Monthly Archives: September 2010

Insulin and Holy Grails

Posted on September 29, 2010 by Jeff Mather

I seem to have something like the anti-Midas touch going on today at work. Instead of turning everything I touch into pure gold, it turns into a freaking neutron bomb, blowing away my MATLAB session when I run the test suite. I’m taking some existing image processing code and using it in a multithreaded harness I wrote a while back. The goal is to easily exploit data parallelism for the newish generation of multicore CPUs. You can see some of the resulting performance wins — though I didn’t do all of the work, and it doesn’t all use this framework.

Anyway, I’ve managed to kill MATLAB more times today than I’d care to admit because of some threading issues in my sandbox. My sanity needs a break while I get myself into a frame of mind to look for threading issues. (That pretty much comes down to asking yourself, “What’s not happening here? What other threads might be giving this data ‘the bad touch?’”) While I let my brain settle down, why not put the final touches on this post about insulin?

Insulin is our frenemy, but what do we really know about it? Here are some recent articles about insulin.

  • Mind the GAPP: Insulin Therapy Woes. An industry group discovered “interesting” things about insulin — such as, 1/3 of people with diabetes (PWDs) skip insulin doses or don’t follow their doctor’s Rx exactly — and along the way manages to get some of us patients a bit indignant.
  • Insulin and Bone Fractures [PDF]. A paper presented at EASD last week exposes the correlation between insulin and bone fractures. It seems that insulin can cause us to be clumsy and fall when we are driving the magic bus have hypoglycemia. Other than being more inclined to feel the effects of gravity, our bones are otherwise unchanged.
  • Novo says cancer risk with insulin drops over time. Evidently there’s some link between insulin and cancer, but the incidence decreases the longer one is on insulin. “Furthermore, the marked drop in risk with long-term insulin use indicate that other factors than insulin may play an important role.” Huh. . . .
  • Sanofi-Aventis Seeks the Holy Grail of Insulin. Um. Okay. This article, which is written for people trying to decide which bio-pharma stocks to buy, has a pretty good recap of the three new fast-acting insulin analogues that may be coming to market within the next few years: Mannkind’s Afrezza inhaled insulin, Biodel’s Linjeta injected insulin, and Halozyme’s rHuPH20 insulin additive/friend/thing. There’s a fair amount of doubt in the minds of PWDs about inhaled insulin — especially since recent research “demonstrates that inhaled insulin rapidly forms amyloid in the lungs causing a significant reduction in pulmonary air flow.” Yikes. And while I know almost nothing about it, Provasic rHuPH20, according to the Seeking α article, uses “an enzyme called hyalronidase that locally degrades body components under the skin to enable quicker absorption of a drug (like insulin) into the blood.” I think I’ll pass. Linjeta sounds cool: faster than Novolog, Humalog, or Apidra; undergoing safety and efficacy tests for injection and insulin pump usage; not likely to “disrupt tissue structure;” etc. But about that “holy grail” comment. . . . I have to disagree with the idea that an insulin to mix with Lantus so that PWDs can have one meal-time-slash-any-time insulin is really equivalent to the Cup of Christ. Maybe for the drug companies, since some type 2 PWDs will have something new and expensive to replace their 70/30 insulin once it goes off patent, but c’mon. Let’s keep some perspective. Srsly!
  • New insulin could cut need for daily injections. Er, “some” daily injections. That is, insulin degludec — if effective and safe — might be able to replace your daily Lantus injection with a thrice-weekly injection. “Researchers found that the variability of treatment effects was lower among patients given insulin degludec than standard treatment.” And “an accompanying study showed that insulin degludec injected three times a week was as effective at lowering HbA1c levels as existing type-2 diabetes therapy.”
  • Biopharmaceutical Companies Developing a Record 235 Medicines to Treat Diabetes and Related Conditions [PDF]. In case one of the four insulins above doesn’t get your juices flowing, here are 231 other diabetes medications for you.
  • The implant that can free you from insulin jabs. First off, I didn’t know there was a link between insulin injections and migraines. The article is kind of a hot mess, but it also picks up the Grail theme, saying that the “holy grail” of diabetes is an “artificial pancreas,” but not the one you’re probably thinking of. No, this one, which is undergoing preclinical trials, “is an implant placed above the hip containing a supply of insulin kept in place by a barrier of gel that reacts to glucose.” More glucose, more insulin. Easy, peasy. Right?
  • Lilly R&D Chief Pursues Late-Stage Drug License Deals. Yup, like Sanofi-Aventis, Lilly needs more of our diabetes-related total healthcare dollars, too.

None of this solves the basic question at hand of my inadvertently destroying MATLAB, but I think I’m ready to get back to it. Except, there’s a cookie here staring at me. If I eat it that means an insulin bolus, but that will make exercise more difficult. Choices. Choices. If only there were an awesome, Grail-looking chalice here to drink and/or dunk my cookie into.

Posted in Diabetes, Fodder for Techno-weenies | 2 Comments

A Person with Type 1 Diabetes Asks You about Type 2

Posted on September 27, 2010 by Jeff Mather

I often think those of us with type 1 and type 2 diabetes might be two people separated by a common disease. We’ve got the bad islets, you’ve got the insulin resistance. We both might be on insulin — though not always for y’all T2s — but our motivations seem very different. We’re both at odds with “the sugar,” but I don’t fell like I understand the type 2 experience very well at all. 90+% of diabetic folk have T2, but it seems like 90+% of the Diabetes Online Community (D-OC™) have T1.

