Change the World – What am I passionate about – Monday Topic 2014 Diabetes Blog Week

Welcome to my attempt at Diabetes Blog Week 2014.  I signed up for Diabetes Blog Week to become a part of the larger diabetes online community and provide some inspiration for some interesting topics.  So that being said, let’s get started!  We kick the week off with the topic post – “Change the World”.  Or, in other words, what causes am I passionate about, what gets me fired up?  Well, judging from the title of this blog, I think one of the main causes that gets me fired up is physical activity.  But it’s more than that.  Physical activity is just one of the many ways that diabetics can wrest back control from this disease.  What I truly am passionate about is becoming an empowered diabetic and helping other people develop the energy and the ability to take control of this disease.

I refuse to subscribe to a victim mentality.  But I wasn’t always this way.  In fact, I was the poster child of someone with a victim mentality.  I ate poorly, I rarely exercised, I had poor control and I actually used my diabetes as an excuse at times.  One of my favourite climbing books is  “The Rock Warriors Way” by Arngo Ilgner.  It’s a wonderful book on realizing your mental boundaries and pushing past them.  It’s a wonderful treatise for the mental aspects of rock climbing, but many of the lessons in it can be applied to everyday life and the challenges we face.  The chapter on “Accepting Responsibility”  really spoke to me.  Here’s one gold nugget, “In Accepting Responsibility, you will use your attention – your power – to cut through delusions and misconceptions in the situation facing you, replacing them with useful facts and an empowered approach.”  So much of this chapter speaks to me as someone living with a chronic disease and not just a rock climber trying to figure out how to deal with issues of imminent mortality on the sharp end of the rope.  This quote, to me, says it all, “The most passive of all delusions is victim thinking.  We pretend that so much misfortune has befallen us that we can no longer be held responsible for taking charge of our lives and improving our situations.”  When I read that chapter, I was gob smacked.  It hit home.  It wasn’t an overnight shift (more like several years), but I began to work on taking responsibility for my actions, empowering myself as a diabetic, and to stop making excuses and start taking action.  All of a “sudden” I felt like I had wrested control of this disease and my future back into my own hands.  How did this happen?

I started become truly aware of my poor control.  I had all the tools in the world to manage this disease.  So why couldn’t I?  I was FILLED with excuses – “I don’t have time” – but I still watched TV and played video games.  “It’s hard” – but I never tried more than once.  So I started incorporating more things into my lifesetyle – I was already climbing at the time, but we started pushing our limits more, and took up outdoor climbing.  We got hiking more, and even though I feared the low’s at time, I stopped using those as an excuse to eat more, and started adjusting my insulin management to better plan.  I started taking ownership and adapting.  I empowered myself, rather than making excuses.  I started noticing I was enjoying physical activity more and more, and adapting my diet to help with optimal performance.  It’s easier to climb when you have less weight to pull up. 🙂  I started finding that anytime I sat down to watch TV I felt guilty.  I felt like “I should be moving”.  Video games began to feel like the biggest waste of time I ever took part in (Note: I still play an IPad game every now and again 😉 ).  That’s around the time I started adding new activities – running, cycling, swimming, you name it.  But as any diabetic will tell you, a new sport is just another opportunity to ride a roller coast of high’s and lows.  And it was frustrating.

Learning how to empower myself, I had numerous lows and ate way too much on this hike, but I learned!

Learning how to empower myself, I had numerous lows and ate way too much on this hike, but I learned!

And this is the point of this post – what am I passionate about – well, around this time I found the community of diabetics.  I discovered the power of “the village”.  I learned how fellow diabetics can empower each other to help ease the fear and confusion around exercise.  You see, as I got into cycling I met a great group of folks.  These were the Dallas-Fort Worth Red Riders.  A “Red Rider” is a diabetic cyclist in the many American Diabetes Association Tour de Cure events.  It’s a wonderful gesture to recognize every one of us – it’s emotional seeing so many people in red, out there, doing their part to fight the disease for themselves and others.  The DFW Red Rider’s would organize training rides to help out other diabetics.  For me, it was the very first time I interacted with another group of diabetics and it was a truly gratifying experience.  People would talk about blood sugars.  Stops would be made to test.  Dosing strategies were shared just as frequently as sugar pills and stinger waffles. This was a pivotal moment for me – I was so inspired by it that I changed from being a recreational cyclist on a hybrid to a full fledged roadie. 🙂

Red Riders lining up at the TdC in DFW

Red Riders lining up at the TdC in DFW

I hope to some day have a guest post from my true inspiration and mentor, Lew Alexander, who drove me to my first training ride, but suffice to say that active diabetics helping out each other is what I am passionate about.  Lew showed me how to take that passion and channel it into advocacy.  I learned so much from all my newfound diabetic friends – it helped me not just participate, but excel.

One of the best moments of 2013 - finishing the San Antonio Tour de Cure alongside my mentor and role model, Lew Alexander

One of the best moments of 2013 – finishing the San Antonio Tour de Cure alongside my mentor and role model, Lew Alexander

My wife and I became involved with the ADA – she volunteered and organized the food for the 2013 TdC, feeding over 1200 riders and families, while I rode in two (supposed to be 3, Houston rescheduled for weather) TdC’s to get the message out, all the while raising over 6500$ for the cause.  We believed in the TdC because of the message – physical activity is a corner stone for a life well lived.  And me?  I lost weight, I got way better control, I became active in the local diabetic community, and I just felt like I had a better life.

