Good days and bad days

When you hear people with diabetes talk about having ups and downs they mean it literally. It's not easy controlling your blood sugar, though we have never had so many tools to help us as we do now. We have better blood glucose testers, we have fast acting insulin and pumps to deliver it, we have continuous glucose meters that tell us every few minutes which direction our sugar levels are going, we have a wealth of apps that allow us to track what we eat, what out blood sugar levels are, and how much insulin we take. Some even tell us how much insulin to take and our predicted HbA1c result. And finally we have the Diabetic Online Community - the DOC. The community of people online supporting each other, giving advice and showing people that they are not alone.

Even with all those tools somethings cannot be helped. Sometimes you get it wrong. Conversely there are days when things just go right. There are good days and bad days, ups and downs, highs and lows. This past week has been one such week. Sunday night before bed I was up in the 240s and before bed and after a correction I woke up at 101.  Pretty much perfect.  I tried and experiment that day, instead of taking some insulin and eating I decided not to "insulate" and not to eat before training.  By the time I was setting off for my warm up I was down to 95 and decided that it was time to eat something small.  At the end of training two hours later I was up to 152, exactly why I normal like to take insulin. The result was that by the time I sat down to eat I, which was an hour and a half later I had risen to 233.  The conclusion from this experiment is that I must take some insulin after training especially if I have not had any that morning.

That night I went out and had a late dinner, and way too many carbs which led to high sugar in the morning on Tuesday followed by an over correction leading to a hypo right after my warm up.  This correction was taken into the muscle on my forearm.  It is not advised to inject in the muscle as it tends to make the insulin work much more quickly than normal, but that was my intention.  I had to take it easy in training and ate much more than normal for a two hour session.  Note to self: muscle injections are a no no right before training.  I was fine for the rest of the day.  I forgot for the second day running to test before bed.  Waking up again at around 240.  I corrected again, this time in my stomach.  I started training this time at 212 but 15 minutes later after my warm up I was down to 164.  By the end of the session I was at 91 and my blood sugar remained nice and balanced for the rest of the day.  Success! Some days things just go right.

On Friday I had been fine all day but hadn't tested since lunch and ended up at 233 before dinner at my mother in law's.  She is a wonderful cook and I struggle not to go back for extra helpings.  I made sure to take a higher does of insulin factoring in my high blood sugar and how much food I would be eating.  Never the less I tried to go easy on the carbs.  Before we left for the drive back to Tel Aviv, I tested my blood sugar.  It was 403! I injected 6 units instantly into my forearm.  It did drop a bit but an hour later it was still very high at 329.  My wife insisted on driving home despite my idiotic protests that I was fine, I wasn't.  By the time I went to bed it was still above 200 many hours later so I took another 4 units.  I had had a huge amount of insulin, it was very bizarre.  The following morning I woke up with a level of 122.  This could not have been better.  I drove out of the city to training, injecting a few units before I left and eating a sandwich on the way.  During the 4 hours of training and the rest of the day my sugar levels were perfect.  There was a point just before a big climb that I tested and had 109.  This was a bit of a worry so I ate a second gel, I had eaten one a few minutes earlier.  My trainer insisted that I checked my sugar 5 mins later, which meant after 1Km of the climb the whole team stopped while I tested.  Funnily enough I still set some new PBs on the climb, including the stoppage time.  My performance really is better when my sugar is under control.

live long and stay health.

See my ride here

Gran Fondo Hermon 2013

This was to be my first time riding in a Gran Fondo.  I have done other much shorter organised rides, but this was different: Timing chips, stops along the way to fill up with water food and isotonic drinks, closed roads, and support vehicles.  I signed up weeks ago for the full 170km ride along with a few guys from my club (X Team). Some others signed up for the 100km start. Regardless there was going to be a lot of climbing

The profile of the 170km, most of the last 100km are uphill!

My Ride

The night before the race I got everything ready and loaded up the car.  Changes of clothes, energy gels, sandwiches.  Everything I could possibly think of.  I went to bed nice and early.  My alarm went off at 4am and I woke up a little disorientated.  I shook it off and tested my blood sugar - 255mg/dl - not a great start to the day.  In the days running up I had lowered my Levermir to 24 units, and I took a lower amount of insulin for dinner the night before.  I took 8 units of NovoRapid and ate a cheese sandwich along with an espresso to get me going.

My food for the day, sandwiches, granola bars, energy bars and gels

My Medic Alert bracelet sill hadn't arrived so I drew myself a little tattoo with sharpie

I set off and go to meet Alon, He comes down and we pack the car up just as its starts to rain.  It rains the entire way there and he tells me that it is supposed to be cold and wet at the start.  This is not looking like its going to be the day I was hoping for.  We arrived at the start, still raining, in time for "Sunrise," 6am.  Normally it would be a beautiful view over the Jezreel valley, this day not so much.  Everyone looks unhappy, especially the people directing traffic, just standing out there in the rain.  Two guys from our group are threatening to turn around and go home.  I ran to the coffee shop to get us some coffees, I did a quick test - 277 mg/dl.  Not ideal, but still plenty of insulin on board and when I start riding that's gonna drop fast.