Help me out with a little favor, if you would. Please tell me a little bit about T2.

  • As a T1 PWD, I take insulin to keep me from falling over dead. Why do T2 people take insulin? Do y’all use long-acting insulin (e.g., Lantus) or fast-acting juice (like Humalog)?* Maybe a bit of both?
  • How many times a day on average do y’all test? (I test about 10x daily.)
  • If you see a high BG, what do you do? Do you take some insulin? Go for a walk? Pop a pill? Wait for later when it comes down on its own? (Told you, I’m a total T2 newb here.)
  • Do T2 folks get hypoglycemia? Some of you must; I remember someone in my support group years ago talking about having a low on a cruise, and I helped a sweet older coworker who had the kind of sweat indoors that you can only get from low BG.
  • This may be the dumbest T2 question I’ll ask — you can decide for yourself, of course — but is T2 mostly about food? Diabetes Forecast is all about low-carb eating and “healthier” food choices. There are a billion “diabetic” cookbooks out there. Most endo reports I’ve seen have a heavy emphasis on “pre-meal” and “post-meal” readings. And so on.
  • How has T2 diabetes changed your life?
  • What do you wish people with type 1 diabetes knew about type 2?

Feel free to answer in the comments below, or write something on your own website and leave a link to it. I’m sincerely interested in learning about this “mysterious” type 2 diabetes that you have. :^)


* — Late last year, I very briefly helped with the diabetes care of an aging family member so that she could attend an event outside her nursing home. Basically, they weren’t going to let her go unless someone would test her blood sugar and administer some insulin. I volunteered. While her BG was quite good — and I was happy to have it in my meter — I have to say that I was a little freaked out giving her the 15-or-so units of Humalog all at once. (And it wasn’t tied to the amount that she ate either.) That’s almost half of my average daily insulin dosage, and I had to triple check the dosage. But I did it, and a couple hours later when I tested her again, everything was fine. Clearly, T1 and T2 people have different experiences with our shared disease.

Note: I moderate contributions from first-time commenters — even “long-time reader, first-time commenters” like you. Sorry. If you don’t see your comment show up right away, have faith that it will eventually appear when I get back to the Internets.

Posted in Diabetes, General | 2 Comments

NPH Exorcism

Posted on September 23, 2010 by Jeff Mather

Editor’s Note: It’s Thursday, which means that something related to my CGM trial must have happened. That’s right, the CGM data from my endocrinologist’s office finally arrived. I’ve spent a little time looking over the graphs and charts and matching them up to my logbook. Let’s just say this: While my blood glucose did run high, I don’t think that’s related to food choices as much as other factors. I’ll write about that later, since I need to investigate more.

Welcome to my exorcism. I’ve already sprinkled some holy water Diet Coke around my laptop in preparation, so let’s get to it. Here’s our demon:

NPH insulin vial and packaging

It first got into my body eleven years ago, through one of the shaded areas shown below:

NPH injection sites

It would enter twice daily, at 7:00 AM and 9:00 PM. Here was how I was forced to summon it:

Preparing to draw-up NHP

The demon kept me in its power day and night, forcing me to eat six times daily whether I was hungry or not, causing me to stop eating after consuming exactly 15 or 60 grams of carbs depending on the meal, fogging my brain between 11:00AM and noon, and giving me high blood glucose readings the rest of the day. This demon starts out benign, gathers strength slowly, grows to full strength after 5-6 hours, and sticks around to toss my internal furniture about for another 12 hours.

Graph of insulin action times

NPH was the only insulin I was on at the time, and I hated it. Every day was the same, and every day sucked. When I think back on it, I’m amazed that my doctor never had me use Humalog with my meals and never swapped out this demon for a long-acting insulin like Lantus.

It messed me up right good, leading me to think that food is medicine and that the way to treat insulin issues was to eat. As my first diabetes experience — a very laissez faire one by my first endo, it seems to me — it also had me thinking that this might be what diabetes was supposed to be like, that it was the best I could expect.

Those thoughts are what we’re exorcising here today. In my mind, this is a crucial part of the reboot. And we’re going to do that with sunlight and the basics.

  1. Diabetes has very few absolute rules. Food makes blood glucose go up, but mostly just the carbs. Insulin makes blood glucose go down, provided you have enough of it. Activity brings blood glucose down, but often not if it’s anaerobic.
  2. Diabetes has many heuristics: insulin peak times, onset lag, and duration; glycemic index values; etc. . . . and Chinese food always needs more insulin than you think.
  3. Diabetes has a billion variables: other people’s food, the intensity of activity, insulin freshness, meter accuracy, stress, caffeine, temperature, weight, girly stuff. Even my pancreas’s beta cells, which continually regenerate just to be killed off again, are slightly more potent in their feebleness from one day to the next.

So while the biological rules are as close as we can get to absolutes in diabetes, the heuristics cover the basic things that we can almost convince ourselves are under our control. The variables, though . . . Oy! They make it impossible to predict anything 100%.

Not that I expect anything close to 100% predictability. I’m realistic, and I know the body has more subtlety than just food and insulin. There’s glucagon and amylin. In a healthy person, those hormones dump into the bloodstream quickly and are mutually self-correcting. This system is organic and continuous — unlike the discrete, large decisions we artificial pancreases have to make.

