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

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."

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!