"Sunrise" over the Jezreel valley

Getting ready at 6am in the rain

Miserable looking skies and people

The weather at the start

The weather at the 100km start

Over the course of the next hour the rain stops and it brightens up.  Our team mates decided to stay and there is good humor among the participants while we get ready.  Then an announcement over the speaker.

"We are not starting from here, it's too dangerous.  The roads are too wet."

They were drying out but clearly the police were unwilling to allow us to go the planned route.  We were all invited to the start for short ceremony to remember a fellow cyclist- Gavriel Lerner, killed in a hit and run earlier in the week.  He had registered to ride the Gran Fondo but had been killed while training for it.  His team mates from Eshcolit were all there to commemorate his passing.  We were given black arm bands to commemorate Lerner on this ride.  After the short ceremony we went back to the car and drove to the newly scheduled start.  It was beginning to feel like this year's Milan San Remo. There were a number of groups that rode to the new start.  Some opting to do the climb others rode through the valley and cut out about 30km.  The organizers had said that they were not offering transport back to the original start so we decided to follow the instructions and just drive.

Ceremony for Gavriel Lerner

We arrived at the new start, having passed plenty of groups riding along the way, with plenty of time to spare.  Alon put the seat back and went to sleep for an hour.  I checked my sugar around 815am - 256mg/dl - still high but hungry I took another 7u of insulin and ate half a cheese sandwich.  I went to find the start and go for a little warm up ride and ate a couple of dates along the way.  I realised at this point that I had taken 15 units of NovoRapid since waking up.  Despite being high and having eaten predominantly carbs I was starting to get worried that as soon as I started riding I was going to drop very quickly.  My test just before 9am was 150, this was much better, but worried that I was going to drop more I helped myself to a tea with some sugar and a couple of dates.  Twenty minutes later I was back up at 174 and I was relaxed that things were going to be OK.

Driving through the Jezreel valley

New start and weather was improving

I went back to wake up Alon and we finished getting ready.  I packed food into every pocket that I could and stuffed a bag with more and some warm clothes for the finish.  We rode together to the start and dumped our bags and spare wheels in another team's follow car.  (This turned out to be a huge mistake as we had the option of putting our stuff in a FedEx truck that would take it to the finish. We thought that we would see the car again during the day, sadly we did not.)  One final test just before the start - 138mg/dl.  Finally in my target range, the sun was out.  This was going to be a great day.  I took arm warmers off and slipped them in a pocket.  I still had a short sleeve and long sleeve top on over that, and my bib shorts and leg wamers on too.  I reasoned that I might be a little warm at the beginning but it was definitely going to get colder.

Refreshments at the start

final preparations

Lining up for the start

Lining up for the start

Finally the start. A couple of kilometers of flat and then straight in to an 8KM climb.  There were many switchbacks and tough ramps.  There was nothing to do but stand up on the pedals and grind away on the steepest bits and try to recover on the shallower sections.  My heart rate monitor had me well of 90% for far too much of this climb.  But at the same time I was feeling really good.  The weather was warm and I knew my increase heart rate was partially due to the fact I had too many layers on.  I was encouraged by the fact I was passing a number of people.  At the start I was with a few X-Team guys but none of us were riding at the same pace, while one guy rode ahead of me and a few others trailed behind, I just stuck to what I was comfortable with and found my rhythm.

Leaders on a switch back

Looking back down the hill, riders and their support cars

Climbing

More climbing

Riders in groups drafting on the flatter sections

As the climb flattened out I had reached another member of X-Team, Doron.  Doron and I recovered from the climb and worked well together.  I was worried about the effort I had put in on the climb and began eating.  Between the start and the first stop I ate 2 gels and a granola bar, along with plenty of water with electrolyte.  At some point this train of about 6 riders starts to come past us.  Doron and I pick up the pace and joined the train.  We were hammering on the flatish section at 40+kmph.  My heart rate was coming down and I was feeling good about the rest of the ride.  We made it to the first rest stop.

Pelotons are formed

The first rest stop

I filled up my water with sugary isotonic liquid, drank a bottle of water and ate a granola bar and a gel.  Way too much all at once.  I should have done that more slowly over the next 15 minutes.  My meter read 116 at 1120am, still had some insulin on board and the effort clearly helping keep my blood sugar from rising.  Doron waited for me but the rest of the group we were with had left already.

"I'll take mine to go"

The route was heading uphill in long drags punctuated by short steeper bumps.  Each time I looked at the sky it was less blue, with white clouds turning to grey and the temperature dropping sharply.  We caught our previous group who had slowed their pace.  Then we started to push on.  Soon we were pretty much on our own, passing occasional riders and one or two passing us.  The weather closed in and started to rain.  At first it wasn't so bad, almost refreshing.  The water running down my face and washing the salt into my mouth was less pleasant.  The change in temperature made my legs feel tight and the food in my stomach was giving me cramp.  I told Doron to continue and I kept a slower pace.

