Insights into my personal life.

This blog includes the personal details of my experiences as a recently diagnosed Type I diabetic and the impact of that diagnosis on my endurance athletic pursuits.

Please understand that I consider myself to be a work in progress. I am willing to share both my successes and failures, so please do not take my words to be professional dietary or medical advice. This is a blog, this is only a blog. I research my choices carefully, and take my health very seriously. The choices I make are my own, I am doing the best with the resources and support that I have. If you have questions or concerns feel free to comment, but please be constructive and understand that this is my life. I value it dearly.

My goal is to live a happy, healthy and active life where I can balance my internal drive to push my physical limits and the challenge of safely maintaining stability despite the challenges of Type I diabetes.

Friday, November 22, 2013

My Ironman Arizona 2013 Race Report - PART TWO

I'll finally get to the race report part.  I couldn't do the telling of my race justice if I hadn't included the prior post, but hopefully this part will be more entertaining.

Remember back to Part One where I described the difference in participants.  Normally when I'm racing I'm focused narrowly on the clock, I've never stopped at special needs, I've only briefly stopped to hug my mother during my first Ironman.  I usually finish in the low 11 or high 10 hour range.  I feel my potential is to finish in the low 10 hour range - of course that was before diabetes.  I'm starting all over now.

My goal for this race was set a baseline.  I need to prove to myself that my choice to pursue a ketogenic diet was not a mistake.  My priorities on blood sugar management out ranked any interest I had in a fast time.  I am an endurance athlete for my health.  I'm not going to harm myself in the process of racing - it just doesn't make sense.  Previously I enjoyed pushing myself to the limit, although I never found a limit, I really don't want to find one now.  My goal was to finish comfortably and conservatively.  Conservative means smart and safe.

It was a lot of extra work setting up for this Ironman compared to previous efforts.  I'm an OmniPod Insulin Pump user.  I stashed extra pods, insulin, emergency glucose tablets and testing supplies in each special needs bag, as well as specific supplies for each transition bag.  I had to write out the plan several times.  I had a program built into my control unit for my insulin pump.

I had to fine tune my insulin levels for the event.  I knew the pattern it would follow, but found it interesting that my swim focus taper was doing wonders for increasing my insulin sensitivity.  This is a great sign for overall health and my blood sugar for the entire week was amazingly stable and my diet was delicious but also perfectly balance with my goals - even with the travel.  It was interesting trying to get my Wholly Guacamole past TSA in Chicago, but I managed.  The downside of the increased insulin sensitivity was that if I didn't adjust my plan, the insulin levels that had been successful in the workouts leading up to the event may now be too high, which could cause my blood sugar to go dangerously low during the event.  Things needed to be tested again.

The Friday before the race I did a 30 minute swim the rates that worked the week before.  I started the swim with my BG in the 90s and I tested post swim on the pool-side and it said 56!  Ah, that was only 30 minutes - Warning Danger!!  But then I realized something.  I felt 100 percent fine.  When I entered the locker room and dried off and tested again.  73.  Phew.  The culprit was wet fingers.  The moisture on my figures pool-side had diluted my blood and caused an inaccurate reading.  73 was still lower than I'd hoped so I made two decisions.  I was going to reduce my insulin a full one hour before the race rather than just 30 minutes, and instead of lowering it to 0.15U/hr I would err on the side of safety and set it to 0.1U/hr.

As for the rest of my insulin program I figured out that instead of setting up a Temp Basal program - which limits me to setting only one flat level for up to 12 hours I would personally build a basal program specific for the day.  My fear was that if a Temp Basal expired after 12 hours, my insulin flow rate would default to a level higher than what I'd handle.  Smart choice.  I also set that base level to 0.05.  The plan was to turn it back up to 0.1 for the run, but I enjoyed the safety of knowing that if things took longer than planned my pump would default to a safer low rate.

The night before the race I felt the best I've felt all year.  It had been so much fun to visit with my godmother and to catch-up with my UBC Tri Club friends.  It's been a challenging year and it was a gift to be able to spend this week with such wonderful people.

Before bed I took a nice bath in epsom salts and was asleep by 9pm.  The alarm was set for 3:30 am - I didn't want to rush in the morning.  I was awoken randomly around midnight by an Amber Alert of all things on my phone, but eventually fell back asleep.  The brief midnight wakeup was good for one thing.  I used it as an opportunity to turn on the basal insulin program that I mentioned above.

