eat before bedtime.  It can really mangle your morning.

2. Feeding your basal has the side effect of giving you lower BGs right now (as does increased metabolism from exercise) but Carbs on Board may not appear till later in your BG.  Must have enough insulin to cover.

Nb. These are my numbers — that work for me.  Your numbers will not be the same as my numbers.

Nb. Blind eating is a curse for diabetics.  It’s something I know I should never do, but I do it.  It causes havoc to my numbers, but I doubt this will be the last time I ever do it.

Apr 18

Sitting vs. Standing When Hill Climbing

By Cary diabetes No Comments »

Found this decent video by Active.com on the difference of standing versus sitting while on a hill climb. It’s done by a Tri guy on a Tri bike. However, if you ignore the aero bars, the message stays the same: keep spinning, don’t mash your pedals. But there is some really nice technique notes in the video.

Apr 04

Feeding the Basal

By Cary cycling, diabetes, exercise 4 Comments »

Yesterday I went for a little 50 mile bike ride.  However, for the past few days I have been running BGs from 60-95 or so.  When I woke up in the morning I was at 70, and after eating a small breakfast, still under 100 a few hours later.  Suiting up for my ride, my numbers continued lower to around 60 — so I started consuming: 26g via soda, 30g glass of chocolate milk, 20g candy, 40g bread and cheese.  I did not bolus for any of that food.  During a few mile warm up I remained in the 60s, so continued drinking Gatorade and downed 1 GU (20g).  So I’ve consumed well over 100g of carbs — and finally start getting my BG to 100.  And that’s where it stayed for the entire ride (where I added a bag of chips, 20g and a sandwich, 35g).  I bolused nothing, zilch from 10am till 6pm when I got home and feared having a huge amount of Carbs-on-Board (COB) and took a few units of Novolog since I was at 180.

Why did this happen and work in my favor?  I’m taking too much Lantus — and this is partly my purpose.  I am doing something known as feeding the basal.  I only slightly reduced my Lantus dose for riding, not nearly enough to require adding fast-acting insulin to the mix.

Mar 31

Exercise without the Pump (and thinking about another pump)

By Cary diabetes, exercise, lifestyle, MDI, pumping 4 Comments »

In all reality, not much has changed in preparation of exercising. COB, IOB are still the two items I am always conscious of – just how they get to me changes. While on the pump, I always disconnected before working out for 1.5 hours or less. This would tend to leave me in a basal deficit when I got out of the shower and reconnected and I would be forced to bolus immediately to both fill the cannula and get some insulin on board. However, now using Lantus, I do not have that insulin deficit when disconnecting. On the other hand, I do not start working out with a BG <180, Carbs-on-board and limited Insulin-on-board. I have purchased fun-sized candy that are 10 grams each – one or two candies are usually enough to get a BG <150 into my acceptable pre-workout range (also ensuring limited IOB). On the flip side, using the pump, I could be at any BG, and as long as I lowered my basal far enough in advance, I could raise my BG manually without additional carbs (however, I would end up going into further insulin deficit during the period of disconnect from the pump).

Not having to worry about the insulin deficit from disconnecting is a huge benefit for me during exercise – one reason why I am currently considering the OmniPod for my next pump.

As for the OmniPod in particular, I used a demo Pod for a few days over the weekend and I was somewhat impressed. Although the device is significantly large, it stays in place and has a smooth surface all around, unlike some of the MiniMed infusion sets I have used over the years. However, the inside information is calling for a 40-50% smaller Pod late 2010 or early 2011 (awaiting FDA approval). From the investor relations slides, it appears to retain its distinctive shape in a smaller package.

Mar 31

Insulin Leakage

By Cary diabetes, lifestyle, MDI 2 Comments »

Since I went on a pump “vacation” back in February, I have been using Lantus/Novolog with decent results. However, one of the downsides has been leakage from the injection site. This tends to happen if you pull the pen away from the skin too early (the pen is still releasing insulin for several seconds after it clicks done).

However, for some reason I feel like I am getting a little more leakage than what is normal and my precision boluses that I used on the pump are getting bumped up 10-15% to cover leakage (this is true to both my Lantus and Novolog).

Experienced leakage woes?  Just another part of living life as a diabetic and playing with the numbers.

Mar 09

Glycemic Variability and A1C

By Cary diabetes, lifestyle 2 Comments »

I have never actually cared what my A1C number said when results came back from the lab.  And this all started when I was a child and learn about variability.  Ok, it may have been conveyed in a slightly different form.

As a kid, it was really quite easy to fake a good A1C by having a lot of variability in the numbers. For reference of variability, I would run 30-50 miles per week and could easily polish off an entire pizza by myself.  As I got older, my A1C went up and unfortunately, the results of A1C became of little value to me.  Over the past 20 years, what is considered a “normal” A1C for diabetics has changed up and down so many times that I made up my own system for determining how good I am doing.

First, we need to have a few baselines: my target BG is 115, I do not correct a BG below 180, my acceptable range is 75-190.  Additionally, every BG usually has Carbs on Board, Insulin on Board, or Exercise on Board (BGs trending up or down) – so a correction (or asterisks) of the number is necessary, since the number on the meter may no longer tell the story.

Once you have this set I can find the number of highs, lows, avg, standard deviations, and how many of them have an asterisk next to it – with an additional story.  If you take a look at a “good” A1C and find a lot of highs and lows in your adjustment, the A1C is not accurate.  However, if I have an “ok” A1C and have few highs and lows, and my average is acceptable – I am far better off health wise and tend to ignore the A1C result altogether.

Nb. I am not advising against getting your A1C checked – as huge swings in your A1C can be problematic of a greater issue.