Deteriorating weather

I was by myself starting to feel the pain of the earlier exertion and regretting everything.  I was now starting to feel the cold.  I kept pushing myself, knowing at some point there would be some downhill where I could relax even just a bit.  I kept an eye on the time so that I knew when I needed to check.  I kept pushing myself, when I get to the next top I will stop and check. It never came, the cloud was all around me, so every time I thought I was close to a peak it just kept going up.  Finally I was starting to get worried, I knew there couldn't be much insulin left floating around my body but I was cold and working as hard as I could to keep my body temp up.  I didn't just want to eat if I didn't need to.

Riders caught in the downpour

Finally I found some flat ground to stop.  As I unclipped my foot from the pedals I hear a chink of metal on the floor.  One of the bolts from my cleat had fallen out.  I laid my bike on the ground, and fished out a tool from the saddle bag.  It was pointless the thread was gone.  I checked that the other bolts were tight and that there was no movement in the cleat.  All seemed OK.  I put my shoe back on and started checking my blood sugar.  For a while I was standing there completely alone wondering where everyone else had got to.  Then two police bikes came past and told me to stand more to the side of the rode.  The made sure I was ok and carried on.  Then a couple of groups came past and they slowed to check I was OK.  The last group contained two of my team mates, so I quickly finished up and jumped back on my bike.  The meter read 119, an hour and 20 minutes after my previous reading.

Having had a few minutes rest and the terrain flattening out I was motoring along and despite eating a gel and an energy bar along the way I caught up with my team mates (Roni and David) from X Team.  I was feeling good, but it was raining and even hailing hard.  I had no jacket as Roni quickly reminded me.  We turned a bend and the wind hit me.  The rain was driving in to my face.  My sun glasses were no use and were hanging off my jersey but the rain was coming down so hard that I couldn't see anything.  I wanted to climb off my bike and give up, but there was no where that could give me shelter.  I was praying for a petrol station or somewhere that I could stop and take refuge.  Alas nothing.  The road began to go up hill again and I just rode at my own pace.  Drafting was impossible the spray from other bikes was worse than going it alone.  My legs were sore due the cold and I was running low on energy.  I was cold, wet and uncomfortable.  I tried to push myself harder hoping that the increase in heart rate would warm me up.  Unfortunately my legs wouldn't respond.  My heart rate would not go up and I was feeling terrible.  I looked down at my computer and I could see that we were closing in on 65KM.  I remembered from the schedule that there was supposed to be a food stop there.

The second stop for refreshments at Ein Zivan

Soon enough I could see people through the spray pulling off to the side of the road into a car park.  I saw plenty of bikes stacked up against a coffee hut.  This hut turned out to be a shipping container covered in wood, but it was a place to find some respite for many of my fellow riders.  I propped my bike up and ran for cover.  The container was full of cyclists all soaking and freezing, and two increasingly annoyed women trying to sell coffee tea and snacks.  Everyone was happy to pay for a warm drink as long as it kept them inside, out of the wind and rain. Despite most people being very cold and shivering people were in good humour.  Alon was there, he had been way ahead of me but wearing only a short sleeve jersey and cycling shorts.  I watched him shiver for an hour.  Pretty soon we heard that the rest of the ride had been cancelled.  Some had made it 15km further on, in the next town, but no one was going further.  After quite some time coaches were sent to pick us up and take us first to the town where everyone else was and then back to the start.  Two coaches came and filled up quickly.  They sent another one but by this time we had been kicked out of the coffee hut and I sought refuge inside a portaloo.

Everyone crammed into the coffee hut

The coffee hut was full to bursting with cold riders

A few of a nearby winery and fields 

Finally the last coach came and picked us up.  It was a huge relief.  While I was standing in the container I checked my blood sugar it was 186 mg/dl at around 13:21.  Later on the bus at around 1500 I checked again 471 mg/dl.  Where did that come from, there must have been something on my finger.  I checked again 395 mg/dl.  Not ideal but not as bad.  Hopefully it will come down soon.  An hour later I checked again - HI.  That could not be good.  HI usually means over 500.  I have never been that high before.  I would have expected to feel terrible but I was already feeling bad from the cold, even though I was on the bus.  I reached for my NovoRapid.  I took 20 units and ate a cheese sandwich to keep me from dropping too quickly.

Everyone and their bikes on the bus

Alon and I feeling worse for wear 

My meter reading just HI indicating I was over 500mg/dl

Over the next hour I checked a couple of times, remaining extremely high and starting to get worried.  Fortunately by 1800 I was getting readings around the 350 mark.  Not at all ideal but heading in the right direction.  This was about the same time we made it back to the start.  The weather now sunny and warm again. We picked up our bikes and finally got our bags back so we could change into some warm clothes.  I asked Alon to drive us home as I was not feeling up to it.  By 1900 my BG was down to 145, and of course just as I got home I went a bit hypo.  Fortunately my wife had prepared a lovely dinner including a great soup to warm me up.  I had a hot shower and went to bed by 2200.

