Just a pinch of basal.

This post feels a bit like the diabetic equivalent of 'first world problems'.  As I continue to learn how to use my Insulin pump, I'm realizing that it has a few short-coming still.

My main complaint is still the reservoir volume.  I used 33 of the 90 units of Novolog insulin in my first 'pod'.  This second 'pod' is on pace to use less than 1/3 of rather expensive liquid which I fill it with.

I need to see if I can find some U-40, which  is 40% of my current concentration U-100.  Either that or figure out how to dilute this stuff on my own.  Wish I still had my old pipettes (fancy liquid measuring tools accurate down to 1/1000th of a milliliter.  But I haven't been able to figure out the storage solution - need to dig out the product info sheet from my pile of diabetic handouts that I've been accumulating. One workout would also be to carefully combine some U-10 and my U-100 to make my own custom.

Other frustrations.  I haven't exercised in a week and I really really need to.  Sure the 'extra' time is nice since that's been more than taken up by the extra effort of managing my pump startup.  Plus, the more I think about it... NOT exercising is abnormal for me.  I understand that we're fine tuning basal rates, but I probably haven't had that many weeks in the last 10 where I didn't exercise.  Sedentary measures don't really give a base-line of my life.

I fuel much differently on rest days than I would on active days in which my total daily energy expenditure goes from 3000 to 5000 calories.  There is a lot more food and carbs on training days.  Rest days I'm not going to be eating a ton of carbs - just what I need.

I also wish this omnipod had a finger stabber built into it.  It's a hassle to have to carry the whole gigantic case with that thing.  The actual PDM fits nicely in my pocket, but if I want to test I need to bleed.  Perhaps I get a few more stabbers to keep in various locations so that I don't have to always rely on carrying the same one everywhere.

Those are just minor details and gripes about cost & convenience.  However, I have one very serious concern that affects my level of care.  This meter that is built into my pump reads 20-30 points lower than my previous meter.  What this means is that when I'm at what used to be 100 on the old unit, the new meter will tell me I'm at 70 which is too low.  If I'm basing all my current doses off of this offset measure I may really be averaging 130mg/dL over the last week rather than 100mg/dL (which I have been).

I need to get more sleep.

Getting my pump on.

This week has brought a big development in my insulin therapy.  Instead of having to do multiple daily injections of insulin, I have progressed to using an insulin pump which will attach to me and deliver insulin on a pre-programmed level for 3 days.  So instead of two daily basal injections and  3-5 injections every time I eat, I now simply stick a 'pod' onto my belly or arm and get stuck only once.

Waterproof.  No tubes, no wires.  It comes with a separate controller that I'll need with me pretty much all of the time, but since it doubles as a blood glucose meter, it's a break even as far as number of items to carry.  (See last blog rant).

There are many nice features that I am gaining comfort with.  I can program in the number of carbs that I plan to consume.  Next, the pump calculates my bolus insulin dose for those carbs based on my current blood glucose level and my correction factor and carb factors. These levels are unique to me and are a measure of how many points 1 gram of carbs will raise my blood sugar, and how many carbs 1 unit will cover in my body, respectively.

Right now my basal rate is set to 0.35U/hr (8.4U/day).  My goal is allow my 'basal' insulin to account for about 50% of my total insulin each day.  The other insulin will come as 'bolus' doses timed with each meal.  All I do is enter the carbs, press a button and the insulin goes from the 'pod' to me.

My current correction factor due primarily to my mass (215#) is 2.  For every gram of carbs I consume, my blood glucose will raise 2 points.  For example if I'm at 70 and need to go to 100, I'll need 30/2 = 15g of carbs.

My carb factor is currently set at 1:30.  That means that for every 30 grams of carbs that I consume (assuming that my blood sugar is at 100 mg/dL) I can cover those carbs with 1U of insulin.