The end result of being an empowered diabetic

The end result of being an empowered diabetic

At the end of 2013 we moved back to Canada.  We are happily located in St. John’s, Newfoundland.  We’ve traded tornados for fog, sweltering 100F weather for rain and drizzle.  We love it here.  However, the support groups that I had become a part of in DFW had not quite evolved yet. However, I’ve luckily met some wonderful diabetics (Penney, Allison, Ashley, Morgan, Megan) who I who have come out on weekly training runs to help inspire an active lifestyle.  This branched off from work Penney was doing to make a Type 1 Diabetic Adults Networking/Support group.  These efforts have been phenomenal, and I’m so glad to have met these wonderful individuals.  I am very passionate about these efforts, and I will continue to pursue them and hopefully make a dent in Newfoundland’s diabetes stats – which are unfortunately not good (highest per capita diabetes rate in the country).  Still, the efforts of these people give me hope that we can start something big!

Active Newfoundland Diabetics!

Active Newfoundland Diabetics!

So what am I passionate about?  Taking ownership of this disease, wresting control back, and realizing we have the power to conquer it all.  We can’t all run across Canada like my newfound idol and fellow Canadian T1 diabetic, Sebastian Sassesville, but we can choose to get off the coach and walk around the block, jog a 5k, or hell, train up to run across the country.  You can wake up each day and say “I’m going to succeed” or “I’m going to fail”, and either way you’d be right.  You are what you want to be.  What I am passionate about is helping people get to that mental state where they know they can make a positive impact on this disease and start the thrive in their own individual ways.

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Race Prep – Still Learning

I’m new to the whole racing scene.  Today I ran my second race, the Harbour Front 10k.  I learned a lot about diabetes management on race day, and I have a lot more learning to do!  What I thought I knew, I had no clue! 🙂 So let’s get down to it.  I ran my first race, a 5k, back on April 13.  I had decent management of my diabetes then, but I really couldn’t learn much because I was sick as a dog and was mostly in sick day management mood with temporary basals, and what not.

So, what did I learn for the 10k prep?  I was actually a bit nervous about the 10k – it’s long enough that I have to start managing my pace a bit more, and it’s long enough that a hypo can hit me.  I’ve run lots of 10k’s on my own time, but I just didn’t know what I’d do in a race.  That’s why we run them!  So I set some goals.  I knew from the 5k race that I was going to beat my training run PB’s – which was ~41:30.  So I set a goal of 40 minutes.  I pre-ran most of the course (well, the hilly section) and knew that this was possible.  But for some reason pace kept nagging at me.  I pushed it to the back of my mind, or so I thought.

Next up was pre-race feeding.  I tend to have a diet that is 40% carbohydrates, and a 10k doesn’t really demand serious carb-o-loading.  For my planned marathon I’ll be bumping my carbs up to ~60% at least 2 weeks pre-race.  That being said, I did have a someone carb intensive supper.  I had an awesome savoury oatmeal – steel cut oats, miso, soya, lightly pan fried veggies, spinach, avocado and a poached egg.  It was delicious with a side of “ginger ale” (1 tbsp fresh lemon juice, ~1 tbsp fresh grated ginger, top with soda water).

Mmmm Miso Oatmeal

Mmmm Miso Oatmeal

My blood sugar was doing great post meal, or so I thought.  My wife then setup a restorative yoga session – aimed at stretching out my hamstrings, opening up my chest, and relaxing me.  It was perfect.  I was so sleepy and ready to hit the hay early to get up at 5 AM.  Then I tested my sugar.  WOWSERS.  Turns out that as I was starting to think more and more about the race I started getting stressed.

Race Glucose

Race Glucose

I had always read that pre-race stress can cause blood sugar to spike, and to plan a temporary basal accordingly.  Well, boy did that ever creep up on me.  I had 4 overnight boluses to try and correct my peak down.  My sugar has not been that high in months!  I was livid – because my sugar went so high and that I was waking up every hour to test and adjust.  I am highly insulin resistant at night, so I was taking large boluses, and then I was terrified of going low.  Anyways, around 2:30 things started looking better and I got to sleep until around 5 AM.  For me, I need to have my sugars in range when I’m exerting myself.  I just perform that much better when my glucose levels are balanced.  My brain is getting the right amount of insulin, my nerves aren’t being stressed, and my muscles are getting glucose from the blood stream.  It’s a win-win.

When I woke up I was happy with my blood sugar, and went about my plans to have my race day breakfast; steel cut oats with chia seed, 1/2 a banana, and an egg cracked into it egg drop soup style.  My mantra is “Eat real food, run fast”.  Of course I had my coffee, and missing from the shot is my morning cappuccino.  This is pretty much my breakfast every morning (except no banana, that’s an event day treat).  I bolused accordingly, and as you saw from the plot above I did fine (well, I drifted close to my low limit once).  I also turned my pump up 40% on the basal program because I knew I was getting a bit nervous.  As I was lining up at the start line my glucose was ~6 mmol/L.  I knew I was going to run the race hard, so I ate a sourdough, PB&J sandwich I took with me for just such an occasion.

Pre-race oatmeal at 5:30 AM, give it time to prime the glycogen pumps

Pre-race oatmeal at 5:30 AM, give it time to prime the glycogen pumps

Now, I’d love to share with you race blood sugar levels overlayed with my HRM data; however, my Dexcom did not report a single sugar during the race.  Maybe it’s because of how tight my muscles may have been (I wear it in my arm), maybe it was a combo of clothing and friction – it’s been known to cause issues.  Maybe having the transmitter in my tights in a plastic bag (it was raining) was blocking the signal.  I don’t know, and it’s going to be another blog topic at a later time, but I am sad to report – no data. 😦  My average HR for the run was 172, so I was pretty high in the threshold/anaerobic zones and was burning glycogen fast.  Still, post race it popped back on at 7.8 mmol/L and started to creep up.  That means I probably didn’t need the whole sandwich or I should’ve bolused, but lesson learned for next time.  Also, there was probably some anaerobic spiking going on there, but without the data in the middle it’s hard to say.  I wasn’t too far out of my desired zone during the race, and my time showed it.  I finished the 10k well under my goal at 38:02, coming in 11th overall and 5th in my age group.  It was a great day! 🙂  Post race I did have one other small peak from eating a bit of recovery food, but it quickly came down as my metabolism was all fired up