I woke up before my alarm at 3am feeling wide awake and ready for the day.  I tip toed to the kitchen and made my breakfast of 4 eggs and 1/2 an avocado, gathered my special needs bags. I ingested a little carbohydrate in the form of half of a serving of Generation UCAN, applied sunscreen, taped up my nipples, donned my timing chip and pinned it in place for safety. Everything on my morning checklist was addressed and I had time to spare. Merri had woken up to send me off - she's a very calming presence that I will forever be grateful for.  I even had time to do 10 minutes of yoga while I waited for Brendan, Winston and Victoria to pick me up.

Once on the race site I had lots of time to drop off my special needs bags, attach my garmin to the bike and check everything over.  Nice and relaxed.  I made the realization that I had to wait until 6am until I could put my insulin controller unit into my T1 bag.  Again this was a bit of an audible, but I figured I'd wait until my hands were drier in transition before testing my BG out of the water - but the important realization that I made was that I still needed to be in proximity of the unit at 6am while the program sent the signal to change from my overnight 0.25U/hr setting to my swim setting of 0.1U/hr.  Once that was done I felt much better.  I still used the monitor I affixed with velcro onto my bike's stem to double check my blood sugar.  It was a reasonable 114 - just a little bump from that UCAN I consumed at 3:45am.

I found Winston near the dry clothes bags and we walked to where the line would form to get to the swim start.  There we found Brendan lined up with the pros.  Victoria was apparently a few feet away but neither of us found her.  She had her game face on so it's probably best she be left to focus anyways.  It was fun to see Brendan off with the Pro Start.  Once it came to Winston and my turn we were probably two of the first 20 people in the water.  I love swim starts, especially when I find people who enjoy getting in early with me.  We sang the anthem and joked around.  I didn't even pick on Winston for probably not knowing the words.

I lined up for the start a bit more aggressively than I planned.  I had planned a 1:15, but since swimming has been going so well, combined with the narrow and overcrowded course I decided it would be better to start up front and go a bit faster.  The 1:15 crowd is usually a cat-fight complete with finger nails.  Once the cannon fired it was pretty easy.  Still crowded considering I was swimming with 3000 people, but I eventually settled in on a manageable pace.  Nothing eventful.  It's and out and back.  The out portion is directly into the sunrise but we were blessed with low clouds blocking the sun.  Plus I found a guy who was a right breather (I breath left).  We used one another to set a straight course just 10 yards off the buoy line.  I thought we were friends, but at about the 15 minute mark when someone squeezed me on my right my friend had no problem clobbering me in the face for a few strokes as I crowded into him.  I can take a punch, no harm done.

The water temp was great at 65.  The water didn't taste bad, but it was too murky to see my hands, nor the feet I wished to follow.  This created a little problem on the backstretch when a guy have me 5 consecutive ankle grabs.  My limit is 3 before I set off some rather thunderous kicks.  I used them to bridge up to the next set of feet, but suddenly everyone was also 5 yards wide of me.  Message received.  I didn't kick to hurt anyone,  I just wanted a little space.  I knew I was swimming a bit faster than planned and didn't have much training so my shoulders eventually felt a little tired, but not bad.  I didn't look at a clock as I climbed the ladder.  I make it a rule to avoid the swim out clock in all races.

In transition I tested at 99.  My volunteer asked if that was good.  "[Explitive] Yeah! That's good!"  T1 was slow as I had to put on a deep pocketed cycling jersey.  I had my nutrition and backup nutrition in my pockets and I had to put my pump controller away in a protective race belt.  I needed it accessible if I needed to make any changes to my insulin rates, and also for it to make it's programmed change to 0.05U/hr for the remainder of the day.

For testing on the bike I configured a clever system with a smaller meter on my stem with a stabber jabber and test strips in my bento box.  I knew there was a chance of dropping these items during the race so I wisely attached them to elastic tethers which actually worked to save me at least once that I remember - a little trick I learned from reading mountaineering books.