The reboot is all about learning more about my body’s variables and discovering my own heuristics, so that I can have confidence to follow the few absolute rules all of the time. But that demon NPH has had me thinking that 2 + 2 = 5.

So how do I exorcise NPH from my thinking? How do I get that little shoulder devil behind me? How do I banish the voices that say, “If you bolus for that snack, you’ll go low?” And, “Your numbers are great now, but shouldn’t you have a little snack anyway?”

I don’t know. Exorcising personal demons is hard, but naming them is a good start. And Lisa may have the best advice: “Snap out of It!”

Okay. Done! What’s next?

Posted in Data-betes, Diabetes, Life Lessons | 1 Comment

A Few Days after the Endo Call

Posted on September 20, 2010 by Jeff Mather

This is a long, earnest post that some of you may not read because of its length. It’s a very important bit of writing for me, but I understand if you don’t read it all. Here it is in a nutshell: I have diabetes. I hate having diabetes. I’m trying hard to make that feeling a constructive one, which is hard . . . so very, very hard. I’m working with my endocrinologist to make it better, but I know it’s mostly on me to do it. So I’m doing a “diabetes reboot,” challenging almost everything I think I know and hopefully getting to a better place. And then I share some interesting diabetes links.

First off, I want to dedicate a little song to my diabetes:

Sorry about the language, Mom. Now that I’ve set the tone for where I was at the end of last week, on with the more constructive part of the post.

Last Thursday, two weeks after sending my CGM back to Minimed, I got a phone call from my endocrinologist’s office. There’s been a very regular cadence to this CGM process. On Thursday the 26th of August, the Medtronic Minimed rep attached the sensor. The next Thursday I put it in the mail. The Thursday after that, my endo got the results. And a week after that — three weeks after beginning the process — I got the first preliminary results over the phone. I had hoped to get the raw data in the mail this weekend, but as of today (Monday) nothing yet. Let’s cross our fingers that I won’t have to wait until Thursday.

I’m hoping to get some new insight out of the CGM data. What’s happening overnight? What happens when I exercise? Do I spike after every meal or just breakfast and dinner? What’s up with lunch anyway? What happens when I eat particular foods? These are things that you can only know with a lot of experience and data. The near-continuous blood glucose data and the logging are meant to fill in the gaps of my experience and correct more than one ages-old habit that’s been messing me up.

Now, I know that my endocrinologist and I are part of a team. She has the specialized knowledge about diabetes — knowledge that allows her to prescribe medication and that’s augmented by working with hundreds of patients (dozens of whom probably have type 1). So I’m trying to put the frustration of last Thursday’s conversation with my endo’s nurse behind me. (I’m not upset with my endo or the nurse at all, really.) It’s just that after waiting weeks, all of the suggestions were just . . . so . . . old-school. Other than the observation that I’m “highest in the evenings” nothing referenced the data itself. Reading between the lines of some of the suggestions, I gather that there must be food-related spikes and that I might be going low overnight.

But the suggestions! The nurse wasn’t wrong when she said that I might not like them. Trying a different bolus rate for dinner, I can get with that; it’s an experiment, after all. Telling me that I should probably eat different foods . . . grrr. It’s possible — likely even — that particular food choices affect my BG more than others and that there might be no way to mitigate those effects, but I felt like the diabetes/food police had infiltrated my inner sanctum. Instead of getting suggestions like “bolus earlier for that” or “keep track of your estimates for that food” or “try using a different bolus pattern,” I got the equivalent of a raised, disapproving eyebrow. And frankly I was a bit depressed and angered by the implications.

(For the record, we tried whole wheat pasta tonight. It was tasty enough, though the jury’s still out on the BG effects. It’s possible that yesterday’s ride is still sucking the glucose out of my blood and converting it to glycogen to restock my muscles, but I think that new dinner bolus rate might be too high.)

I would love to be able to tell these suspicions to my endo, but without a real accounting of all the different variables at work and some real confidence in my evening and overnight basal rates — which is actually what led my endo to suggest the CGM trial — I don’t feel like we can actually have a successful conversation. My A1c isn’t where I want it, and we’re both working to bring it lower, but I think we’re coming at from different, possibly conflicting directions. I’d love to have most things worked out so that we can have that kind of focused discussion on one problem area, but I suspect it’s going to be rough to get there. What depresses me most is that I had hoped to be at that point already.

Since that conversation with the nurse, I’ve had a few other conversations, mostly with Lisa, who is (as always) great. We’re redoubling our efforts to eat “better,” though we already eat much healthier than even a couple years ago. We’re recording the carbs in what we eat along with the resulting BG experiences. And she’s put up with a lot of what might pass for whining to the untrained ear.

I also talked briefly to Karen about this at the WEGO Boston Health Activist Meet-up last Thursday. That event turned out to be a good experience, but I was so disheartened by my phone conversation, which happened a few minutes before I needed to leave the office, that I probably would have just skipped it if I hadn’t been so excited about meeting Karen in real life. I learned some things that I hope to use with my own health activism, and I’m glad that I got to meet a fellow traveller in the diabetes online community.