It gets a little more complicated when my BG is lower or higher than 100.  I need to combine both of the above formulas. I also need to consider the amount of insulin currently in my system. This final detail is rather difficult to calculate, but if your interested I'll explain those details on how I conceptualize 'basal on board'.

If I just ate a dinner with 60 gram of CHO and I was at 100, I would take 2U.  But say I want to have an additional snack 90 minutes later, what to do?  First I'd retest my BG just to double check, then I'd think about the fact that the type of insulin I'm using has a 4 hour time course (peaking after 2 hrs).  Since I'm only 90 min post meal, my insulin has not yet peaked, or has it?  Has the sugar load of my meal peaked - I don't actually know.  Uhh, what to do?  I could make an educated guess... erring on the side of less insulin rather than more (stacking too much insulin is where the danger lies).

Compound this with my rather high carb ratio and the fact that even my 'juvenile' insulin pen with it's 0.5U increments requires that my snack is at least 15grams.  Granted this was twice as refined as my adult pens which only dial in single unit volumes.  Plus knowing what I know about accuracy of syringes at low volume ranges, and it's not long before I realized there had to be a solution with more fine tuning options.

The solution lies in my insulin pump.  This thing pumps increments of 0.05U.  So if 1U covers 30, I can fine tune my dosing at steps for every 1.5grams of CHO! Not even I'm so anal to as actually bolus for that.  That would be two small grapes.  But you get the point.

Added bonus is that the control unit for my pod (PDM - personal diabetes manager) records not only my blood glucose history, but also my insulin dose history.  This not only makes record keeping easier, it dummy proofs the process.  I live a busy life.  There have been plenty of times where I'm been standing there with the insulin pen in my hand with the cap off only to realize that that phone call, or commotion with the dogs left me not remembering whether or not I actually injected.  You'd think that would be obvious, but it's an easy mistake to make.  Especially when you're not fully awake, or you're not thinking clearly due to poorly controlled blood sugar.

There is definitely some fine tuning to be done.  I may already lower my basal rate down to 0.30U/hr (7.2U/day).  I've only been on the pump 3 days but each evening I've had to snack on carbs before bed to ensure my levels would stay stable overnight.  And I can eventually figure out any daily rhythms.  I suspect that I could keep my day/afternoon insulin at 0.35U/hr and perhaps lower it after dinner to 0.3U/hr until noon the next day.

I'm already much more relaxed about the pump.  My original concern was with ditching my Lantus (18 hour time course) as basal insulin. I fear operating without it, it has been pretty good.  But this is better.  My only major complaint is that the minimum reservoir volume for my pump is 90U.  That means that I will be wasting a lot of insulin, which wastes a lot of money.  But they design these pods for the masses.  The full capacity is 200U.  I bet there are many more people out there using more then 200U/3days than there are people like me using less than half of 90U/3day.   And I can't suck the insulin out of the pod - I ask.  While I can suck it out, in the process I could verify that the insulin was now starting to become cloudy, indicating that being at body temperature for 3 days does degrade the insulin - I wouldn't trust it for another 3 days.  Only in an emergency when there are no other resorts.

Speaking of emergencies - I get to fly with this whole setup in two weeks.  The pod is safe to go through the scanner.  The rest of my supplies will all be scanned. Can't wait to try to get a bunch of needles and vials with electronics through security... in foreign languages.  Luckily I can leave the USA with fruit and food.  I'd hate to get on the USA Border Security 'Fruit Violator' list.  (an issue that seriously affects my ability to bring home fresh Okanagan peaches the next time I visit Penticton, B.C.

That's plenty for today!  Thanks for reading.

Bells & Whistles

With regards to accessories, here's a little background into the type of person I am.  I hate them.  I only recently started wearing hats (but only because I've been freezing).  I own many hats, I don't ever take time to match a hat to a color, only to how warm of a hat I need.