So fast I'm a blur! :)

So fast I’m a blur! 🙂

So, it’s still a work in progress, but here’s what I learned:

  1. Pre-race; plan to start an increased temporary basal early – as early as supper time the night before;
  2. Run some more runs at race pace without fueling to see how I respond (do I get an aerobic peak);
  3. Test ALL clothing combinations for Dexcom compatibility; I think this may have been the plastic bag as that was the only new variable in the equation;
  4. You can’t always rely on your CGMS. Have a plan for longer runs;
  5. Run more races prior to the August marathon by the sea;
  6. Continue to eat real food for races.  It works. 🙂

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In closing, just a heads up that I am taking part in the Diabetes Blog Week starting tomorrow.  It’s a post a day on various topics.  It should be fun!

 

 

Burnout, Massage and Diabetes – You learn something new every day

I am a huge fan of massage therapy.  It seems expensive at times, but it’s always paid off in spades.  It’s an investment in my bodies health and a long term performance enhancer.  I border on addicted to exercise.  I have a hard time taking rest days because of the subtle shifts in blood glucose control that happen after a couple days rest.  The risk of all this is overtraining or overuse injuries.  I actually had an example of this happening this winter – I had gone too hard, too often, and started showing some classic overtraining symptoms.  I was borderline depressed afterwords, I had no energy, I didn’t want to get on the bike, and when I did I couldn’t turn the pedals.  I hit the wall.

So how did I deal with this – well, I took some rest days for starters.  I re-evaluated my goals – why was I pushing myself so hard; had it gone past blood sugar control.  I still wanted to train, but I needed to step back some.  Not every day can be a Sufferfest day.  I had gotten addicted to the burn and the massive gains I was making and ignoring what my body was telling me.  But, a huge thing I realized is I hadn’t gotten a massage since October!

I used to make massage therapy a monthly (if not more frequent) part of my routine.  Massage therapy helped me deal with some leg and back issues I was having.  I needed deep tissue massage to help loosen up some very overworked muscles.  Plus, desk work was not gentle to my back and shoulders (but a sit-stand desk has helped fix this).  Deep tissue is phenomenal, but it can hurt so be forewarned.  The therapist is trying to get into the scar tissue or chronically tight muscles.  It hurts, but almost immediately you see the benefit.

So, I went for my first (and shortly after second) massage here in St. John’s.  During my second session he mentioned that they do train massage therapists to handle diabetics different.  This caught me off guard – what would a well controlled diabetic require different.  He mentioned they do less “cleansing” strokes after a deep massage.  I wondered what happened to the “recovery” part of the agony! 🙂  But seriously, there was some comment about not wanting to flush stuff as much through the system.  I filed it mentally to look up afterwords.

Turns out, if you Google “Diabetes massage” you get all sorts of things – it cures diabetes, if you have diabetes don’t do it/it’s the best thing for you, etc.  The usual!  However, one interesting article written by a Type 1 diabetic massage therapist sheds some light.  Apparently, we do present differently (especially depending on activity level).  We can tend to be more fibrous as a consequence of periods of higher glucose.  Also, injections can lead to thickened skin.  I asked my therapist about this and he said he did actually notice this in his other two diabetic patients, but that it wasn’t noticeable in me.  Maybe he was trying to be polite, or maybe the level of activity has an impact on the fibrous presentation of muscles.  Tighter blood sugar control may make the muscles less fibrous which seems to support my belief that tighter control makes it easier to exercise.

But that still didn’t address why a massage would be modified, just why they may have to work harder with us.  Then, common sense clicked in after I read this site.

Basically:

  1. Massage therapy can cause hypoglycemia – if you have recently injected insulin and do not advise your therapist where you did this then there is a chance that their techniques may cause faster absorption of the insulin.  The response would be similar to injecting insulin into a working muscle group – it works fast!  I guess this is why my therapist was avoiding his cleansing techniques.
  2. If you have neuropathy you may not feel just how much pressure the therapist is applying.  Trust me, they can apply a lot of pressure as is evidenced by the sheer number of F-bombs I can drop in an hour.  If you suffer from neuropathy, deep tissue may not be for you.  Use common sense.

I guess I had never though about this.  Then, reflecting on some of my massages I’ve had after a meal I now know why I would suddenly drop in blood sugar and then rise high later.  Basically the massage was pushing that insulin into my system quickly, and it was peaking way earlier than usual.  Lesson learned.

So, long story short – what did I learn.  Well, I still believe that massage therapy is an important part of athletic training, performance and recovery.  But I’ve also learned that, as per usual, we diabetics must balance our management strategies to make the most out of a massage.  My management strategy for massages is now:

  1. Make sure the therapist knows you are a diabetic and knows where any infusion/injection sites are.  That way, they won’t think you are a human pin cushion.
  2. Time massage appointments so they do not immediately follow a bolus.  Try and schedule it so it’s not immediately after a meal, that way the risk of hypoglycemia is lower.
  3. Always have a glucometer (CGMS, traditional meter, or both) and sugar pills beside you.  Keep checking in on yourself, make sure you aren’t trending low.  Treat accordingly.  Keep your therapist in the loop on how your glucose levels are and how they are trending.  You’d be amazed at how curious they are about it all.  Some websites suggest the average response they observed (non-scientifically) in diabetics was a blood sugar reduction of  ~1-2 mmol/L.  As you learn how your body responds you can adjust your strategies.
  4. Be very aware of your signs of hypoglycemia, but also be aware that they may be confused with signs of massage response.  For me, I sweat profusely during a deep tissue massage due to the pressure (and let’s be honest, pain), and sometimes can feel light headed from that.  That’s why it’s crucial for me to have my CGMS beside me- I can’t rely on my typical hypo response to alert me.  As always, test frequently.
  5. Don’t be afraid to ask the therapist to stop if you need to test.
  6. If you have neuropathy, talk to your therapist and/or doctor about how to incorporate massage therapy.  The last thing you want to do is harm!