Karen showed me her nifty insulin pump, which is one generation newer than mine — I liked what I saw — and she answered all my newb questions about her CGM. This is one of those times when I think a new gadget would be quite beneficial, and I really want to get one. Frankly, I just need to know what’s going on more often than I can see now, and I need alarms that tell me if I’m going too much in one direction. I want to see for myself whether my beloved chocolate croissants are worse for my blood glucose than my tasty but rather pedestrian strawberry All Bran cereal. (I don’t think they are, and Karen agrees that I should not give up my weekly chocolate croissant fix.) I want to see when I should start lowering my pre-exercise basal rate. I want to get to the place where I can have a meaningful conversation about particular events and not just broad WTF trends.

Since last Thursday, the internal dialogue about the mixed messages of freedom and diabetes has gotten louder. Pumps are supposed to be liberating, and they can be. I’m never going back to the strictures and twice-daily hypoglycemia of the NPH regimen that I had before the pump, but I’ve never had lower A1c test results than I did when I was taking “the devil’s insulin” (as saraknic called it). Device manufacturers all but promise us better test results while eating what we want, which turns out to be a bit of an oversell. I don’t like that the thought “I’d be happy if I could just not eat” even occurs to me. A life of endless trade-offs brings to my mind Christopher Hithcens’ recent reflections on his own mortality and some of the life choices that gave him great pleasure but probably also gave him esophageal cancer.

I hope that I’ve found a way out of my current “food/insulin is the problem/cure” conundrum that leaves me feeling trapped in a world of choices I don’t like. It won’t be easy, and it looks a lot like the path I’ve been on for the last year or so.

It’s a reboot.

Yes, I’m basically going — if not to the very beginning — to a “last known good place:” a place where I’m confident that my morning basal rates are “good enough” to get me through the morning without food if I want that; a place where my morning bolus ratio gets me through everyday except Monday just fine; a place where afternoons are mostly worked out, and lunch works, too; and a place where exercise starts higher than I’d like but ends in a safe place. And from that starting point I’m going to continue to work my way through the day, finding where my rates and ratios are off. I’m going to look at that CGM data from earlier in the month when it arrives and answer as many of my own questions as I can, pose the rest to my endo, and have a real conversation. I’m going to get those CGM sensors that talk to my pump and watch what happens before, during, and after exercise. I’m going to continue along the healthy eating road that Lisa and I have been traveling and see what kind of impact that really has and (only then) decide whether certain foods really have to leave my regular menu.

And that’s where I am now, trying to stay positive whilst being my own pancreas. (I still love you, Lil’ Paperweight. You still produce happy digestive juices I need. It’s the diabetes I could do without.)

Because I’m trying to stay up-beat after the beat-down, here are some things I learned about my disease in the last week while awaiting my own data:

  • Did you know that type 1 diabetes is an autoimmune disease? Read more about it. (Hey high school kids, if you have to do a report on T1 diabetes, that’s your primary source.)
  • The word of the day is “micro-biome” — although “gut flora” is a good phrase, too. There’s some indication that the bacteria in your digestive system (among the 90% of your body’s cells that are alien) play a role in developing type1 diabetes. Of course, viruses have a part to play in the development of diabetes, too. Then again, there are rogue proteins at work, too. I wouldn’t be surprised if researchers are close enough to understanding the factors that go into the development of diabetes that they’re able to induce diabetes in laboratory animals within the decade. Producing disease is, ironically, an important step on the way to being able to cure it.
  • One of the big annoyances with insulin therapy is that there’s a lag between current “fast acting” insulins’ abilities to lower blood glucose and the quickness that food is metabolized into blood glucose. I’ve been trying to prevent the resulting “spikes” that happen with some foods by delivering my insulin boluses 5-15 minutes before meals, but I can’t tell for sure whether it’s working. Even faster acting insulins (like this one) would be useful.

And I promise that in the next post I won’t drop the F-bomb again.

Posted in Data-betes, Diabetes, Life Lessons | 12 Comments

Cape Cod 100-miler

Posted on September 20, 2010 by Jeff Mather

I had a great ride yesterday on Cape Cod. I had originally planned an 88 mile ride from Woods Hole to Provincetown. After seeing the distance, I figured I’d tweak it a little and make it at least 100 miles. After all, that’s less than an hour of extra riding. So instead of heading directly to Orleans from Brewster, I swung southeast to Harwich and Chatham before rejoining my originally plotted route. Voilà, 100.2 miles.

Lisa was very sweet and drove the route, stopping every 25 miles or so to let me top off my waterbottles and grab some extra food. She was also my shuttle home from Provincetown.

It was a really enjoyable ride: cool enough for arm-warmers at the beginning, sunny and warm later but not hot, with a light tail-wind for a good portion of the last half.

The roads from Woods Hole to Bourne through Falmouth were really great. Smooth, curvy, uncrowded. I can’t say exactly why, but I really enjoyed riding under the Bourne and Sagamore Bridges. Once I got onto Route 6A — which I was on for about 30 miles through Sandwich, Barnstable, Yarmouth, Dennis, and Brewster — the ride changed in complexion quite a bit. 6A is a bit busy, especially compared to the rural roads in Falmouth, though it’s still scenic.* Unfortunately there aren’t many east-west roads on Cape north of US-6, so I did my best to enjoy the views of the cranberry bogs, ponds, marsh grasses, and cutesy galleries and shops along the way. I was happy to leave 6A and head on backroads to Chatham, where I picked up Route 28 and then headed north — on Route 28 South, mind you — past the sailboats in the bays, and the beach-goers, and the expensive resorts. After more backroads in Orleans and Eastham, I picked up US-6 in Wellfleet for what must have been the most soul-crushing part of the ride: miles 78-92.