I don't wear watches.  My wrists are huge and constantly bashing into stuff.  I can't stand wearing sunglasses.  I'd rather squint and get windburned.  I don't like sunscreen or lotion, hate lipbalm especially carmex.  I own 3 belts, black, brown and one shiny.  I wear only my wedding ring - and never take it off.  I'd rather it get scratched and dinged than lost.  Necklaces? Santa got me a herring bone gold necklace in 94.  It didn't survive '95.

I was the last of my friends to get a cell phone.  Why did I need one when I was surrounded by my friends who were more than willing to let me make a call when needed.  I do have a few vices for sporting goods (understatement of the year) and sure I own many shoes, but never more than 3 pairs per sport - if you count trail running, track and pavement as 3 separate sports.  It's good to keep a healthy rotation.  One favorite shoe equates to one favorite running injury. But I digress.

I hate carrying stuff around.  I was criticized as an adolescent that my head was in the clouds.  It was.  That's where it was supposed to be.  Why waste the energy tracking whether you had your swimsuit packed, remembered to take your soccer-ball home after practice, or packed underpants.  That's part of being a kid - you are happy to be irresponsible.  You're not harming anyone or yourself, you're usually just annoying your parents.

As an adult it would be unwise to continue these same mistakes, but that doesn't mean we should actively choose to live such complicated lives.  Complicated lives require extra accessories.  Free and easy is still just as enjoyable, but I find it increasingly difficult to get away from needing all this stuff.  Everywhere I go, it used to be (w/ 3 slaps to my pockets): wallet, keys, phone.  Boom - out the door.  Now, there is a much longer list.


Call me an optimist, but I see shorts season rapidly approaching.  I don't want to be that guy with a purse.  Right now I carry enough stuff to fill 3-5 pockets.  It's not so bad when those pockets are your winter coat, but it's going to be a different story in running shorts and a tank top.  Where will I keep all this stuff?

"Canary in the coal mine"

The following video is proof that it can be done.  Parkinson's, Alzheimer's, Multiple Sclerosis, Diabetes...  

Please take 18 minutes to watch Dr. Terry Wahl's TEDx Presentation.  She touches on the nutrient deficiency of the standard american diet (SAD) and how she has been able to take herself from wheelchair bound with MS to living a normal life.  Hope.

TED talks are a great seque to the topic I wanted to address today.  (It's amazing how overwhelmed I am currently with topics).  If you are unaware of TED as I was until last year, you can definitely learn more here: TED: Ideas worth spreading

Independent and Alternative resources are important.  There is so much information out there.  Dr. Terry Wahl has the background and understanding to dig through the PubMed materials on her own.  We all have access to massive amounts of materials, but do we have the skills to understand it?  Do we have the time?  Do we even care?

So here I am putting out more info... thanks, eh?!  But I promise to only share the pertinent info, I'll try to filter - but I don't want to present too much bias as I am aware that I am already harnessed up and ready to belay down the cliff to hippy vegan liberalism.   Not that I don't think love should be free, but I understand that it taking things too extreme is off-putting to most.

In this sea of information, where do I get mine?  Well I started by rocking it old-school.  Good old books with a new school twist.  Amazon!  Not that Amazon is an improvement over the mom & pop book stores (Shout out to The Frugal Muse, my wife Kim's favorite bookstore).  But Amazon and their algorithms of shopping has a convenient big brother ability to suggest related materials, a useful feature that has guided my exploration.  "You may also enjoy...."  Shit, they were right.  I'm learning that big brothers can be good guys too.  (Right Rob?)

Another great alternative which surprised me was Netflix.  We originally switched to Netflix (over cable tv) due strictly to budget.  We did it in Canada where the budget was very tight.  Now back in the states, Netflix has rights to many more options.  Tons of options, now the trick is finding the good stuff.  And beside the ability to watch Breaking Bad, West Wing, How I Met Your Mother, and marathons of The Bernie Mac Show (Who ya wit!), there is a great selection of independently made documentaries.  There are even a ton of TED Talks broken down to a variety of topics, among the topics are Disease and Nutrition.  Entertaining and brilliant stuff.