And as always, log what you did, how your blood glucose responded, and adjust as necessary.  My last massage I asked him to not make any accommodations for it and my blood glucose remained fairly constant.  He was curious and kept checking in to see how things were going.  It became a teachable moment about diabetes and day-to-day management of a chronic disease, and that’s a good thing.

Fellow diabetics, do you have any experiences/lessons learned or funny stories from massage therapy appointments?  I’m sure we’ve all had lots of “teachable moments”.  Do you use massage therapy?

Why I exercise in the morning

I’ve gotten into the habit of exercising at ridiculous hours of the morning.  5 AM runs, sure!  A long trainer ride – I better get up at 4:30!  I even did a mock triathlon by waking up at 3:30 AM in Texas.  I never used to be a morning person, but I started doing early morning workouts so I had more time for Megan and our two fur kids (Molly and Gus).  We like to spend time together. 🙂

Family

My wife and Molly and Gus (our two fur kids) on a boxing day snowshoeing trip. My inspiration!

However, I quickly learned that my blood sugar behaved differently right after waking up.  I wasn’t dropping low as quickly (without food), everything just seemed to happen more slowly.  If I did the same workout at 5 PM I’d have a totally different blood glucose response.  What gives?

Here’s an example of my experience.  Below is an overlay of BG and HR from a high intensity trainer ride (Sufferfest: There is no Try) done right after waking up.  No food.  No insulin reduction.  My HR is lower in the second half of the intervals because I had to scale it back to 90% – I just haven’t fully adjusted to my new FTP…or I need to HTFU, who knows (insight!  see below).  Anyways!  What this shows is that I started my ride at 4.8 mmol/L and ended close to 5.9 mmol/L.  No lows, no highs.  There were no signs of zone 3-4 causing me to drop, and no sign of the potential highs some diabetics see when operating in anaerobic zones.

Blood sugar in the AM

Blood sugar and exercise in the morning – it can be done, and it’s actually quite easy to manage

So how did I exercise and stay in the “golden zone” (4 to 7, your in diabetes heaven!)?  Well, it turns out that in the morning you still have lots of those dawn phenomenon inducing hormones still present in your body (like cortisol) – they increase insulin resistance.  Furthermore, unless you had a late night correction bolus at like 3 AM, you probably only have basal insulin circulating in your body.  The combo of these two things may work together to help stave off a low.  In my experience, I also find that it helps in keeping my metabolism up for the day ahead and was very successful in reducing my overall total daily dosage of insulin.

Now, researching for this post I did draw a lot from experience – I’ve been exercising at 5 AM or earlier for the better part of a year – non stop, maybe a rest day a week.  I’m pretty much dialled in.   I know what blood sugars I feel comfortable going for a 10k run on , and what duration exercise I need to start fuelling for.  However, this takes time and effort to figure out.  There are some great resources out there for trying to figure this out.  One that I thinks is quite helpful is Ginger Viera’s “Your Diabetes Science Experiment”.  I don’t get any money for promoting it, I just think it’s a good book to help you plan how to sort this stuff out.  However, common sense and the scientific method work well too. 😉

Now, the insight I had while writing this post?  After a bit of reading it may be a lack of glycogen.  While researching for this blog post, I re-read “Your Diabetes Science Experiment”.  In the book, Ginger makes a comment in regards to lifting weights prior to eating, but interval training is anaerobic in nature, so I will quote her here, “if you were to try and lift weights on an empty stomach, you would find yourself feeling burnt out very quickly, because as we talked about earlier, your muscles need to release their stores of glycogen so the glycogen can be converted to glucose and carried back to your muscles with insulin for fuel.”  Since I was doing some HIIT without a spec of food I may have been pushing a wee bit too hard without any fuel.  Lesson learned!

However, your diabetes may vary, and even various authors can’t seem to agree with the theory – even the same author in different years (see 2008 article and 2012 article).  Reading between the lines I suspect there’s a lot missing between the leap from the 2008 to 2012 article – what diabetic therapy is being used, what type of exercise, how long, etc.  So, what do I recommend?  Try it out.  Test often, test before, during, and after exercise.  Learn from your experiences, and keep at it.  You’ll figure it out and your body will thank you! 🙂

 

Diabetes and fueling for endurance – planning food for a long run (my experience)

2013 was a very satisfying year for fulfilling goals – I got to ice climb with some great friends, climb a mountain with my wife (a life long goal), cycle in two centuries and over come my total inability to swim and compete in a triathlon.  When reflecting on goals for 2014, a couple goals stood out, one of them being to run a marathon.  Since it’s really only one goal that I’m setting out, I want it to be ambitious – I’d like my first to be  less than 3:30, and I’d love to hit a 3 hour marathon (but let’s not get crazy, I’ll settle for 3:30).  This goal is starting to crystallize into something palatable, and I already have the jitters.  I don’t know if I’ve ever trained this far out for something.  I know I’m capable of a decently paced half marathon in non-race conditions, but I haven’t yet put my body through the glorious agony of a full 42.19 km (or 26.2 as it’s affectionately known).  I have a fuelling strategy for a half marathon, and it generally involves one hand held bottle of water (in warmer temps), and a couple of sticky bites (and emergency sugar pills to boot).  Eating on the run is challenging, and eating as a diabetic is challenging, so I want whatever I eat to be good!