The bike ride is a 3 loop out and back course.  My plan was to go very easy on loop one and wait for my metabolism to kick in.  I'm still not sure why it takes so long for my body to reach that point but I know the pattern and respect it.  I felt a slight twinge of hunger at the 5 mile point so took one of my 200 calorie packets of Almond Butter.  At about mile 10 I decided to test my levels.  I eased to the right and sat up, tested and as soon as I saw a 102 I was happy.  And then I realized I had just flatted.  Turns out I pulled to the far right along a stretch of median with lots of cacti, definitely a cactus thorn puncture.  It only took about 3 or 4 minutes to change. Between the slow transition, my easy pace and now the flat I had just let the bulk of the main field catch up to me.  The course was now miserably crowded with huge draft packs as the bulk of the field had caught up to me.  Everyone was going much faster than they should.

I was patient and waited.  I talked to a few of the amoral souls and discussed the ethics of their choice to sit in a group and draft, but I knew my kind advice fell on deaf ears.  It really is a shame.  Sure it was crowded, but I was able to ride clean.  So could everyone else if they chose to.  Shameful indeed.

I reached the turn-around on the bike just in time to see Michael and Merri walking to the course.  Without that flat tire they never would have seen me.  Another blessing in disguise.  After the turn it was downhill.  I made a big pass on pack of about 50 riders and settled in to a comfortably easy pace again, it only took a minute for that entire pack to pass me back.  There were 100lb women in the group... passing me at 215lbs... on a downhill?!  Arggh.

My plan was to take the downhills easy and use them as an opportunity for my metabolism to catch up.  As much as I wanted to drop the packs I restrained myself.  Midway back I tested again at 109.  Took a stinging insect to the face, but took stock that I was lucky it wasn't the eye.  I dislike wearing sunglasses, but after that I put them back on.

I started loop two feeling stronger, I hadn't spent much time training in aero so I stretched as often as possible, but held my position well. I tested at about the same point on the course again.  98!  I wasn't hungry but figured if I was going to eat anything sooner is better than later. I had a second packet of almond butter.  This packet had a maple flavor (the store was out of plain) so I bumped up again to 115, but that's the highest I'd be on the bike all day.

Lap 3 things finally spread out.  I was getting sick of riding the same flat course, but my body actually felt it's best at this point.  I started the lap with a BG of 95, feeling the diesel now!  Finally all those people who had gone out too hard (or had drafted their way ahead of me) started to get reeled in.  I felt superhuman.  I didn't even get stiff.  Everything was working well.  I was passing masses of people on the final uphill portion.  Saw Micheal and Merri one last time at the turn around and then eased it back towards home.

As per my plan I pulled over to the side at the mile 100 marker.  There I rested my blood sugar with my pump meter, 93.  Knowing that the transition to running spikes me by about 30 points, I took a bolus of 0.5U of insulin at this point (presumably 45 minutes from the finish of the ride).  This is the trickiest decision to make because I feel that adding insulin at intensity is akin to playing with fire.  If I got another flat and was delayed it could backfire - although I knew I had backup carbs on hand (in every possible location), my goal was to not have to rely on them.  My goal was to manage my blood glucose with my insulin rates, not with corrective carbs.  That is how I trained and that is how I planned to execute this day as well.

I entered the transition to the bike and my blood-sugar was now down to 66.  That might sound low but that's exactly what I wanted.  Technically I wanted 70, but that's damn close.  I had a great T2 volunteer who laid everything out and really knew what he was doing.  That's so nice.  I already had my insulin controller on the belt around my waste.  The volunteer handed me my race number, hand water bottle, helped me with my shoes and my change of shirt.  Again another slow transition due to the full change, but I wasn't going to bounce around with all the gear in my cycling jersey.

I always enjoy the hands of the sunscreen volunteers as well.  With their help and that of my wonderful cowboy hat I was safe from the sun all day.

I ran the first 2 miles at 10 minute pace as planned.  They did not feel good.  I wasn't expecting them to, but I had a little bit of discomfort in what I could only described as my kidneys.  Danger Warning!!  I stopped at mile 2 to test.  BG now 90!  Bingo again, I nailed that part of the plan, but I did not feel good.  My heart-rate was higher than I planned.

Looking back this is probably a result of a combination of factors.  I was a bit undertrained.  I probably should have been more conservative on that last loop of the bike, but I was having fun.  I have spent almost no training on my tri-bike this summer so I definitely used different muscle group than I had trained with and I knew I was gambling with the bike choice, however I just couldn't bring myself to sit up on a road bike on such a flat course.  My triathlon bike definitely is a more quad dominated pedal stroke.  Another factor is that I hate to admit I probably let myself get dehydrated.  Without taking in my usual volume of liquid calories on the bike, combined with the dry desert air I had a likely cause for the heart rate increase.  I had consumed about 7 bottles of water on the bike, but this may not have been enough.

