My last Diabetes check up

Last meeting with my Diabetes team I had a really good result of 6.6%. I went to the meeting and got in trouble because my meter had too many hypos on it from the previous 2 weeks.

The annoying thing was that they didn't really pay attention.  There was probably less than half the actual hypos as I often double check or check 10-15 minutes later when I am still coming up, but the meter still registers me as low.

The second problem is a lack of understanding of statistics. They claimed that my good result was not any good because a I had too many lows, therefore balancing out the highs.  A wild extrapolation at best, the readings on my meter were for 2 weeks, the HbA1c test is and average for 3 months. Additionally the amount of time I am high for, when I am high, is usually significantly longer then the amount of time I am low for.  I treat lows very quickly with lots of sugar, and I treat highs very slowly with small amounts of insulin so that I do not end up low. So pretty simple statistics tells us that I would need an extreme amount of lows to balance out a few long highs.  Therefore my control must have on average been better than they were suggesting.

Their final comment on this was that its bad to have too many lows, as you can lose sensitivity to them.  OK fair point, but considering I don't normally have that many lows I think I will be OK.  Then came the knock out punch.  I was told it can lead to problems with the brain if I have too many hypos.  What the hell.  That was new to me.  I am aware what can happen if I don't treat my hypo, then its quite possible that I could cause damage to many of my organs.  But when I refer to a hypo I am just low, nothing too serious.  Still able to treat myself.

Everyone knows about the long term complications of high blood sugar. But now I am learning about the long term problems with low blood sugar too!  According to this article research done states that there are no problems associated with too my low blood sugar incidents and in fact it is preferable, and expected,  if that is the consequence of keeping blood sugar low.  Phew!

to quote the relevant part:
"Researchers also found that intensive management, which often resulted in more frequent low blood sugars, had no negative effects on the minds of patients. You can rest more peacefully knowing that low blood sugars do not seem to have any connection to cognitive impairment."

One year on

It was around this time last year, my brother was racing in his first triathlon, the Tour de France was starting and my addiction to cycling at an all time high.  Bradley Wiggins, who I had been following since he was a track champion in 2004, was going into the tour as the big favourite.  So I pumped up my tires and started doing some cycling.  Some days when my wife needed the car I got a lift to work with my bike and rode home.  By August I was ready for a bigger challenge.  I got up early one Saturday morning and rode.  I rode until I couldn't any more.  I made it to Tal Shachar, my cousins moshav, after riding 60Km.  I was really happy with that.  The following week I was back at it.  In September I bought a new bike, Merckx EMX 1, and started riding more and faster each week.  I rode in the Tel Aviv bike ride and then the Sovev Galil Maarav.

By November last year I was a little unsure about how I was managing with my diabetes, especially as I had an HbA1c of 7.4%.  So when I met with my dietitian she recommended that I meet with the sports consultant at the diabetes center.  The consultant, Yaara, advised me to join a cycling club and recommend Carmi and X-team.  I have been training with them since the beginning of December.

Since then I have met some great people in the team, done some fantastic rides, and some not so fantastic rides.  I have raced in the national championships and now I am preparing for a 3 day tour over the Pyrenees.

I have a had a great time riding my bike and I am getting stronger and fitter than I ever was before I was diagnosed with Diabetes.  My weight has come down, my control over my blood sugar has improved and my HbA1c result was 6.6% last time it was tested.  I am thankful to Carmi and X-Team as well as my health care team, Dana, Yosi, Yaara and Dr Hazanov, for helping me achieve my goals.

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.

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.