Most of the ride was easy because it’s essentially flat. The Cape is a huge sand bar that never really got past the last ice age, when it was more or less flattened by the glaciers; and while there’s some varied topography in the central spine, most of the drumlins and moraines are now underwater due to rising sea-levels about 10,000 years ago. There’s a current that moves sand around the flexed arm of Cape Cod, but it isn’t until you get north of Orleans that you start to see the rolling sand dunes. US-6, which cuts across those dunes and sand hills in Wellfleet and Truro, is a good highway, designed for efficiently moving cars to and from the outer Cape. It has a wide shoulder for cyclists, but (as with all US highways in the Commonwealth) the inclines are artificially long in order to shallow out the grade. I prefer a shorter, steeper grade or rolling hills to long, barely perceptible uphills. But that’s just me, and I did appreciate the longer downhill stretches on the other side, where I was able to rest my forearms on my handle bars and get some speed. But I just don’t like a long, wide road with zippy traffic no matter how nice and wide the shoulder is. It’s too wide-open, the sight-lines are too “good,” and consequently I don’t feel like I’m actually going anywhere.

The last eight to ten miles were fantastic. Once I got back onto Route 6A, I was really flying. I knew that I was almost done, and I was ready. My saddle was starting to get a touch uncomfortable; I could feel a blister developing in the webbing near my left thumb; and I was dealing with an intermittent cramp in one leg, which I think might have been related to slowly rising blood glucose. So I gave myself just a tiny bit of extra insulin — an almost insignificantly small 0.2 units — and decided to finish this ride out as quickly as possible. I’m not one of those “Oh, I don’t want this long ride to be over” kinda guys; I’m more of a “Let’s get this MFer done and look good while doing it.” So I got down into a nice tuck, alternating between the drops and draping my palms over the brakehoods, and just started cranking away. In my mind I looked good riding through the heart of Provincetown, and really, when you compare me to the casual cyclists on its streets, I’m probably not wrong. My hope is that someone thought, “That crazy man attacking the hills going out of town must have just started a late afternoon training ride,” rather than, “That sweaty, salt-encrusted guy looks sad. And what’s with those socks?“** Of course, it being P-Town, I would have even been okay with “mmm… sexy.”

In the end I made it, and it was fun. I didn’t want it to be longer, but I enjoyed it, and I probably could have gone another hour or so before ennui set it. It was great seeing Lisa at the end, although when she drove into the National Seashore parking lot I thought she had knocked over a bank and we had to get out of town fast. “We have ten minutes. Let’s go,” she said out the window as the car slowed to a stop. Turns out, if you (as a miscreant cyclist) go through the “Do Not Enter” gates at one end of the parking lot, you miss the sign for the $15 fee that cars coming the other way have to pay. Lisa conned her way in, but we had to make it quick. After changing clothes (elsewhere) and having rather generic ice cream and drinking my first Diet Coke of the day, we were on our way home.

What’s next?


* — I finally got to have the conversation with a Massachusetts driver that I usually contemplate a few times every long outing. First off, I should say, I believe I’m a very safe rider. I stay to the right-hand side of the road, usually 3-18 inches to the left of the white line if there’s no rideable shoulder. The white line is bumpy and slick (relatively speaking) and you need a little distance to avoid storm drains and broken pavement. I’d rather stay a tiny bit wide of the line and ride a straight line than swerve around. I believe it’s safest. When I ride, I prefer to get at least three feet of clearance from passing vehicles, and I almost always give more when I’m driving. If you can’t give that much space, you should slow down and pass when you can. So what if you have to slow down from 35 mph to 15-20 mph for about 15 seconds. It’s worth it, right?

I also don’t like to yell at drivers. It doesn’t do a lot of good, and most of the time they can’t hear me anyway. And I don’t like gesturing either; it encourages small-dicked drivers to just be jerk-faces the next time around. But I am known to yell at drivers who pass within my three-foot bubble while driving too fast, and anyone who passes me within 18 inches gets a good dressing down. I try to keep it courteous and clean, but I have a good deal of volume, and if your windows are down you will hear me. (And if you turn left directly in front of me while your windows are down with your kids in the car, you will likely hear something that will prompt an interesting dinnertime talk. “Mommy, what’s a ‘motherfucker’ and why did someone shout it at Daddy while he was driving today?”) But that’s not the conversation I’ve been waiting to have.

It started with a very loud shout: “MOVE OVER!!” I quickly pointed to the left and then straight at the rear-view mirror of the driver who just passed me going the speed limit, completely within our shared lane, although there was no one in the on-coming lane.

Then I saw the taillights come on, and I smiled to myself knowing it was finally on. “What did you say?” he asked as I rolled up on his passenger side, still riding right along the line.

“I said, ‘Move over.’ There’s no reason to pass anyone that closely.”

“You should stay more to the right.”

“I was barely off the white line. No one was coming. You should move over.”

“But you were taking up too much of the road as it is, asshole.”

“Then you should wait until it’s safe to pass.”

“You should get out of my way.”