It was not the best day riding for me.  It was quite horrible in fact and not much better from a blood sugar point of view.  Some of it was my fault.  If I had taken a rain jacket with me it would have been much better, I may have even finished the 80KM.  I really do not know what happened to my sugar, feel free to leave me a comment if you have an idea.  I think the organizers did a great job changing the logistics at the last minute to accommodate the unseasonably bad weather.  I look forward to trying again next year.

The pictures of X Team

All the official pictures from the Gran Fondo.

My diagnosis

As it is World Diabetes Day today I though I would post about my diagnosis inspired by the story of @ninjabetic1 which is found on The Independent's website.  Let me start off by saying I was one of the lucky ones.  Like ninjabetic my brother also ended up in hospital with DKA (diabetic ketoacidosis).  DKA is pretty horrible, when you become diabetic your body thinks you are starving because without insulin your cells do not get enough sugar.  So the body compensates, fat and protein are broken down, this is significant people lose a huge amount of weight.  This makes the problem even worse.  Your cells still aren't getting enough sugar but the body is dumping more sugar into the blood.  So your sugar rises and rises.  The fats that get broken down release ketones into the blood stream.  These ketones cause the blood to become acidic.  It goes with out saying that this is bad.  This is usually the point where people find out they are diabetic.  Your body does not like having and acidic blood stream and it rejects it by telling you in no uncertain terms, pain, lots of it, and vomiting are the main ways.

How do people get to this point?  Well they don't know, their parents/teachers or guardians don't and sometimes their doctors don't know either.  What don't they know? They don't know how to recognise the symptoms of diabetes.  DiabetesUK has a campaign on coinciding with World Diabetes Day to educate people about the 4 Ts. They are:

• Toilet - you need to pee all the time, I mean ALL the time
• Thirsty - nothing will quench your thirst
• Tired - you literally have no energy
• Thinner - because your body thinks it is starving it breaks down all the fat and protein

Educating people about this will help people realise when they have the symptoms of Diabetes before it gets too serious.  Unfortunately I am talking about Type1 diabetes.  There is no way to prevent it or delay it.  Once you have the symptoms it's not going away.  But you can avoid ending up in hospital like my brother and ninjabetic.

I was lucky, my brother had been diagnosed with Type1 Diabetes 12 years earlier.  At that point, being the budding scientist that I was I learned all about it.  In short when it happened to me I knew early, I knew so early that there was no rushing to get me an appointment with the specialist just a casual blood test and confirmation.

My Story:
October 2004, I had wrapped up my yearly Succot party.  Since I was a student we had been having a get together once a year at my mum's house.  Many (up to 10 in the house at once) of my friends would come over.  We would build a Succah, cook up a storm.  And have a great time.  We had friends come for meals in the freezing cold and rain of Manchester.  Plenty was eaten even more was drunk, and everyone had a good time.  After a couple of days of this I woke up on the Monday morning to get ready to go back to work.  I felt terrible, I was thirsty I had a headache, I was tired.  Of course, I thought to myself.  I am hungover.  Too much partying.  Tuesday morning was the same, and this time I knew I wasn't hung over and my thoughts went back to 12 year previous.  I remembered how thirsty my brother was, he would drink coke because no one had any idea that it was making him worse.  I remembered how tired he was, and ill all the time.  And why did I need to pee all the time, this added up to one thing in my mind.

The thirst, tiredness and needing the toilet all the time got worse all week.  That weekend I was staying with a friend.  A friend I have known most of my life.  He is also a doctor.  I told him what was up, and what I thought it was and like a good friend told me to go see a doctor.  Thanks for that!  He checked some things in a textbook and we read up on it together.  He told me that I needed a fasting blood glucose.  A few days later I went to the doctor.  I got my blood test and I got referred the the Manchester Diabetic Center.  A place were 10 years earlier I had done work experience shadowing Prof Boulton who was head of the center and an expert in Diabetic complications. (At one point I wanted to be a Doctor, a medical one)
My first appointment was mainly with a nurse.  She was wonderful.  I explained I knew something about my disease so she suggested I tell her what I knew and she fill in the gaps.  I did, she didn't have much to add.  But she tried to prepare me for the reality.  As I found out knowing all the theory just does not prepare you.

I was lucky.  I had the knowledge then that they are only just trying to get across to people now.  If I hadn't known a couple of months down the line I would have been in big trouble.  8 years on I am not only healthy but training for endurance cycling.  I have an amazing care team and my friends and family are amazingly supportive. Being Diabetic is a pain in the ass, but I am not letting it get in the way of anything, in fact it gives me more determination to reach my own physical goals. TeamType1 say it best.

"Diabetes doesn't stop us. It fuels us"

Do not get frustrated

Having diabetes is frustrating. It just is. While other people are tucking into their food I am sat fiddling with testing equipment, needles and pens. Even worse when I am keeping my logs, I have to type into my phone what I am eating.  Worse still when out with friends it looks rude to be sat there typing on my phone while at dinner, I am not on twitter this is a medical necessity ... mostly.  When we go out to restaurants for dinner I have to ask the waiter what carbohydrates come on the plate.  When we go to friends I look impatient because 5 minutes before the meal starts I am asking them whats for dinner, so that I can get my calculation correct.  And that's just the day to day management.

