Category Archives: Diabetes

Speed of Carbs

On Tuesday I had a little conversation with a coworker about carb-loading. (He ran a 2:23 on Monday, finishing 41st in the Boston Marathon and 33rd among men.)

“I crammed so many carbs in the days leading up to the marathon. How do athletes with diabetes, such as yourself, do that?” I was once advised by a sports nutritionist at Joslin not to bother with it; eat well, take your insulin, and you’ll have plenty of energy. Since then I’ve realized that it’s possible but difficult, and I tend not to eat a lot of extra carbs in preparation for an event. With that said, I can definitely tell based on my insulin sensitivity whether my glycogen stores are topped off or not.

I mentioned that one of the few good things about diabetes is that it gives me pretty good insight into what’s happening with the food I eat before, during, and after exercise. When is its energy from food available to my muscles? Which foods spike blood sugar faster? Which ones digest more slowly? How much carbohydrate do you really need per hour to maintain blood sugar and energy?

We’re all different—and your level of insulinization matters—but here’s what I’ve discovered about the speed of carbs. From fastest acting “exercise carbs” to slowest:

  • Glucose tablets
  • Gatorade
  • Clif Shot Blocks / Gu Chomps
  • Banana
  • Clif Shots (gels) / Gu gels
  • Skratch Lab drink mix
  • Hammer gels
  • Honey Stinger waffles
  • Clif Bars

Lately I’ve been eating bananas before exercising, and fueling with one Hammer gel every half-hour while running or cycling. I also bring glucose tablets with me, of course, for that life-saving, just-in-case energy. If I’m going for a long bike, I’ll also bring a pack or two of chewy Clif Shot Blocks, which I’ll eat instead of a gel when my blood sugar drops. (I find that I can’t really eat these while running, so I save them for the bike.)

How about you? Does this sound familiar, or do you have a different take on it?

Posted in Diabetes | Leave a comment

Diabetes Stuff and Its Cost

Here’s my take on last week’s kerfuffle concerning the NY Times article about diabetes improvements and their high costs:

That’s all of my diabetes stuff . . . and that doesn’t include the pump and continuous glucose monitor (CGM) transmitter that I’m currently wearing. Over the last fifteen years, my insurance company, employer, and I have been a mint for pharmacies and corporations in the diabetes technology and biological pharmaceutical areas.

If you look closely you’ll see the “consumables” on the right-hand-side of the picture: test strips, infusion sets, reservoirs, CGM sensors, batteries, lancets (*ahem*), alcohol swabs, and various tapes and preps. In the left foreground are the “just in case” spares that I carry with me everyday: a pump, meter, reservoirs, infusion sets, syringes, and all of the things I might need to use these things—inserters and chargers mainly—whether I’m at home or away.

Everything else is just stuff. Maybe I used it once, but nearly as often it just came with something else as either a freebie (lancets with a new lancing device) or as something billed to my insurance company when I got a new device. I keep it because it’s useful once or twice a year or because (as a disease that can instantly demand your full, life-or-death attention) diabetes really encourages preparedness. But somebody paid for all that stuff, even if it goes unused.

The observant reader will notice two insulin pumps in there: the last Medtronic 512 I used before getting my Medtronic 522 about five years ago and the most recent 522 I wore before getting the 530G that I’m wearing right now. It’s been beneficial to have a second pump; the first one sometimes breaks, and I also use it along with my regular pump on days when I compete in triathlons. But why three? Unlike the 512, the 522 supported CGMS. Unlike the 522, the 530G supports the Enlite sensor. Otherwise, they’re pretty much the same with minor tweaks.

Is it medically necessary to have upgraded? No. Have the expensive technology upgrades improved quantifiable health metrics, such as A1c or the number of lows and highs I have? No. Have they improved my overall quality of life with diabetes? The 522 certainly did, since it brought me into the world of CGM; the 530G hasn’t been nearly as impressive or transformative. (In fact, it’s been a bit of a disappointment, but more about that another time.)