He was starting to get ready to roll off, and I could see that he was not going to back down. “Share the fuckin’ road,” I said and waved as he sped away. (back)


** — Somehow I only brought along one cycling sock. So I had to ride the hundred miles in a pair of black socks that I usually wear to work. Fortunately this pair was a bit slouchy, and I was able to fold them down a bit. It could have been worse, but I felt like a middle school gym class dork. I’ve since burned the socks I wore yesterday. (back)

Posted in 101 in 1001, Cycling | 2 Comments

Sneak Preview: Cape Cod

Posted on September 14, 2010 by Jeff Mather

Here’s my plan for the weekend.


View Larger Map

Posted in Cycling | 4 Comments

Reading a Freestyle Blood Glucose Meter with MATLAB

Posted on September 10, 2010 by Jeff Mather

Here’s some MATLAB code that will read data from a Freestyle blood glucose meter that is attached to your computer via serial cable. (Be sure to replace the “smart” quotes with appropriate single quotes. And the “…”, too. Sorry.)



% Jeff Mather - 3 October 2001
% Connect to meter.
s = serial('com1', 'baudrate', 19200, ...
           'FlowControl', 'Software');
fopen(s);

% Initiate communication.
fprintf(s, 'mem');
fprintf(s, 'log250');

% Read diagnostics.
fgetl(s);   % First line is empty.
meter_ID     = fgetl(s);
software_ver = fgetl(s);
current_time = fgetl(s);
num_readings = str2num(fgetl(s));

for p = 1:num_readings

    reading = fgetl(s);
    sprintf(reading)
    
    pause(0.25);
    
end

fclose(s);
Posted in Computing, Data-betes, Diabetes, Fodder for Techno-weenies, MATLAB | Leave a comment

The Ultimate Blood Glucose Meter

Posted on September 8, 2010 by Jeff Mather

Let’s talk gadgets.

Usually I can hold off getting things with buttons and displays. I’m a guy whose “smartphone” is an unlocked multi-band phone from the middle of the last decade that we took to India and that now mostly sits in my bag uncharged unused. It has a camera and Bluetooth, and I can play Monopoly on it (using a Java virtual machine) but that’s pretty much it. Fancy MacBook Pro laptop (from 2006)? Yes. 4th-gen iPod (ca. 2007)? Also yes. iPad/iPhone/Android/everything else? Not so much. After that decision to get an overpriced HP iPAQ hx4700 with a short shelf-life in early 2005, I’ve been reluctant to get many expensive, shiny things.

I’m definitely not opposed to gadgets, though. After thinking about the experience of recording my diabetes events at the end of last month, I’ve decided that I would like one shiny, new thing. Unfortunately, what I want — an awesome, new blood glucose meter — doesn’t exist yet. What would such a sugasheen have?

First off, it would be part of an integrated system. It would work with my pump, sending BG readings to it, similar to the way my OneTouch Ultra Link does with my Minimed Paradigm pump. It would also accept sensor data from a CGMS.

It would be easy to get data off of it. We’re talking as simple as docking an MP3 player, preferably using a standard USB connector. The data should be open and sharable. I hate that Medtronic’s software lets me download all of my pump’s events — including suspensions, temporary basals and bolus wizard suggestions — but then stores them in a password-protected Microsoft Access database that I can’t open because they won’t share the password or let me change it. And unlike the Freestyle connection cable, Medtronic won’t provide the API calls that I could use as an application developer to retrieve the data from my pump/meter. It’s my data. They don’t own it. It’s my life I’m trying to improve. Meter manufacturers should help me do that, right?

It would be open. There are lots of ways to slice and dice and visualize data if you have access to it. I should be able review my data, get averages, display events, and plot my activity in a billion different ways: time series, modal day, statistical box plots, histograms, even pie charts. Basically, if you can think of something to do with BG data, it should be possible to get the data and do it. That doesn’t have to happen on the meter itself, but it could. Wouldn’t that be sweet?

It would have lots of metadata. My Freestyle meter didn’t have any metadata at all. My OneTouch has two axes: before/after meals and a limited set of comments. But I find the events don’t often describe the reading I’ve just taken. “Not enough food” and “too much food” might describe the experience of people with type 2 or those unfortunate souls still on NPH, but I find myself wanting something like “miscalculated carbs” and “infusion set change.” I would love to be able to define my own events — especially a “WTF?!” comment — and be able to tag particular readings for follow-up with my endocrinologist or her nurse.

I would love to be able to type short, free-form notes to myself about my BG and bolus events: “Bolus wizard said 5.0 units, but I took 4.0 because of exercise” or “Had some ketones.” We’re talking Twitter-length here (140 characters) not Anna Karenina. Since a lot of diabetes is tweaking things, the perfect meter software would let me remember what I’ve tried and try it again or change it up next time.

As long as we’re talking about notes and readings and metadata, let’s talk sharing. I would love to be able to e-mail a portion or all of my log to my healthcare team for consultation. There’s no need to post my results to Twitter, but then again, why not?

Switching to the nuts-and-bolts, getting-the-BG-reading level, let’s try to think beyond blood and consumables: The ultimate BG meter would take blood and test strips out of the picture. Strips are expensive and have to be disposed. Pricking fingers isn’t exactly painful for me (I know it is for some people) but it is a bit 20th century. How about something that uses subcutaneous light scattering or UV “tattoos” that change depending on BG levels? However it might work, we’re talking about something noninvasive that doesn’t require another trip to the pharmacy every month in order to buy something I’m going to bleed on and (responsibly) throw away.