I'd love to share my reading list, but let's be honest, we readers are a minority!  How are we to get through to those who are too rushed in their lives to sit down and devote 6-8 hours to reading a book?  Audible books are probably a good option.

Another option is radio.  I love NPR podcasts like To The Best of our Knowledge (TTBOOK.org), and recently added in the Rich Roll Podcast.  I don't think Rich is correct on many of his topics, but I have serious respect for the fact that he brings interviews with people that present views that he disagrees with.  That's how we learn folks.  Republicans should spend a week reading The Nation and Democrats should listen to WTMJ (local Waukesha radio).  If all we do is listen to opinions that we agree with, we only get further entrenched in our narrow views and don't learn anything.

We may be older, but we are not done learning.  I've probably learned as much here in the past 3 months as I have in a semester of studying Anatomy Phys, Organic Chem, Rhetoric of Campaign & Revolution, Psychology 411 Topics: Stress & Coping, and another Topics course on the Environmental Toxicity.  (This was actually my Senior year - good stuff).  But I'm also able to learn on my own with out the expensive tuition.  How do you like them apples?

One giant leap.

This is a big week.  With the weather due to break at any moment (tapping fingers.... tapping...) clients are starting to plan our their race seasons - that means plenty of business for me.  I am very happy about that fact.  The work is rewarding - that makes all the difference.  But my job keeps me busy, odd hours and what not.

The challenge being (another) that my schedule doesn't line up with many other people's.  While this is perfectly in alignment with my disgust for traffic - it interferes with my ability to train.  As alluded to earlier I need to be careful when I workout out alone - frustrating.

So yesterday I said to hell with it.  I'm going to have to figure this out sooner or later.  I'm a fan of sooner, so I went to one of my favorite sections of Pheasant Branch trails in Middleton and did a nice 90 minute out & back run.  Almost a double out & back with the way the route loops so I wasn't ever more than 2 miles from my start point.

Nothing notable about the run really.  Just another 10 miles in the snow on trails.  I paced rather conservatively, and I wanted to fuel as aerobically as possible.  I've been seeing some interesting shifts in mood, hunger, and energy level.  They all connect into blood sugar values.  I test my blood sugar very often, 10 times a day,  some think that's crazy and are lucky to test twice.  Until you commit to testing often you don't know what you aren't seeing.  I'm learning glucose response curves, trends in my insulin activity, how illness & stress affect my levels, the list goes on and on.  It's like I now have a fuel gauge for life.  Unfortunately that comes with a severely choked off carburetor.

Okay, I'm not a car.  And while I'm great working on a bike, I don't know automotive mechanics nearly as well.  But the analogy is close.  Without my body in control of its own insulin requirement, the sugars in my bloodstream are left without a way to cross into the cells that need the energy stored in the bonds of its carbon, hydrogen and oxygen molecules.  Pretty simple molecules really.  But they have amazingly complicated influences over my life.  Jerks.

The highlight of the run was the end.  I enjoyed my run and would have kept going if that was my plan, but the end was definitely the highlight.  90 minutes of 70% heart rate and 53g of carbohydrates (C:H:O) and my blood sugar was dead level at 120mg/dL.  That is victory folks.

The story doesn't end there however.  This is the point where I would have destroyed a huge portion of homemade pizza with whole grain crust in the name of recovery.  But now that I'm free of that non-sense I was barely even hungry.  Normally when I run in the cold I would return craving something massively hearty.  Instead I had bacon, kale & cheese omelette plus greek yogurt and cantaloup.

However I was getting full before finishing the melon.  My numbers started to go low because I had dosed my insulin ahead of time to account for it.  I have to time the mealtime doses about 15 minutes ahead of the food for optimum stability.  So once I look at a food I have to decide how to dose for it, how to time it and then wait.  That's a pretty good system to follow to give your body time to catch up to the impulses of eating habitually.