Feb 26

The Accuracy of Glucometers

By Cary diabetes, glucometer 6 Comments »

“I don’t take a corrective bolus if I’m at 180 or lower.  My doctor and I believe that the enemy of good control can be great control… meaning if you’re at 170 and correct, then you often drop down to 70, and then treat and bounce back up. It becomes a yo-yo effect.” -Kris Freeman, on Diabetes Mine

I made a comment on the blog post

Talking with guys like Kris and talking through the numbers and what effects certain things have is probably the most useful information out there — since guys like Kris keep phenomenal records (and I don’t mean logging every BG), I mean exactly what went in the body and what went out the body and adjusting.

I’m wondering how Kris actually feels about BG accuracy on his meters — reading his comments about not correcting anything over 180. I have had the same opinion for the past decade — mainly because of the inaccuracy of the meters. In his example: 180 could actually be 140, and if you correct to 110 — you’re dropping down to 70 (add exercise on top of that and you end up bonking hard).

The tighter control you have the harder it will become to have tighter control without bouncing around (is a 65 actually a 90?) — from what I see as poor accuracy from the meters.

June chimed in with:

I agree with Cary above, though, who warns Kris that a 180 reading on a meter could actually be as low as 140. In the almost 38 years since I was diagnosed with Type I, I have had the worst control – yo-yo-ing all over the place, BG-wise, when I tried to keep my numbers TOO close to normal.

The published data that glucometers really only have +/-20% accuracy becomes concerning if you are looking for a target range of 80-110 mg/dl.  Since it is far too easy to over bolus on a “false” number. 

In anemic subjects in the intensive care unit (ICU), we noted up to 30% error in glucometer results compared to the laboratory value. A 30% error from 80 mg/dL yields a true value of 56 mg/dL, a clinically significant difference.

As part of the JDRF artifical pancreas project, I would hope would eventually want to address this issue as part of their pipeline.  Although, they seem more concerned about combining the CGM with Pump to be more self-aware (reducing huge high and low numbers).

CGM versus a more accurate glucometer?  They are for totally different purposes — for looking at trends the CGM is more effective.  For a point in time analysis – I want the more accurate glucometer.

From a technical stand point, why can a normal glucometer have accuracy of less than 5%?  This is a note to LifeScan, Roche, Bayer, Abbott, et al — I will pay hundreds of dollars in cold hard cash for a significantly more accurate glucometer (rather than the 5 different $20-to-$200 meters that I pay[paid] for in test strips).  I’d make a gamble that there are others who would be on board for reducing lows and reducing highs by simply increasing the accuracy of our equipment.

Feb 26

Kris Freeman “bonked”

By Cary diabetes, exercise, pros No Comments »

I have been thinking quite a bit about why Kris Freeman “bonked” in the 30KM Pursuit in Vancouver.  It has been very well published — for the more normal audience.  But it is a perfect case study for all levels of athletes.  It is important to realize that at the level he competes there is no way he could be competitive starting a race and keeping with BG 200 like many others try to keep from going low.  Kris understands his body and what it needs to be close to perfection.  However, this being diabetes, and countless changes that can result over the course of race as long as the 30KM — pushing a little harder to make a pass may result in a tiny bit more of a BG reduction without ensuring a carb to back up that move.  Basically, Kris cannot compete with the “buffer” that many of us use to keep from going too low.  That brings with it risks — especially when he cannot test his BG during an event (he would lose).  Therefore, only by training over and over — he learns how his body will react along a race course by testing BG over predetermined areas.

Bonking in in diabetics can really be a two fold event since a more traditional bonk where you are at the end of your glycogen stores.  However, it may look and act much like a hypoglycemia in diabetics.  It would not be unreasonable for both to happen — although it seems as though Kris really just had hypoglycemia — since a few minutes after getting sugar into his system, he was off and pounding the snow again.

Feb 09

The Basic Workout

By Cary diabetes, exercise, MDI, pumping 1 Comment »

Because New York winters are cold, rainy, and sometimes snowy, working out in a gym is almost a necessity. Not to mention sunrise near 8am and sunset at 4:40pm is debilitating to the mental game of getting outside before and after work.  However, going from 8+ hours at the office sitting at a computer, talking on the phone and eating – changing gears to workout mode can through you out of wack.

For the diabetic athlete the working out poses an interesting challenge.

  • Carbs on Board: Carbs consumed before, during and after the workout
  • Insulin on-board: Insulin used before, during, and after the workout

For the insulin pump user there are a handful of key issues to think through:

  • Temp basal pre-workout, during workout, post workout (timing and percentages for three distinct stages)
  • Optional disconnect during workout

All of these types decisions rest on a few key decisions: your personal insulin resistance, Insulin on Board, Carbs on Board and the type of activity you intend to take on.

The diabetic using Lantus actually might have it a little easier — since the basal adjustments are not a factor until an injection takes place – and you can feed your basal carbs as needed.

For an easy example, let’s say I have no carbs or insulin on board and have a BG of 120. Potentially a perfect way to start a workout, but it still requires a little more work. If I plan to do 30 minutes of reasonable cardio (say 10/min mile pace on the treadmill) and lift for another 30 minutes, I will have a low BG if nothing is done. One option would be to eat carbs prior to the exercise in an amount and time that would counter act the exercise to. A second option would be to run modify the basal 30 minutes prior to the exercise (to artificially increase the BG) and during exercise either disconnect or run another lower basal during exercise. Neither is a foolproof system nor you will find that most pumpers will utilize a combination of the above, since even in our simple example it becomes complex rather quickly.  Especially with disconnecting a pump, because a lack of basal can be debilitating when you reconnect (and somewhat scary if you bolus immediately after reconnecting after a workout to “replace” the basal).

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