And, of course, it would be very accurate. None of this ±10% nonsense. We’re occasionally making life-or-death decisions with those BG readings, especially when deciding how to treat a high BG. The values should be precise and accurate enough that we can’t overcorrect because we’re in the margin of error.

It would also be possible to use this meter at night. LEDs are cheap. Use them. Put one in the front so that I can see my finger and another behind the display so that I can read the results w/o blinding myself at 4:00AM.

And for the love of g-d, if you’re going to require batteries, use normal ones that you find at a gas station on the NJ Turnpike or at the Eiffel Tower gift shop. AAAs would be nice.

Since blood glucose self-monitoring is the first step in a decision-making process, the ideal BG meter would help me with the rest of the process. Get a BG reading, add in the name and amount of the thing I’m going to eat, and voilà the carbs show up for the bolus wizard. I should be able enter in foods that I frequently eat as well as downloading nutritional information for those place we won’t tell our nutritionist about. If I’m going for a bicycle ride, the decision-support part of the system could remind me what works and suggest some snacks or insulin pre-gaming that I need to do based on my own history. It could even point my attention to the fact that I’ve been going high around 4:00 most afternoons for the last month and suggest that I bring it up with my healthcare team.

Finally, it would be at least as small as my current meter. If it has to be a separate device, it should fit into a stylish case that won’t get nasty after a year of constant use. But . . .

Look at this:

iPod Touch

Look closer!

iPod Touch

The data ports on the iPod and iPhone are perfect for attaching something small that can communicate with the software on the device. The ultimate BG meter would just attach to an iPhone or iPod Touch (or Android device), adding the BG reading capability to a platform that is perfect for everything else. Basically, I want a smartphone with “an app for that,” where “that” is diabetes.*

BG database with flexible journaling? There’s an app for that.

BG results analysis? There’s an app for that, too.

Bolus wizard support using a food database? E-mailing results? Decision support? Apps for them, of course.

These devices already have a backlight for those late-night readings and wireless connectivity to integrate CGMs and insulin pumps.

And we already carry them around. Or at least I would go buy one now if this were available. I’d probably buy two.


* — Look at what Apple has already done with the point-of-sale (POS) system in their own stores. “Running an Apple supply chain? There’s an app for that.”

Posted in Computing, Data-betes, Diabetes, Fodder for Techno-weenies | 6 Comments

CGM

Posted on September 8, 2010 by Jeff Mather

This is the third part of a triptych of diabetes posts. The first part references the time just before my diagnosis. The second part covers the most recent year of my post-diagnosis life. Here I cover some recent developments and provide a view of the near future.

What follows is one of the few things I remember from the classical Greek class I took in my senior year at Grinnell: “᾽ͅΟμοι κακαδαιμων. Ἐγενετω τυφλως. Ω Ζεω, χαλαπως ἐστι ὁ βιος.” That pretty much means “Oh the misfortune! I have become blind. Oh Zeus, life is so hard!” As someone who fears going blind, that story in the primer had a bit of an impact. Another thing I clearly remember is the inscription I put at the top of my final exam: “᾽ͅΕγαρ μα πραχοιμι κακος.” (I hope that I don’t do badly.) Athena didn’t help me as much as I’d hoped.

What does this have to do with diabetes, or with continuous glucose monitors (CGM) for that matter? Not much really. I’ve always just loved those sentences, and any time I hear “blind” or “blinded” they instantly spring to mind.

Last week, I wore a “blind” CGM to gather data for my endocrinologist. Yes, for a week — from Thursday to Thursday — I had a small device attached to me recording close approximations of my blood glucose every five minutes. A thin filament was inserted horizontally into my skin — it didn’t hurt, honest! — and the readings were recorded in a little device about the size of two stacked quarters that was attached to the sensor. Everything was held in place by a boat-load of tape. I couldn’t see the data as it was recorded, hence “blind.”

I was told to do what I normally do with two exceptions. #1: Take at least four blood glucose finger-stick readings every day using their special meter. No problem there. I usually test 7-10x day, and I seemed to test extra knowing I had this thing gathering loads of data. #2: Record everything I did on paper. Blood glucose tests. Food. Insulin. Exercise. Infusion set and insulin changes. Everything. I made a photocopy of the log (five pages!) before sending it all back to Medtronic Minimed.

I should have the results back sometime in the next week, but here are my thoughts after a week of wearing a CGM sensor:

  • I hope to finally know what’s happening overnight. Do I go low and rebound? Do I steadily climb throughout the night? Do I wake up with high readings because of dawn phenomena that I can counter with extra insulin?
  • What really happens when I exercise?
  • Does bolusing 10-15 minutes before I eat make any difference for me? I hope to find out.
  • Wearing a CGM is totally something that I could do, and I definitely want to know when I’m going up or down too much.
  • Wearing the sensor didn’t hurt at all, although I’m not sure I could put one on my own back.
  • One strip of tape over the sensor was not enough, and I had to add a full metric tonne more over the week.
  • Logging (or journaling or whatever) is a total pain in the ass, but I did start to notice some trends on my own.
  • “Observations of daily living” (ODLs) should be as easy to make as a blood sugar test or an insulin bolus. It’s currently a pain in the ass to integrate all of the data that people with diabetes use in our heuristics for self-management, but there’s no need for it to be that way.
  • I don’t eat nearly enough fruits and vegetables. I’m glad a dietitian isn’t looking at my logbook.