Then there are the highs the lows and the swings between the two. They are both horrible in different ways. Highs make me feel terrible in a lethargic and fuzzy headed way.  They are not so scary in themselves but I know what long term bad control does to people.  I have seen a lot of complications of diabetes and it is not pretty.  Blindness, kidney dysfunction and worst of all loss of limbs is a horrible prospect.  Especially when I wake up high and I know I have been high all night, that is when I start to remember what I have seen.  It is scary.  The hypos are more scary at the time, they can also have a prolonged effect even after I have recovered my blood glucose levels I am still affected by it later.  The worst is early morning or in the middle of the night.  I wake up, a neat reaction to low blood sugar, so I can deal with it before it gets too bad.  But the interrupted sleep usually messes up my next day.  The additional problem with hypos is other people, some know what to do, some don't, some panic some don't.  My wife knows what to do, she will get up in the middle of the night and get something from the kitchen if need be.  She will also stop me from doing something stupid.  I had a hypo while were out the other day and she stopped me from carrying on and made me sit down and drink a coke.  It must be frustrating for her too.

This reminds me of something that happened to me a few months ago. We were returning from London on a British Airways flight. It was towards the end of the flight and people were being told to return to their seats to prepare for landing.  I started to get that feeling.  Slightly fuzzy head, and tingling in my lips and tongue.  "Uh oh" I said to my wife as I started fiddling around with my BG monitor.  The reading was in the 40s (mg/dl - thats around 2.5mmol/L).  I stumbled my way to the back of the plane.  I said apologetically that I was diabetic and I needed to sort myself out. They were really quick on their feet, water, coke, something to nibble on.  I waited while I recovered and chatted to these two wonderful women.  They said they had had training in how to handle this situation and one of them had been a nurse earlier in her career so was familiar with my condition.  They handed me some more water and coke to take back to my seat just in case.  I was stunned, I mean it was so well handled, no panic, no calling doctors.  Just understanding the situation and handling it perfectly.

So I do what I can to get it right, I am frustrated by what I have to do, and more frustrated when I get it wrong.  I am sure I calculate my insulin correctly then I check a few hours later and find I am really high, or low.  Then I have my recent Hba1c result 7.4%, not terrible but after the training that I had been doing and the loss of weight I thought maybe it would be and improvement.  This is the biggest frustration.  With all the other frustrations one would hope that it would lead to better results.  But when it doesn't it gets super frustrating.  The natural reaction is to say to yourself, its not worth it.  Why bother trying so hard when it makes no difference.  Why test? why exercise so much? why bother trying to calculate how much insulin, take less and just avoid the hypos.  Why not? because its worth it in the long run.  This disease takes practice and a lot of work.  You cannot expect to get it right every time, but you can learn to listen to your body, you can work at every aspect of what you do, and you can get better results.  Getting frustrated and giving up is the worst thing you can do.  If you want to scare yourself into getting it right ask your doctor to tell you about diabetic complications.

It may seem like it isn't but this is a simple problem.  It is.  It is a closed loop, you are closed loop.  Your results can be calculated, what goes in will come out in the result.  It is not as simple as the equation of insulin exercise and food.  That's the starting point, know how your body reacts to these 3 main components.  What changes that reaction; time of day; illness; stress.  You can understand how you end up with the results you do by keeping a log, keep as many details as you can, test often.  Get in tune with your body, accept that you will have bad days and bad results, but don't let it get you down.  Keep going, keep striving to get it right.  Live a long and healthy life.

Nearly 100KM

I set out to do a 100KM ride.  I planned the route, set my self a target, and almost made it.  I got to 97.5KM and got a puncture.  At this point I decided enough was enough and called my wife to come and get me.  I had no energy to change the inner tube at this point and I wasn't too far from home.  So that was a little disappointing.  From a diabetic point of view I did things differently and I found that it resulted in a much better outcome.

The big difference was that I probably used a lot more insulin than I normally would have.  I retained my 30 unit dose.  I took a little less at dinner the night before, and only 4 units with my sandwich and coffee in the morning.  This meant I had to be super careful and eat enough.  I checked regularly on the ride and ate too.  I had about 4 gels and a couple of granola bars during the ride.  I was told I needed about 15g per hour but that sounded too little I trusted my gut and I was right.  I had 4 energy gels and a granola bar while out on the ride which is more than double what I was recommended.  As you can see from my sugars below, this worked well for me.  If anything I could have eaten more.  I think next time I plan to ride for as long as this I need to do better carb loading.  Perhaps eating a little more bread before the ride would have been helpful but no extra insulin.  When I finished my ride I was heading for a low, fortunately I tested and had some food immediately.  I think I should have eaten soon after I finished the ride instead of waiting until after my shower and nap.