Since there was some concern about the ache in my kidneys I decided to walk until that went away and to let my heart rate reduce to a point where my body could catch up.  While I was walking I realized something.  I liked the view.  I've never really slowed down in an Ironman before.  I can still walk plenty fast and my garmin read 15 minutes/mile - but without pushing myself I was able to take in the full experience.

This is where I connect the early part of Part One of my race report to my experience.  As I walked and once I settled in I really began to enjoy myself.  I ran a few more sections and they started to feel better, but I made a decision to give myself a break and enjoy the marathon.  I knew I wasn't going to meet any long standing goals.  (I still want to run a 3:40 Ironman Marathon).  So even if I did run and manage a 4:30, I've already done that or better several times.  I saw no harm in the change of my mindset.  I really enjoyed being able to catch views of all my friends on the course, and even stop and chat with a few.

I believe I finished the first lap of the marathon in 2:50. When I reached the 2nd loop the temp was starting to cool, my body felt much better and I was ready to run - however just as I was about to run I stumbled across a woman who was walking just as fast as me.  She was just starting her first lap.  I believe I started a conversation with her about her wonderful walking pace (most walkers are incredibly inefficient shufflers / aka death march).  As we were talking a girl I met earlier in the week passed with her insulin pump on her waist - she asked about my blood sugar.

I reported back that I was starting to peak at about 130.  I had previously consumed another half serving of Generation UCAN in hopes of running this second loop.  And although my blood sugar tested at 118 when I consumed it I was curious if some carbs would make me feel any better.  That's how things used to work before I was diabetic.

Meeting this fast walking woman was when my goal changed.  I started talking with Bernice.  She's a 60 year old retired nurse from St. Louis.  She was adorable, complete with a Boston Accent.  She signed up with her husband and a small group of friends also racing.  This was to be her one and only Ironman.  She was incredibly nervous that she wouldn't make the midnight cutoff.  She was one of the last few riders off the bike course and her stomach was killing her after following her trainers advice of consuming 300 calories per hour on the bike.  Yikes.

But she was walking a great pace.  15:30's per mile. We started talking.  She shared her experiences and I shared mine.  We bonded pretty quick.  There was no way I was leaving her.  It was much more fun to have company.  Plus it gave me an opportunity to do what I love from within the race.  I am a coach after all.

I helped her keep an eye on her posture while walking.  She was worried about the pain in her feet so I had her focus on the tempo of her arms.  She couldn't take in any more nutrition and had a stomach ache.  I waited for her at the potty stops and did what I could to distract her from the discomfort.  Before long she was at mile 8.  She was worried that she should be running, but I told her she could always choose to run later, and that if she ran too soon she might not be able to even walk later.  We did the math together and calculated that if she held pace she'd finish with 20 minutes to spare.  She could always run at the end if she needed to.  Her goal was to finish - and I had the pleasure of helping her.

It was a bit sad that we had to eventually part ways.  Over nearly 3 hours we had a lot of fun.  I had finally gotten her to eat a few bites of solid food near mile 10 for her and 23 for me.  We discussed how she'd manage the rest of the race on her own.  We did a few Yeehaws under the acoustics of the underpass.  Shared a mile 23 in silence to honor Jesse Alswager.  I advised her to try to get some food in once her stomach settled, and that some flat coke could actually help her stomach near the end.  I was confident that if she stuck with what we discussed she'd do just fine.  I had even debated walking an extra third lap with her, but Merri was too excited to see me at the finish line to do that.

When we parted ways I finally started to run.  It probably was upsetting to those around me as I felt great running that last half mile.  I was so well rested from my nice long walk that I comfortably holding 8 minute pace.  Not a single ache in my body, and I was feeling very good about how I had chosen to spend my day.

I had no expectations for the clock.  Before I left for the race I told my friends to expect me in the 13 to 14 hour group.  But while I was carefully calculating Bernice's paces and finish times I hadn't actually thought about mine at all.  I was a bit surprised to realize that I still managed to finish in 13:07 despite walking nearly the entire marathon.