Enter the sticky bites.  I’m a huge fan of eating real food.  Skratchlabs has turned me on to this, and I truly believe in it.  In the Feedzone Portables cookbook there are lots of great recipes for food you can eat while exercising that aren’t gels or sugar pills or gatorade.  They taste delicious and they are real food.  You’re the envy of a peleton when they are sucking back gels and you are munching on a sweet liege waffle.  Or how about blueberry chocolate rice cakes while they choke down a honey stinger.  Really, there’s no competition.  Plus, for diabetics it’s a win-win because their goal is fast carbohydrates that get in and fuel your muscles (and blood sugar) quickly – so it helps us maintain blood glucose instead of dropping.

For running, I choose the sticky bites.  You can easily stuff 4 or 5 of them in a SPIbelt, they weigh next to nothing (38g per for the last batch I made), they are easily digestible (69% water), and they are ~9g of net carbs per bite.  They take maybe 15 minutes to make and…they taste great!

Something as simple as this:

Sticky Bites 1

Becomes this:

Sticky bites 2 Sticky Bites 3

And no, that’s not vodka, it’s home made vanilla. 🙂  Apple walnut sticky bites, yum!  My plan for my Saturday long run was to take 6 of these in my SPIbelt, a tube of sugar pills in a hip pocket, and CGMS in hand and put on more miles than I have yet.  I’d like to hit 30k.

For a longer run I try to ensure I have enough fuel on deck to start off right.  It’s called “priming the pump”.  My food of choice is oatmeal.  I setup the rice cooker on Friday night to have a nice, steaming bowl of steel cut oats ready for my wife and I.  She had to fuel her brain for yoga teacher training so it was a win win.  Anyways, oatmeal with an egg “cooked” into it, chia seeds, nuts, greek yogurt = 47 g net carbs, 42 g protein.  I bolused for the 47g carbs (80/20 combo, 2 hr delay), but not the protein (I usually bolus protein if it’s over 20g, at half value, so normally that’d be (42-20)/2 – easy right!).

Rice Cooker Oatmeal

I hit the road with an 8.3 an arrow up because I dosed to ensure I’d have a bit of breathing room.  Now, here’s where I debated uploading my HR/CGMS data.  My sensor is a bit old (i.e. past the 7 days).  It was reading a bit off – when I tested 8.3, it was only reading 5 with an up arrow.  So I knew that it was running a bit low.  Literally, right after I started running it bottomed out and started alarming.  The thing is, I know from lots of runs what I feel like when running low, and I didn’t feel that way, so I made a decision to run with the “low” CGMS.  I didn’t trust the number, but I trusted the trend.  If I could keep it flat or elevate it some then I’d be happy.

Below is a comparison of heart rate data and CGMS.  Overall, I’m happy with the results.  The HR data got really sporadic as I got more drenched in sweat, but I have a solution for that in the near future.  Also, after a couple stops you can see some erroneous heart rate spikes – I was not sprinting, the HR strap just read high when it shouldn’t have.  Other than that, you can see that I tried to stay in zone 3 for most of it.  The zone 4 at the start was the uphill portion from my house to the start of the Tely 10.  HR dropped for the remainder of the run because the Tely 10 (run the proper direction) is a mostly downhill course.  Anyways, enough about HR data – what I want to talk about most is how well the glucose and HR data tie.  First, a bit about my fueling strategy.  During the uphill portion I fueled up more –  I ate 2 bites at 28 minutes in (+18g carb), and another at 1 hour (+9 g carb).  The first two managed to keep my glucose steady for the whole uphill portion.  By eating the third right before the downhill you can see my BG actually rose – this was probably because of the lesser effort required in the downhill (and the corresponding drop in HR).  As you go into Zone 2 and 3 your body uses less carbohydrates and this shows it.  I did not bolus for any of these bites based on my trends and knowing I had that combo bolus active.

With only 1/3 of the run done I consumed 1/2 of my nutrition.  This was intentional because I knew I was putting out more effort on the uphill and needed to keep my carbohydrates up because of the higher exertion.  On the downhill return I consumed at 1:27 and 1:56 (+9g each), here I was trying to space out my eating to ensure a constant level of carbohydrates.  I think the trend shows I was pretty good at this.  I probably should’ve eaten two balls at 1:56 because I started to feel pretty run out by the time of my last fueling – at 2:28 with 3 km to go. Still, I made it home, tested and sure enough I was a 5.3, not a 2.7 like my CGMS suggested.  I did drink my entire water bottle (10 oz).  I did not eat one sugar pill or use my backup gel.  I did not bolus for any of the bites on the run, again because I knew I had an active drip from my combo bolus.  Still, when I got home I did bolus for that last bite as it was only eaten several minutes before.

Glucose/HR

And 32.5 km later, it’s a success! I’m really excited about running a marathon in August – I know I can do it, and I know I can plan my food accordingly!

32.5 km #DiabetesEmpowered

 

Overall, I’m really happy with the run.  I do wish the CGMS data was more accurate (vs. reliable), or that my HR wasn’t being stupid, but I think you get the picture.  I did learn a few things – the SPIbelt felt cumbersome, so I just stuffed my jacket side pocket (that won’t be possible in the summer) – I may try and find higher carb bites to help me get more for less.  I also learned that unwrapping these bites mid run is not possible when you have gloves on – that won’t be an issue in August.  Still, it made me a bit mad because I normally don’t stop when running, so that added around 5+ minutes to my time.  Finally, I learned (or relearned) about the importance of body glide – no I wasn’t bleeding, just tender. 🙂  It made me laugh.  My feet and knees felt great, but my legs were starting to get quite tired.  Given this was my longest run to data, I did 32.5 km in 2:39 – a 3:30 marathon should be no issue, yay!  My next long run shouldn’t have half the issues I had on this one.