That evening I allowed my blood sugar to rise so that I would not have a low over night.  I thought it might be a little high and having eaten something unexpected in the evening I decided that I should add a correction.  This was a mistake as I ended up waking up very low.  I know better for next time that after a long ride I need to leave my blood sugar on the high side in order not to have hypo over night.


Friday evening
20:03 - 167mg/dL,Friday night dinner,11units short term,30units long term,
22:59 - 312mg/dL,
01:00 - 254mg/dL,
01:28 - 234mg/dL,

Saturday morning
06:13 - 152mg/dL, Bread Roll with peanut butter, Coffee with milk 4units short term
06:55 - 188mg/dL, - leaving the house
07:29 - 196mg/dL, - warm up done, 1 41g energy gel
08:27 - 159mg/dL, - 1 41g energy gel
09:04 - 132mg/dL, - half way point  (50k)1 41g  energy gel and half granola bar
09:50 - energy Gel
10:21 - 141mg/dL, - 80KM, half granola bar
11:30 - 90mg/dL, - back in the car, 2 cookies
11:53 - 108mg/dL,
12:14 - 119mg/dL,
13:18 - 144mg/dL,
13:55 - 139mg/dL,
15:10 - 163mg/dL,Noodles with chicken, 4units short term
16:14 - 183mg/dL,
17:17 - 146mg/dL,2 Bread rolls with cold meat and humous,9units short term.
20:04 - 238mg/dL,
20:47 - 30units long term
21:15 - Some fish and chips I was eating off a friends plate
22:15 - 268mg/dL,
22:15 - 3units short term as a correction for the fish and chips
22:58 - 225mg/dL,

Sunday morning
06:24 - 43mg/dL,3 cookies
07:03 - 106mg/dL,

Meeting my medical professionals

Today I had my meeting with a nurse, dietitian and a Doctor, all of whom specialize in diabetic treatment.  Because of my change in regime due to my training I came armed with a bunch of questions as well as the past week and a half of documented sugars levels, insulin and food intake.  I see the same people every 3-6 months and have a blood test a couple of weeks before I go.  The blood test is Hba1c and once a year I have a full panel to check my kidney function, cholesterol and a few other things.  The most recent Hba1c result was 7.4% up from 7.0% the previous test 6 months earlier.  I was a little disappointed.  With my change in regime I was really hoping for an improvement in my result.  Sadly no, I have got my weight down from 91Kg to 87Kg (fully clothed).  I am happy about that but I really want to get down towards 80Kg.  I am sure that will come with time.

Both the appointments with the Dietitian and Doctor were productive.  I have an additional appointment with the dietitian and someone who can advise me on sport in a couple of weeks.  I hope that will be useful too.  I had a number of questions that I needed answering plus we talked about how my training was affecting my blood sugar.  The most interesting thing was that I have been making a mistake with my long term insulin.  I have been told to keep that constant and only vary the amount I eat and the amount of short term insulin that I take before and after exercise.  Additionally we calculated that I should be eating about half what I eat every hour.  I eat about 30g of carbs in energy gels and bars, I need to try to eat 15g on every hour.  I should also eat some slow burn carbs before I ride and take a small amount of short term insulin.

Hopefully my next meeting I will learn more about the food and insulin intake that I need to do long rides without hitting the wall and without having hypos during and then having huge swings after.

I had some questions prepared for the appointments, I have listed the ones that I have already discussed above with the answers I was given:

I have hard bumps around my injection sites, they are more noticeable to the touch not that I have lost some weight.  Is it hard insulin, and can it be released slowly into my system.  Will they ever go away?

A: It is not hard insulin.  I didn't fully understand (a consequence of us both speaking to each other in our second language) but I believe what she told me was that it is fibrous tissue that forms at the injection site as a reaction to too many injections in the same place over too short period.  They do not go away. (sadly as I am losing weight they are becoming more noticeable)


Can I get a Continuous Blood Glucose monitor?

A: No currently I am not eligible on my current Kupat Cholim (health plan) - Maccabi Gold.  I am not at risk enough and they are very expensive.  I am free to buy them at my own cost but they are very expensive.  Dexcom Medtronic Abbot.

Should I eat late in the ride to stop excessive glycogen breakdown?

A: I should eat throughout the ride to try to keep constant levels of blood glucose and avoid large swings in either direction.

Where can I get a medic alert bracelet?

A: The Israel association of diabetes has information about them on their website.

If I have a chocolate chip cookie that weights 45g total (it is home made so I know its flour, sugar, butter and chocolate) how much insulin do I need to take for it?

A: About 50% carbohydrate to 20 to 22.5g when estimating how much sugar to take.  Bear in mind that the chocolate and butter are fats which slows the uptake of sugar.  This makes such a food item less suitable for recovering from hypos

Why is my Hba1c so high?

A: Not sure, possibly from the high swings after riding. 

Hill climbing repeats

Today I did some hill climbing repeats as suggested by this answer on Stack Exchange.  I did not have much time so I thought this would be a good exercise for training.  My hill climbing is terrible.  Looking at previous climbs I can go hard on the flat and descend with the best of them.  My hill climbing however is slow compared to other riders who I can keep up with on the flat.