The meter story is similar, except my out-of-pocket expenses are higher, and each time I’m sent a “free” meter, the test strips fall into the ultra-premium, high deductible tier of my pharmacy benefit. So, I’m using the medium tier test strips which work with the meter that sends BGs to my pump. If I were a person of lesser means, I probably wouldn’t care enough about that integration to pay extra each month.

(By the way, this is just a small collection of the meters I’ve had over the years. I’ve lost some, broken one or two, and given away a half-dozen or more to coworkers who sent them home to type-2 parents in India, China, and Russia.)

The impact of cost probably holds just as true for insulin as it does for test strips. I get good results from Humalog, but it’s not the only insulin analogue out there, and Novolog costs less for some people. I would consider using it if it meant significantly lower out-of-pocket expenses. Of course, there is a lower-cost option currently available: “regular” (non-analogue) insulin. I know a couple of pharmaceutical insiders who lament that Humalog doesn’t have enough of a difference in action compared to regular to justify its higher price. But for me, their action curves are different enough in rapidity of onset and shorter overall action to be worth it.

If you were looking in from the outside—perhaps as someone who pays more out-of-pocket than I do or as a coworker who shares some of the shared burden of our insurance pool or as a health economist—would all of this seem like money well spent? I find that debatable. And I think that’s the point that’s been lost in the DOC about the NYT article. Sure, I disagree with it on the value of insulin analogues and CGMS, but I think it raises interesting points and questions that we can’t ignore:

  • New diabetes “improvements” often aren’t based in medical necessity or add only marginal value when you consider them based on clinical indicators. (This is sadly true for a lot of medical “innovation” these days.)
  • A lot of recent research and costly new developments—incremental changes to pumps, CGMS, test strips that use less blood, integrated devices, and better insulin analogues—are critical parts of various “artificial pancreas” projects. We’re developing a very expensive “cure.”
  • Many people with diabetes (type-1 or -2) have trouble affording the basics, and many more have large out-of-pocket expenses for the durable goods and consumables that comprise artificial pancreas solutions. Are we developing solutions that only some of us will be able to afford?
  • As people impacted by this disease, we naturally want all of the newest things that might make our lives easier, even if the research hasn’t proven its cost-effectiveness yet. How much can we really expect the other people in our insurance pools to contribute for this stuff? Where do lower cost options fit? Will we accept people suggesting that we reconsider or who flat-out tell us “no?”
  • How should we effectively communicate our need/justification for these things to people outside our community? And how can we handle pushback from people who justifiably question the value of the stuff that isn’t strictly necessary?
  • How can we in the community help drive down prices for the stuff we need and use?
  • What are ethical/legal ways of “redistributing” high-cost diabetes technology once you’ve upgraded or switched vendors?

So, dear readers, what do you think?

Posted in Diabetes | Leave a comment

Crash, Part Two

Am I Kris Freeman? Nope, pretty sure.

Am I in Vancouver, having just watched him go hypoglycemic during an Olympic race? I think this looks like my bedroom. Why would I be in Vancouver? Why wouldn’t I be in Sochi?

Why am I wide awake? Where is that weird feeling coming from? And What time is it anyway? Oh, it’s 2:30. I must be a bit hypo myself.

I started eating glucose tablets before I even tested, since the world was flashing in that particular way it does when my blood sugar is low. The result: 46 mg/dL (2.6 mmol/L).

It had to be the skiing.


Lisa says that I need to steer clear of hypnotists because my subconscious seems very susceptible to suggestion. But then again there has been a lot of skiing in my world recently, and it would make sense that it would sneak into my dreams. Saturday, I watched someone a year older than me win a gold medal in the men’s biathlon 10K. The next morning I watched the women’s race from Sochi while running long on the treadmill, and in the afternoon I watched the skiathlon, which combines classical and freestyle Nordic skiing. Then I waxed my own skis, which I used yesterday after work before going home to (among other things) watch more men’s biathlon. Some time in the evening, Lisa and I watched this short NBC profile of Kris Freeman.