Hopefully, I’ll be able to glean a lot of useful information out of this week-long endeavor. And if the accuracy is there, I also hope that I can get insurance approval for CGM sensors that will send data to my insulin pump. I’ll keep y’all posted.

Posted in Data-betes, Diabetes, Fodder for Techno-weenies | 5 Comments

Community

Posted on September 8, 2010 by Jeff Mather

This is the second part of a triptych of diabetes posts. The first part references the time just before my diagnosis. This part covers the most recent year of my post-diagnosis life. The final piece recounts some developments from last month and a view of the future.

It’s that time again. September 8th. The anniversary of my diabetes diagnosis. My “diaversary.” D-Day.

A lot has happened since last year when I wrote about my 10th D-Day. I wouldn’t say that date was any kind of watershed, but it certainly reminded me that my ability to get the results I wanted out of my diabetes self-management wasn’t where I had hoped it would be ten years in. In fact, I would say that my whole time with diabetes has been a gradual improvement from complete ignorance to middling abilities with a healthy dose of almost daily “WTF?!” moments and compromises. But that just wasn’t working for me.

I wish I could say that since last D-Day I’ve figured a lot of things out and that I’ve seen an overall improvement in my diabetes indicators — those being my 14-day blood glucose average and my quarterly A1c labs. While I have moved a lot closer to having confidence in my basal insulin rates, bolus dosages, and exercise rubric, my A1c is slightly higher than it was at this point last year.

Nevertheless, despite all these struggles — and, yes, I do consider them “struggles” — I feel like I’m in a much better frame of mind than I was around this time last year. For sure, I still get very frustrated from time to time, both with my own abilities and (mostly) with my lump of a pancreas and the cyborg technology that tries to pick up the slack. But I feel like I have a better support system than I did earlier last year when I was really trying to get a new handle on everything.

That support mostly comes from the Diabetes Online Community, the D-OC. I do still get my medical advice from my endocrinologist, her staff, and my friendly nurse educators. And I’m constantly amazed at the level of engagement, sacrifice, encouragement and flexibility that Lisa gives when it comes to my disease. There’s just something about that virtual community, though, that really helps my mind.

It all started late-ish last summer via Twitter. My Twitter relationship started much earlier after having lunch with a far-off friend that had a lot of “Twitter this” and “Twitter back-channel that” and more hashtags than I could handle. So I went on, got an account, added a few people I already knew, and then treated it like a second Facebook status stream, since I had no idea what it was actually good for.

Then one day I searched for “mg/dL” and it all changed.*

As with so many people with diabetes, I think I found Kerri first. If diabetes has an online superstar — albeit a totally humble, accessible, down-to-earth superstar — she’s the one. From there I found an active group of people that seems to grow by the week. I can’t keep up with everyone, but I find myself getting a lot from the people with diabetes I do follow: information, advice, conversation, encouragement, opportunities for activism, news, indignation, banter, jibber-jabber, and all those tasty-tasty links to blog posts and articles that I never find the time to read. I only hope that I’ve given back a fraction of what I’ve gained.

From these wonderful people — online friends, really — I’ve learned about devices, medications, and treatment philosophies that I never knew existed. But more importantly, I’ve seen what’s possible. The low A1c and more-or-less normal blood glucose levels while leading more-or-less normal lives. The marathons and triathlons they’ve done. Heck, even professional cycling and the winter Olympics!

But mostly I’ve found community. A bunch of people who know what it’s like to try to do everything “just right” and still end up with crazy high or low blood sugars. People who have spent a lot of time in doctors’ offices (and occasionally in the ER). People who wake up in the middle of the night in a cold, hypoglycemic sweat and worry about the toll these nighttime events have on their families’ peace of mind. People who don’t need anyone else’s pity or ill-informed advice but will settle for a little leeway to do the best we can. People who are willing to share our triumphs and frequently our setbacks.

This is the first online community I’ve really connected with. It’s (not coincidentally) also the first I’ve found that isn’t cliquish or riven with political/ideological/petty differences. Thankfully, it’s pretty free of trolls and spammers and general ass-hats. We’re just a friendly collection of people striving to do the best with our insulin the only way we know how. And I’ll take that, because whatever the limitations diabetes puts on us — and let’s be honest, it does make everything a bit harder — it’s nice to know there’s someone else out there who has gone through it and is willing to open up (even a tiny bit) about what it’s been like to work through it and (maybe) get beyond it.

That’s my hope for the coming year, my twelfth with diabetes: to continue to make progress — even if it doesn’t always show up in my numbers — and to share that hope with the people who care about me in real life as well as my fellow travelers I’ve met over the last year online.


* — I think this tweet may have been among my first after I became aware of the D-OC.

Posted in Diabetes, This is who we are | 3 Comments

Voicemail

Posted on September 7, 2010 by Jeff Mather

This is the first part of a triptych of diabetes posts. It references the time just before my diagnosis. The second part covers the most recent year of my post-diagnosis life. The final piece recounts some developments from last month and gives a view of the future.

This may be the most important voicemail I’ll ever receive:

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But this one is a good one to remember, too…

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… especially since that first message was her calling me on September 7th, 1999, the day before I was diagnosed with diabetes. Thanks, sweetheart, for all the help staying well these last eleven years.

Posted in Diabetes, Historical Record | 5 Comments