My max speed from last weeks ride.  I am a bit of a demon descender!

Even the slightest incline can see me dropping off the pace.  So my goals were to do this hill (a category 4, 2KM climb) in under 6 mins and to see if I can manage my sugar better to avoid the huge swings I am getting after intensive training.  In case you don't want to read on I did not achieve either goal.  I did cut my best time for the hill down to 6:12, 24 seconds better than my previous best, and I climbed the hill 7 times in total in under and hour and a half.  So that being said it wasn't a total bust of a day.

The past two weeks have been a similar pattern.  Fine during the ride, and blood sugar rising fast after the ride.  I make the same mistake both times, over compensating for the hyper by taking too much insulin and have a low blood sugar episode sometime later that day.  From the previous ride until this one my blood sugar control has been really good.  The raise in metabolic rate as a result of my exercise seems to be keeping everything else in check.

In More Detail

The night before the the ride we went out for dinner.   I always find this a little tricky.  I have learned not to take my short term insulin before I get my main course or at least until the first course arrives if it is accompanied by bread.  The reason being if I take my bolus when I sit down and there is a delay in getting the food then I will have a hypo before I get to eat anything and that will be dinner ruined.  Inevitably service was very slow, the staff were great, and we were given a number of complimentary dishes.  They were mainly deserts so I missed out on that somewhat, but thankful as every that I waited to take my insulin.  The other tricky part is I never know how much food I am going to get (unless I have been to the restaurant and ordered the exact same dish before).  So I wait until I can see my food to do a better estimate of how much insulin I need.

I took 2/3 my normal dose of long term insulin (20units) and lowered my bolus a few units as well.  I probably should have skipped the alcohol, but it was only a glass and a half of wine, not like a serious binge. After dinner I was out playing poker with some friends until 2am.  Whilst I have done this before I am pretty sure I would have a better performance if I had 2 or 3 extra hours sleep the night before.  I do not believe however that it makes much difference to my diabetic control.  I woke up with higher than normal blood sugar as expected.  I decided this time not to eat substantially before riding.  So I had a cup of coffee and a granola bar on the drive to the area where I was riding.

After a little warm up I started the repetitions.  I checked my blood sugar after a few repetitions and ate an energy gel and a granola bar during the training period.  As usual after the training my blood sugar started to rise.  After I returned home I ate and had some insulin to try to bring my blood sugar down.  This was fine, but I found myself a little later at a picnic and eating again.  I only ate a small amount and the additional bolus was unnecessary less than 3 hours after my previous one.  As a result later that afternoon I had a serious hypo, which while resolved was unpleasant.  I made sure to go to bed with high blood sugar and the following morning I was fine.

Friday evening
23:39 - 254mg/dL
02:02 - 228mg/dL

Saturday morning
06:48 - 157mg/dL, - leaving the house
07:39 - 196mg/dL,Granola bar - before exercise
08:49 - 166mg/dL, Energy gel, Granola bar - during exercise
09:36 - 249mg/dL, after exercise
10:21 - 279mg/dL, back at home
11:25 - 313mg/dL,Hafouch. Tuna toast, Insulin 14units
12:48 - 256mg/dL,Some pita and humous, Insulin 6units
17:08 - 41mg/dL,Cookies, 1 piece of toast.
17:36 - 99mg/dL
20:03 - 234mg/dL
20:32 - 253mg/dL,Beet tart (pastry) with goats cheese, Insulin 10units
22:46 - 306mg/dL

Sunday morning
07:19 - 136mg/dL
08:13 - 126mg/dL

Hard day in the saddle (cont.)

We arrived at the zimmer around sun down, having checked the location of start.  It was just a few flat kilometers from where we were staying.  A nice little warm up.  The zimmer was comfortable and spacious.  It had a nice size hottub and a little kitchenette.  We relaxed, made dinner and had a quite evening while I prepared for the bike ride the following day.

In preparation for my ride I put some tape on my bike with a message saying that I have Type 1 diabetes and if there are any problems / emergencies call my wife.  I tried to stick the same message to my jersey but without success so that went on the back of my phone instead.

I am going to try the following format for these blogs where by I list my sugars what I ate and how I felt in the run up to, during and after a big bike ride.  It maybe dull, but this is how I manage my life on a daily basis.  Other diabetics maybe able to learn something, or possibly help me out by commenting on my results.

Bare in mind my usual dose of long term is 30 units and short term is 4 units per 15g of carbohydrate at breakfast or lunch, plus 1 unit for every 25 I am over 100mg/dL and in the evening 3 units per 15g carbohydrate and 1 unit for every 30 I am over 150mg/dL.  Usually I reduce my long term before and after a ride to 20 - 24.  I also reduce my short term insulin for the evening and morning meals before a ride and the meal immediate after too.