Last year, skiing didn’t go very well. I managed to fall a lot during my lessons, injuring my left shoulder. So I was rather nervous about giving it another shot. But then again, there’s a huge stubborn streak in my constitution, and I was looking forward to doing better this time around. Yesterday, my first time skiing this season, I just wanted some time on the snow. I needed a chance to work on my balance and get a little confidence back. If that meant double poling for the better part of an hour, then so be it. And that’s pretty much what I did: sticking to the parallel ski tracks for about two miles, while occasionally throwing in some really ugly-looking V1 when no one was around. I did fall a couple times in the same spot on a downhill turn—clearly something to work on—but I wasn’t hurt and consider this a successful outing.

The only really bad thing which happened is that I managed to pull out the infusion set which delivers my insulin. I don’t think it was from the fall—although that might have helped—or because my abs look like this:

I don’t, for the record, look like either of them. Nor do I put my infusion set on my chest. (Ouch!) I have enough of a spare tire that I can usually find a place in my abdomen, although I do occasionally find muscle when starting a set, which hurts like you would not believe.

Anyway, when I put my new set in yesterday, the tape was a bit wrinkly, and as I smoothed everything out, I must have loosened the cannula, which is supposed to sit under my skin. Sometime as I skied it worked itself free, meaning that no insulin was going into my body. An hour after eating dinner I discovered the problem, but by then my blood sugar was ridiculously high (500 mg/dL, or 28 mmol/L). There was nothing to do except change the set, take extra insulin, drink lots of fluids, and wait . . . and wait. I couldn’t be sure how long I had been insulin-free, so I gave myself a lot of it. When I went to bed I was still quite high, so I dosed even more, which combined with all of the skiing and caught up with me four hours later.


Tomorrow’s weather looks pretty good, and I think I’ll head back to the ski track after work. Let’s hope for better balance and blood sugars.

Posted in Diabetes, Skiing | 1 Comment

Retrospective

I’ve been gathering all of my diabetes related data for more than a year now: carbs, boluses, BG readings, CGM traces, exercise data, insulin changes, etc. Almost all of this data is automatically generated and captured through my pump/CGM, and I don’t have to do much of anything to aggregate it. Making use of it is another matter entirely.

Collecting all of this diabetes data is just hoarding unless I actually use it to make my diabetes better. And do I ever need to make improvements. For reasons that I’m trying to figure out, the last six months have not been kind to my BGs, and the last three have been even worse, giving me my highest A1c since I was diagnosed with diabetes almost 15 years ago. Tomorrow morning I will meet with my endocrinologist, and I know the question of “What changed?” is going to come up. In order to answer “What?” I’m first trying to answer the question “When?” How have my BG readings changed throughout the day compared to six months ago? Looking at that information, I can move on to the question of “What’s different at those times of day?”

Here are the statistics from six months to three months ago, and then from three months ago to yesterday (when I had my blood drawn).

There’s a lot of data there, but you can see that I’m lower overnight and slightly unchanged during the first half of the day, but then the rest of the day is up, with the afternoon and evening readings quite a bit higher. All of this combined to raise my overall BG average by about 20-25 mg/dL (1-1.4 mmol/L). The variability is more or less unchanged, so if we subtract the mean and median values from these sets of data, we can see the changes more clearly.

And that is pretty much what I know. Tomorrow the trial-and-error phase of figuring out what to change begins, but at least we can start from the data.

Posted in Data-betes, Diabetes | Leave a comment

How Glucose Works

I want to talk about glucose a bit. People with diabetes (and our caregivers) think about it all the time, but we’re usually just thinking about blood glucose. That makes sense, because that’s the part we’re most actively trying to manage. But what about the other kinds of glucose in the body? What is it there for? How does it affect blood glucose?