I was slowly eating my delicious meal and started to feel my brow break into a sweat.  Some dizziness upon standing (my blood pressure has dropped back down to 110/70).  It's mostly a loss of clarity of thought that I'm aware of for symptoms of low blood sugar.  I guessed that I was at 60, but test at 50.  The lowest I've been.

Know that trained method to treat a significant low would be to consume high glycemic index simple carbs. A Snickers bar has sugars, but the fats and proteins will satisfy you.  They weren't kidding.  The glycemic index of a Snickers is actually low: GI 41.  Glucose is 100.  White Bread is 70.  The number is a measure of how reactive the sugar is.  There may be more energy in a snicker bar, but it is released much more slowly.

You're seeing why this could be hard to calculate when your experiencing low blood sugar.  But I'm trying to eliminate rapid swings, both down and UP.  Blood sugar swings cause swings in everything, my metabolism included.  Had I gone with the quick fix of 6 corrective dextrose pills (really just smarties) at 24g total sugar (CHO) I would have raised 2 points per gram- 48 points.  48+50 would get me to 100mg/dl in 5-10 minutes.  But I don't want to eat 24 grams of pure sugar.  I'll eat 24 grams of carbs, but there is going to be some value to them.

First thing I did was speed up my eating.  Finishing my cantaloupe   I could have had more cantaloupe, but more isn't always better.  Less is better?  Less of more things is - at times.  Follow?  Cantaloupe is a super choice for carbs, but I chose to pick up my 48 points with a small apple with 10-15g CHO and 10 large black grapes.  Each grape is 1g CHO.  Nailed it.  That's how you do it.

The glycemic index of my carbohydrate sources was lower, although grapes are pretty high at 60.  Notice that a raw apple has the same glycemic index as that Snicker bar.  Not what you'd expect.  It took me longer then 10 minutes, maybe 30-40 but my blood sugar responded as planned.

This drop in blood sugar was in response to 3 Units of Novolog insulin with my meal.  3 little units and I overshot.  It obvious why.  My body was pulling sugar from my blood to aid in the post workout rebuilding.  There is a receptor molecule that comes to the surface of cells to help transport glucose independent of insulin. If I remember correctly, these are same molecules in the signal cascade that allows insulin independent glucose utilization at higher intensities. That mechanism combined with my background long acting twice daily 6 Units of 16-18 hour Lantus.

Another concept I'm excited to dig into further is a side effect of our adrenal system linked to flight or fight response. Flight sounds good, right.  It's rumored that some short all-out sprints will be able to raise my blood sugars while I run - no aid station necessary.   I've already experienced this effect.  During the few more intense soccer games I've played in (once in my first fast paced Liga Latina game, and again during the President's Cup Tournament), the adrenaline coursing through my veins that keys my into 'the zone' also causes my liver produce glucose through good old gluconeogenesis-expialdoshis.

"If the current pace hurts, try a faster one!"  I've been racing with those thoughts of Jack Daniels in my mind my whole running career.  It works.

Just got off the phone with my Diabetic Nursing Specialist.  Pump training is set for Tuesday and we'll be putting in my application for a Dexcom 7 Plus, a continuous glucose monitor that has an embedded sensor that test many times per minute.  Complete with bells & whistles that alert to rapidly changing levels.  It's accuracy isn't as good as a finger prick test (fresher blood flow).

However, it is precise.  From what I hear it's manly a problem of a time delay by 5-10 minutes due to detector location.  Whatever it's issues it will be a huge leave forward from having to take of a glove, open the bottle of tiny test strips, load the strip, snap the container closed, wait for the meter to beep alerting that its ready to read.  Then wipe clean your finger (no residual sugars), poke finger, squeeze blood droplet (about 10uL), align droplet with appropriate point on test strip, record reading on Glucose Buddy app on my smart-phone, dose my carbs in response to reading, put everything away, put back on gloves, look up and hope that my bike is still going the right direction in traffic.... Okay, I'll pull off the road to test.