Summary:
The night before the ride I had a relaxing evening and an early night.  Dinner was pasta with tomato sauce cheese and tuna, I took a reduced dose of both long and short term insulin.  Woke up before the ride with slightly elevated blood sugar, ate and had a small amount of insulin in order to continue raising my blood sugar.   I filled up two water bottles with water and electrolyte powder, almost 1.7l in total.  I took in my pockets my tester, glucagon hypokit, phone, insulin pen, 5 granola bar and 5 energy gels.  By the time I started the ride I was pretty high.  I ate and drank when I could en route, when ever there was a stop I checked my blood sugar.  I finished with acceptable blood sugar, which then rose to unacceptable levels followed by dropping to hypoglycemic levels.  All leveled out in the evening and the following day my sugars were great all day.  Below is a more detailed diary of my sugars and food intake.

After such a hard ride I was expecting to have worse cramp than I did.  This may have been prevented by drinking water with electrolytes instead of plain water.  I think I need to eat more often on the ride than I did.  I am worried about my huge swings after my rides and I think I would benefit from a continuous glucometer. I am also worried as I have been training reasonably seriously since the end of august and my Hba1c which I did 3 days before this bike ride came back at 7.4%, which is much higher than I was hoping for.

Arriving at the start

What a lovely place to start a bike ride

It's gonna be a warm one

Me and my Merckx EMX-1 before the ride

Some other riders relaxing before the start

lining up on the start line

The start and the Lebanese border

Me getting ready for the off.

Lining up to go

resting at the midway point

joined by hundreds more at the midway point getting ready to start the rest of the ride

starting the second part of the ride

Friday evening
19:54 - 145mg/dL - Before dinner, 9 units of short term term insulin and 20 units of long term.  Dinner was pasta (two large helpings) with tomato sauce, capers and artichokes, cheese , chopped salad, and a tin of tune for some extra protein.

21:26 - 111mg/dL, I was surprised at how low I was here

22:10 - 144mg/dL, as my sugar was head in the right direction I was less worried

22:37 - 172mg/dL, this is about right before bed

Saturday morning
06:35 - 158mg/dL - Coffee with milk, bread roll with peanut butter, 400ml of orange juice. 4 units of short term insulin.  I was expecting to be higher after taking less insulin and eating a lot.  I would not start a bike ride without eating something.  My usual calculation is 180-200mg/dL before heavy exercise for 45-75 mins, where I would not expect to eat during.

06:57 - 161mg/dL, last check before leaving for the start line.

07:29 - 238mg/dL - granola bar

energy gel during the ride, not sure when exactly I took this, I think I should have had another one, I felt extreme tired going up hill and it felt like I was pedaling squares it is possible that I bonked (hit the wall).

09:45 first stopping point - 175mb/dL - granola bar, 2 minute break at the top of the big climb, blood sugar ok, supplemented food to keep me going for the next bit of descents and climbs.

10:31 second stopping point - 149mg/dL - energy gel and granola bar.  I had pretty much finished my water by this point so it was a good chance to drink and fill up my bottles.  I felt that considering my earlier test and that I had eaten 45 mins earlier that my blood sugar was coming down hard.  I wanted to avoid dropping any lower.

10:47 just before leaving stopping point - 252mg/dL, mission accomplished, sugar on the way up, enough to last me to the end of the ride (30km more predominantly down hill)

12:10 at end of ride after 70KM - 184mg/dL, I was happy with this blood sugar, high enough that I would not be dropping low any time soon, but no too high either.  My worry was that it was going to go up from here as it often does after exercise.

couple of small protein snacks when I got back to the zimmer

12:57 - 281mg/dL, this rise could not solely be due to the snacks.  This is my body breaking down glycogen and fat (hopefully).  The result very high blood sugar.

13:12 - 298mg/dL, that takes a while to go down

shower and a lie down

15:04 - 265mg/dL - 10units of short term insulin, cheese sandwich, salad, pickled herring.  This is the point where I must be most careful.  Too much insulin and when my body stops breaking things down my blood sugar will drop fast.

16:04 - 301mg/dL - apple 6 units of short term insulin.  I felt that I had misjudged how much insulin to take to bring my high sugar down gently.  I may have taken too much here.

16:44 - 260mg/dL - cafe latte, trying to stay awake for the drive home.  Normally I estimate this as 15g of sugar or 3/4 units of short term insulin but as I had just taken 16 units in the previous 2 hours I did not think it was necessary to add more

back home
18:28 - 120mg/dL, though normally I would be happy with this I felt that my blood sugar may be dropping too fast, as I found out later I was correct.

19:35 -  53mg/dL - 3 cookies, this is usually about right to sort me out when I am low.  I know it wont make me too high afterwards.

21:01 - 159mg/dL - dinner, roast beef sandwich, mashed potato, 1 pint of beer. 9 units short term, 24 units long term.

23:11 191mg/dL - On my way up after dinner.

Sunday
00:13 - 238mg/dL - just before bed. A little higher that I would like on a normal day but probably the right amount to avoid over night lows.

07:30 - 120mg/dL - just after wake up. Perfect!