If it interests you, here’s a link to my Strava upload of the run

I hope sharing this experience helps other diabetics understand that it is possible to plan and execute these, and eat good food while doing it.  We already have to choke down sugar pills, don’t suffer through gels!

Managing Blood Glucose by Heart Rate Zone

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One of the big mysteries I found as I was trying to learn how to “safely” exercise with diabetes was trying to figure out when I was supposed to cut my basal rate, when I should eat, when I should bolus insulin, and when I should not through my glucometer across the room. 😉  Seriously, trying to figure out how to plan your sugar and fuelling strategies can be one of the hardest things to figure out when exercising.  Until you get it dialled in it can truly feel like you are always low and eating more than you burned just to stay alive.  But take heart, you’ll figure it out eventually!

The key to figuring it all out is, of course, test your blood sugar and test often.  Eventually it gets less onerous as you figure it out.  Finally, it probably goes without saying, but CGMS is a knight in shining armour when trying to learn how exercise affects your glucose levels.

When exercising, your body has a few fuel sources it can work with – fat, carbohydrates and protein.  As your exertion level increases, the mix of fuel changes.  Generally speaking, the amount of protein burned is negligible, so we won’t worry about that – you probably have more than enough.  That leaves fat and carbohydrates to worry about.  Our bodies store more than enough fat to provide fuel if that is the chosen source, so that leaves us with carbohydrates.  Our muscles store glycogen which provides roughly enough energy for our muscles to perform for ~1 hour.  After that, normal people risk “bonking”; we risk much worse.  So, long story short – you need to eat carbohydrates when you exercise vigorously enough.

So how do we know what to plan for.  Well, if we know how hard we are exercising, we can at least try to make an educated guess on how plan our glucose strategy.  One way to do this is by heart rate zones; generally, people put them into five zones, but good luck finding a consistent labelling.  One classification of them is:

  1. Recovery – easy, not very strenuous, you could go at this pace for ages. This is where most of us start – this is a primarily fat burning zone.  For me, blood sugar doesn’t do much in this zone if it’s an activity my body is used to.
  2. Aerobic – this is a zone where you start “building”; fuel is generally fat in this zone as well.  It’s a great training zone to work on your “aerobic base”, and also great for active recovery for athletes in training.  It’s a great zone for weight loss too.  Zone 1 and 2 kinda blend together for me.  My blood sugar is pretty level in this zone due to the high fat burning percentage.
  3. Tempo – this is where the rubber starts to hit the road.  This is when I start to notice a noticeable impact on blood sugar.  In this zone you start to move towards some anaerobic fuel sources – carbohydrates.  You start to produce lactate at this point, although your body is still able to funnel most, if not all, of it away.  This zone is sustainable – I won’t say it’s easy every time, but it’s sustainable. 🙂  Most of my runs end up in tempo and my bike rides end up averaging at about tempo levels (with some zone 4 and 5 in there too).  If I know I’ll be in tempo for a while, I’ll start to plan a fuelling strategy; if it’s under an hour, then I may not fuel for it (depending on my starting blood glucose; I’ve gotten comfortable with this around a 5.0).  If I do fuel for under an hour, I dose about half the bolus for it.  If it’s over an hour, then I start to plan out a fuel strategy – 30-45g carbohydrates every 45-60 minutes with ~50% (or less) insulin bolus, depending, to ensure I have insulin to help the glucose get out of the blood and into the tissues that need it.  If it’s >2 hours, I reduce my basal insulin.
  4. Anerobic – This is probably a misnomer, as you aren’t actually at the anaerobic threshold, but let’s not argue semantics since we can’t even agree on what to call the zones.  What we can agree on is that zone 4 uses very little fat – you’re pretty much relying on carbohydrates.  This is when you’ll start seeing blood glucose drop without proper fueling.  Zone 4 is a great zone to train in to help build your lactate threshold (or anaerobic threshold, or any other name for it), but it’s not very comfortable.  The perceived effort of this zone is pretty high; but you’ll still have a bit of room to “drop the hammer” and go into zone 5 if you have to.  This is probably more of a race pace.  If you plan to be in this zone you had better plan your carbohydrates accordingly.  For me, it’s probably closer to 45g of carbohydrates every 45-60 minutes, with less bolusing.
  5. Speed/Power – Owww.  This is simply not sustainable.  You are burning carbs in the form of gylocgen.  Nothing else.  You better have some glucose on board and some glycogen left in your muscles or you will crash!  This is a zone for speed and power training.

EDIT: This is where my diabetes may vary – some diabetics, especially some Type 1’s, find this (and zone 4) may cause their blood sugar to temporarily spike.  Typically, this zone is hit in power lifting or high intensity interval (HIIT) training.  For me, I rarely have this reaction when doing HIIT, but during a race scenario I may have a post race spike.  Ginger Viera’s book, “Your Diabetes Science Experiment” discusses this.  The best advice I can give is test often, learn what your body does, and adjust accordingly.

There’s lots of sources debating what the zones are (see Wahoo, Fitscript, Competitor) but generally, the more anerobic your workout becomes, the more you need to take in more carboyhydrates to match what you are burning.  As you shift from zone 1 to 5 you drastically increase the percentage of carboyhydrates your body is using to fuel your performance.  So say I am going for an easy, leisurely bike ride.  I know from lots of HR monitoring that this will generally put me at ~100 bpm and my LTHR is ~160, so I know that this will be a mostly recovery level effort, and my body will mostly burn fat.  So I don’t generally eat extra for this.  However, if I am going for a 2-3 hour bike ride at tempo levels with some zone 4 and 5 work peppered in there, well, then I will adopt a strategy of 30g-45g of carboyhydrates every 45-60 minutes or so (a split between solids and liquids, temperature dependant).