That unacceptable.

Think of the time-course responses to fuel sources that I can figure out!  Data!!

Have fun looking up stuff.  http://www.glycemicindex.com/

Diawheeties

Kid President!  Wow, where has this been?  How have I missed it - my life hasn't been complete.  I love this kid - love the fact he picks on Wilfred Brimley.

In my continued nutritional exploration I came across an interview from Dr. Lim of Skratch Labs.  Skratch is a product we just started carrying at SBR, Jess came across Dr. Lim at Kona this year.  He also brought his mobile nourishment vehicle to cyclocross nations at Badger Prairie in Verona this year.  Our rocket tent was right next to them.

So after making the connection that this stuff might be worth looking into, I found an interesting article from Dr. Lim where he talks about hydration and race nutrition for the cyclocross racers in the cold weather.  Normally I'd disregard a California boys advice on how to manage in the cold, but as you could guess I have new concerns with the cold and how it relates to my diabetes.

Workout out in the cold complicates things for me.  First off, I'm on a reduced carb diet and feel like my body's thermostat has been reset and optimized for warmer climates.  I've been really enjoying hot yoga.  Circulation and nerve issues in the extremities are common with diabetes, and I doubt that I'm already experiencing any of those (nor hopefully will I ever), but I notice that I just don't enjoy the cold like I used to.  I'm constantly bundled up.

Cold is complicated for another reason.  I could freeze to death.  Not much margin for error if I went for a midnight run in below zero weather.  If my numbers dropped and I had problems I'd be rather S.O.L.  I've noticed that while cross-country skiing, my numbers drop much more apidly in the cold. It requires that I fequently stop to fuel with what I have (often gels, which are less than optimal from what I'd prefer to consume these days).

Working out in the cold also requires frequent testings of my blood glucose.  My meter doesn't work in the cold.  That's a problem I'll need to figure out.  I need to bring a hand warmer to tug in with it, but now I'm carrying a boatload of extra calories, a meter, a glucagon kit, two dogs with leashes, poop bags, a garmin with heart-rate monitor and I've suddenly became everything I hate about the 'modern athlete'.  Too much shit.  I just want to head out he door and relax!  Grrr.

Back to the topic.  Dr. Lim's article, which I was originally reading for a rice cake recipe got into the topic of the adrenal response from the cold and how the body responds to the stress by relying more heavily on carbs as it's primary fuel source. Ah hah.  That explains things.  Makes sense now that my numbers have been dropping on easy 3 mile endurance paced runs at a level similar to rate they would for a much more intense trainer workout (The Sufferfest,)  I love Sufferfest and will talk about them more on a future date - they're paired up with Davis Phinney to raise money for Parkinson's Disease.

So now that I know what's going on, I know how to better prepare.  But enough being a wimp.  I finally got up the nerve to run alone in the cold.  I got in a solid 5 miles on snowy slow trails averaging under 9 min pace overall.  Sub 8 minute pace on clear path, while not effortless, felt very efficient.

I'm excited to reboot my running.  The changes to my body composition as a result of my dietary adjustments has leaned my up.  I've gradually lost some of what I consider to be my "Wheat Belly".  Most of the loss is fluid and inflammation, but I predict that I'll continue to lean down.  I'm down to my Canadian racing weight at 214.  It feels great to run 10-15 lbs lighter than I was this summer.  But not much about this summer felt good so perhaps not the best base-line.

But I feel good.  Even rocked out a hard as all hell kettlebell workout that would have made Ber proud.  Even got through the warmup and stretch/cooldown.  My body feels great once got a little nap.  It's been a whole new experience with how I feel as a result of my improved fueling and my bodies ability to sustain energy is much more level.

That's all for today.  The journey continues.