When I crossed I found Merri, got a chance to call my mother and let her know I was safe and hear my father's voice, which always makes emotional.

I was surprised I couldn't find any water at the finish line. only muscle milk?!  I walked through the food tent to get water.  I didn't see any food I would choose to eat there either.  Surprisingly, I wasn't hungry anyways.  I had just gone 140.6 miles and consumed only 450 calories and I wasn't hungry?  It's a strange new world.

Now to repeat myself.  I choose my management strategy for my own personal reasons and I do not advise anyone out there to try to follow my plan.  The calories that I burned on the day were the ones stored in my cell, primarily my body fat, my own glycogen reserves and other intrinsic sources.  I still likely burned 6000 or more calories.  My ability to perform for 13 hours on less than 20 grams of carbohydrates is only because of how I've adapted my body to function on ketones.

I realize that my walking leaves questions unanswered.  Could I have ran with this nutrition strategy?  I think so had I managed to train better and avoided getting dehydrated.  My blood sugar while on the marathon course was between 90 and 130 which is actually a bit higher than had it been while I was training.  I have a theory that I actually run best when my blood sugar is in the 70-80 range.  Higher blood sugar seems to have an inhibitory effect on the liberation of ketones for fuel, although I'm not sure how to prove this beyond what I feel and how my heart rate in training and perceived exertion is lower when my blood sugar is in that lower range.  Perhaps I should have adjusted my temp basal level for the run to 0.15U/hr.  Questions for another day...

I'll aim to slay those demons at my next event which will be a 50k ultramarathon on some very challenging mountain trails on February 2nd at Orca's Island.  But for IMAZ I achieve all I had set out to do.  Sure I look back and see the success I had and it's tempting for me to be greedy and think, what if I actually ran?  But I'm not really concerned with 'what ifs'.  What I am concerned with is what I consider amazing blood sugar control over the course of 140.6 miles by someone who has only just begun their journey as a type I diabetic endurance athlete.

I will be able to race more in the future with confidence that I can build on this success.  I know what worked best in my training and I learned a ton about my body.  I'm excited for the future but I don't care to rush things.  I have the goal of competing in Ironman Wisconsin again in 2015 which should give me time to really dial things in and perhaps then I will have the confidence to push myself hard.

Below I will include a few notes as far as my basal rates leading into the race as well as my blood glucose tests during.

10/6 Basal rate: 0.4 (0.3 from 10pm to 6am) - Normal
10/12 Basal rate: 0.8 - I had gotten into some Halloween candy- hey, I'm human.
11/4 Basal rate: 0.6
11/6 Basal rate: 0.4 (0.3 from 10pm to 6am) - Back to normal
11/14 Basal 0.3  - Swimming really seems helps
11/17 Basal Program:
          Midnight to 6am: 0.25
          6am to 8am: 0.10
          8am to midnight: 0.05.
                   1pm Temp Basal set to 0.10 for run.
Blood Glucose History for the day:
Midnight- 86
3:20am- 90
5:15am- 107
6:00am- 115
8:11am- 99 (T1)
8:27am- 102 *consumed Justin's Almond Butter (and flatted)
9:13am- 109
9:52am- 98 * consumed maple flavored Justin's Almond Butter
10:38am- 107
11:15am- 115
12:09pm- 95
12:42pm- 93
1:28pm- 66 (T2)
1:58pm- 90
2:29pm- 90 (consumed 1 serving of UCAN)
3:09pm- 119
3:40pm- 118
4:27pm- 131
4:45pm- 131 (bolused 0.2U)
5:10pm- 115
5:45pm- 101
6:35pm- 98
7:02pm- 92
8:17pm- 102 (Finish Line.  The increase is due to running)
9:30pm- 109 (Bolus 0.25 for a gyro sans pita)
11:15pm - 116

4 eggs scrambled in 1T coconut oil. Half an avocado.  1/2 serving of UCAN

Race nutrition:
8:20am: Justin's Almond Butter:
10:00am: Justin's Maple Almond Butter
2:30pm: 1 serving of Generation UCAN.

Post Race Food:
4oz of PHD brand protein drink (0g CHO) * I may want to consider protein during the race)
Naked Gyro:  Meat, lettuce, onion, tomato and dill cream

Dinner:  Guacamole and cheese.

Recovery Basal Rate:  12:45am- 7:45am Temp Basal set to 0.15.
Woke up at 98.

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