Skratch Lab Rice Cakes

When fueling, eat real food! Homemade rice cakes, yum!

To illustrate, here’s two overlays I’ve created of my CGMS output and heart rate monitor.  The first is from a 2 hour, mostly zone 3-4 bike ride.  I started the ride high because I was delayed getting out the door – my tire bead wasn’t holding, so I was pinch flatting my tires.  I had bolused 50:50 combo bolus, so I started a bit high.  As you can see, my fuel source was mostly carbohydrates for the first part of the ride, and my blood sugar reacted accordingly.  I ate some to slow the decline.  I knew I was halfway finished with some hills coming up, so I only bolused 50% of the carbohydrates.  I ended the ride right where I wanted to, at 4.0 (and the trend stopped once I stopped).

The impacts of heart rate on blood glucose

The impacts of heart rate on blood glucose – bike ride, zone 3-4 mostly

My second example is from a run I had at lunch yesterday.  It was my best 10k yet!  41:35!  I had a bit of insulin active in my system, but I knew I’d be less than an hour so I did not fuel.  I started just above 6.5 and I knew I’d be running hard but I also know how my body reacts and that I had enough of a buffer.  Of course I ran with sugar pills in hand, but I knew after my training that I would not need them for this effort.  You can see that zone 4-5 really drive carbohydrates (glycogen) as a fuel source – my blood sugar started to decline about 5 minutes into the run.

The effect of heart rate on blood glucose - zone 4-5 run

The effect of heart rate on blood glucose – zone 4-5 run

 

I’ll try and add a HRM vs. CGMS post for Zone 1 and 2 to show the difference, but I hope this helps you see the impact of heart rate and blood glucose.

Until then, what’s the morale of the story.  Test before, test during and test after exercise.  Test a lot.  If you have a CGMS, use it.  When you first start out, stop and test.  Anytime you think you should, stop and test.  You will figure it out, and you will get more confident in what to expect.  It’s  not a perfect 1:1 ratio, but knowing how your body performs aerobically will help you understand how to fuel for performance.  Eventually it becomes second nature, and you’ll be comfortable with exercise and blood sugar management.  It gets better, it just takes a bit of work.  And as always, your diabetes may vary!

Did you ever feel selfish?

Have you ever been in the middle of a long run, or a great solo ride or some other great endeavour and felt selfish?

This thought dawned on me in the middle of a long run this past weekend.  It’s not the first time the thought has reared its ugly head.  I don’t know why I thought of it on this particular run, but I did.  Maybe it’s how much time I already spend on “myself” – even half-baked diabetes management takes time.  I don’t ask anyone to shoulder this disease, but my wife is a very active participant in sharing my lifestyle.  Still, while we’ve changed our lifestyle it still feels like we’re all doing it for me.  It feels selfish.  We weigh every food item, portion it out, spend time to plan meals (while balancing macronutrients) and the list goes on.  On top of that, I spend a lot of my mental time thinking about my blood glucose, why is it trending a certain way, what can I do better, what am I doing right.  So, long story short – I feel like I/we spend a lot of time on me because of diabetes.

So on top of that I add on long bike ride (3+ hours), a 20k+ run, whatever.  Something that takes time to plan and execute.  Something that takes time away from my family.  It starts to feel like I’m being selfish.  I have to remind myself that this is mental trickery – that diabetes management does not put me in some kind of “debt”.  It’s just part of who I am, it’s part of my normal, and that I should not feel like I’m being selfish when I’m out trying to improve myself and train, but still, the thought creeps into my head.

The irony of these thoughts is that I am notorius for not taking rest days.  I crave the endorphins and I love what it’s done for my blood sugar management.  I struggle to allow myself rest days – but I do, because they feel good and your body needs time to recover.  Maybe this adds to my selfishness – because I know how much I crave activity.  And maybe it’s good that I am mindful of how I spend my time, and make sure that it is well spent.

Then to bring everything full circle, I check my CGMS, put my head down and keep on running, keep on pedalling, and keep on living.  And I remember I have a wonderful family that supports me as I put in these long hours.  Diabetes takes time – that’s the truth, and we don’t have to feel selfish about the time it takes to get it right.

GravelGrinder

Finishing a 100k Gravel Grinder on a hot Sunny August Sunday – one of those days I felt a bit guilty. 😉

Understanding your own blood work

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I had quite possibly the worst doctor’s appointment this past week.  I was so excited to see my A1C after all the hard work I put in these past few months.  Good news, it was down (6.1%, my lowest ever), but I expected a bit lower.  I have some figuring out to do.

But onto the real point of this post.  First of all, a bit of back story.  My internist is new to me (definitely not the trade).  On my first appointment I felt rushed.  He did not look at or take my file I offered him.  I was disappointed, but thought I’d give it one last chance.  So this appointment was the last chance.  It did not go well.  During my appointment I asked how my blood work was and he said he was pleased.  There it was, I was judged by one number – my A1C.  I asked the admin for a copy of my labs as I always do, and what I saw shocked me!  I had some very scary results:

  • Two high LFT’s
  • Significant hypothroidism
  • Microalbuminuria!

So…A1C aside I was mortally terrified.  I was also gobsmacked that he didn’t mention any of this to me.  I managed to stop him before he went to another appointment and I got some handwaving about how the eGFR was fine so he wasn’t worried, and that he did not know my previous microalbumuria numbers, so he said it may not even be new (it isn’t, I’ve always had undetected levels).  He still didn’t want to follow up in less than 6 months.  So I went home and spent a few hours freaking out that my kidney’s were failing, etc etc.  You know, usual diabetes complication panic.

Then rational set in and I spent time googling and comparing old labs and new.  Then I got thinking – what’s different, why is my labwork so different.  Then it dawned on me – I had a home blood draw and ran a vigorous 10k 30 minutes before the draw (including a 1 km uphill finish).  Surely that can’t cause problems, can it?

Yes, it can!

It turns out liver function tests can be impacted by vigorous exercise.  Furthermore, TSH (and my hypothroid result) could also have been impacted by aerobic exercise.  Finally, a short burst of maximal exercise can create urine albumin: creatine ratios above the microalbuminuria threshold.  Now, if only my internist A) had pointed out these crazy results B) had kept a copy of my file to know this isn’t normal and C) ask me about my lifestyle to see if these were false positives.  I was frustrated, but I learned something – schedule blood draws during rest days, or even better – the morning after a rest day!  Some of these numbers can stay elevated 24-48 hours post exercise.  At least I learned that.

Now to find a new internist.

On the importance of nutrition

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One nugget that never really clicked with me for a while is that you cannot perform at your best if your blood sugar isn’t controlled.  To me the first step in controlling blood sugar is knowing what you are eating.  I don’t just mean reading the label.  I mean, eat real food – if you can’t pronounce it, don’t eat it! Plus, we all like eating good tasting food right?  You’d be amazed how much better freshly made things taste.  If you know what you are putting in, you can bolus accordingly and your control will be all the better for it.  Tonight’s menu was fish tacos, with handmade tortillas, cilantro-lime baked cod, pan fried veggies and homemade guacamole.  Talk about delicious!  Two tacos with 4 oz of fish and a side salad with balsamic vinegar – 40 g carb, <500 calories.  Win win!

So morale of the story – eat real food, enjoy it, and work on gaining control of your sugars.  I think that’s a tasty first step, and you’d be amazed at how much better you perform when your engine is fueled properly.

Here’s me rolling out the tortillas, Dexcom clearly visible in kitchen prep. 🙂

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Starting something

I never thought I’d write a blog, but a few things this month have been moving me towards this first post.  So why write a blog, what do I have to add?  I guess I should do the obligatory “long first post” where I dole out my credentials and you can judge what I know and what I don’t.  Well, if you hadn’t judged by the title – I’m a diabetic.  Specifically, I’m insulin dependant; DX’d in 2002 in my third year of university.  I’ve had my ups and downs, and I was not a role model of personal care for a long time.  

Things quickly changed in 2011 when I had a seizure from a bad hypo event.  You see, I was not a paradigm of health.  Sure, I liked to hike and rock climb.  But these undertakings were few and far between.  I still ate too much, sat too much, and spent too much time in front of the computer and TV.  In fact, anytime I hiked or climbed I could never really get my blood sugar right – I’d plummet, have to eat food, then bolus for the high, repeat ad nausea.  So, back to the seizure – I was actually on a rock climbing trip when that happened.  I was eating food I probably shouldn’t have, did not have the appropriate bolusing strategy for it, and dropped like a rock.  As a Canadian expat, living in Texas at the time, I quickly learned how expensive it can be to ride an ambulance!  After that event, I decided something had to give.  I couldn’t put my body through that, and I couldn’t put my wife through that – I needed to take responsibility for myself.  I didn’t want to just survive; I wanted to thrive.

So I started to make changes.  A lot of changes.  My wife supported me through them all, and made every single change with me.  I had a lot of lows, a lot of highs, and a lot of frustration.  It was experiential learning at it’s finest.  All the diabetic literature on exercise had pretty much instilled the fear of dying into me.  It was too cautious, yet so much literature said how beneficial it was.  So, I experimented a lot, and starting figuring out how things worked for me. 

In 2013 I met a great group of folks through the DFW Tour de Cure.  It was the first time in my “diabetic life” that I actually talked to other diabetics.  It was revolutionary.  It was mind blowing.  We could share stories, compare blood sugars, see what worked for one person, what didn’t work for another, and try and figure out why we saw different results.  I went from just starting cycling in 2013 to riding a couple centuries and polishing off the DFW Tour at 20.2 mph, and cycling just shy of 5000 miles in 2013.  On top of that, I started running, did a triathlon, climbed a mountain, and had lots of adventures, all the while still learning what the hell my body was doing in these situations.

Near the end of 2013 we repatriated back to St. John’s, Newfoundland.  We miss our Texan friends, but we love being home.  After a period of settling in I realized that I needed a local diabetic community.  Luckily, a T1D adults group was just started and I got to meet some wonderful people.  It’s been through this venue that I’ve been inspired to write this blog – you see, some of these folks supported me when I tried to setup a group for diabetics trying to be active.  We’ve had three consecutive weeks with growing attendance and it’s been great.  The #DiabetesEmpowered movement that Team NovoNordisk has started has also inspired me.

So, back to the question – why write a blog.  Well, I just find it so damn hard to find any information on physical activity, diabetics, and how they manage it, how they cope, how they thrive, and when they have good days and bad.  What do diabetic athletes eat?  What do you think about on a long run?  Where do you mount your CGMS while cycling?  How do you keep pump tubing from tangling in your cams when leading trad?  These sorts of questions just don’t seem to pop up that often.  I thought that maybe by sharing my unsolicited experiences that some people could get something from it.

Now, the obligatory – I AM NOT A HEALTH PROFESSIONAL.  This is NOT a how-to guide.  If you learn something from me that’s useful – great!  But, please be careful.  Your diabetes may vary.

So, please enjoy or at least tolerate me.  And with that, here’s to new beginnings!Image