As I wrote last month, a body stores energy in many forms, and blood glucose is dwarfed by muscle and liver glycogen and fat. We’ll leave stored fat out of the picture for now and just focus on glucose and glycogen.

When you eat, much of the energy content of the food—especially the carbohydrate part—is broken down into glucose, which enters the blood stream as—you guessed it—blood glucose. Insulin (either from a working pancreas, an insulin pump bolus, or an injection) reduces the amount of glucose in the blood, but have you ever wondered where it goes?

Insulin, our favorite hormone, acts as the doorman for glucose at two main kinds of cells: muscle cells and the liver. If your muscle glycogen is low because you’ve been exercising, glucose will enter the muscles, getting them ready for the next time you’re active. It can take upwards of 24 hours after a multi-hour endurance activity to restock your muscle and liver glycogen stores. Also, people who exercise more often can store more glycogen in their muscles, making them capable of working longer. This is a key part of the so-called “training effect,” and it’s also why people with diabetes tend to be more insulin-sensitive when starting a new kind of activity: New muscle groups are getting their own training effect and storing more glycogen.

At the same time, insulin is opening doors (big, BIG doors) in your liver. In people without diabetes, insulin flows directly from the pancreas to the liver, causing much of the glucose from food to be stored as glycogen there, too. (This is one of the reasons to bolus before eating; it gives subcutaneously dosed insulin a chance to get into the bloodstream, preparing the liver to receive glucose and prevent post-meal spikes.)

When your muscles and your liver are full, the extra glucose gets converted to fat and stored away for winter . . . or whenever. This is normal, even desirable. Almost 100% of the energy stored in a body is in the form of fat. Glucose burns efficiently and right next to where it’s needed. We need glucose, but it takes up a lot of space. Fat is more energy dense and still convertible to a form that cells can use. Think of it as the difference between your car’s gas tank and the underground tanks at a filling station.

“What purpose,” you might ask, “does liver glycogen serve? If glucose is there for cells to use, why put it in the liver?” That’s a great question, my dear readers.

Most of the time even the most active of us aren’t doing much. We’re sitting. We’re sleeping. We’re digesting. We’re thinking. Maybe we’re doing a low-level of activity: cooking, typing, standing, walking from one room to another, talking, etc. All of these activities use glucose. Muscles have stored most of what they need internally as glycogen, and when they use some of it, they dip into the life-sustaining river of blood glucose and basal insulin flowing past to replenish it. Other cells, such as nerves, don’t need insulin at all and just suck glucose in via osmosis. [1]

As the cells slurp up glucose from the blood, insulin levels drop and glucagon production increases—at least in people without diabetes. This stimulates the liver to release more glucose into the bloodstream. Voilà! Homeostais. Basically, the liver is (among other things) a giant blood sugar battery. It gets charged when you eat, and it slowly discharges as your cells do something. Blood glucose is the internal wiring, continuously moving small amounts of energy around to wherever it might be used.

That’s probably enough of the story for now. I foresee several more posts demystifying how the body makes and uses energy, all part of helping us athletes (with or without diabetes) understand how to optimize our training and racing. Feel free to ask me your questions, and I’ll do my best to answer them.


1 — This is the main reason why diabetes complications affect nerves so much. Cells that get their glucose from the blood by osmosis without insulin’s help can’t rely on low insulin levels to keep it out. When BG levels go up, more glucose enters those cells and changes their internal chemistry, modifying their proteins (called glycosolation). These protein changes damage the cells and make cellular repair more difficult. It also causes changes to blood flow, further damaging the tissues.

Posted in Diabetes, Fodder for Techno-weenies | Leave a comment

Diabetologia

Did you know that if you say the journal name “Diabetologia” three times real fast, Wilfred Brimley appears? It’s true.

Posted in Diabetes, Video | 1 Comment

Diet Coke

I started using the Medtronic Minimed Enlite sensor about 10 days ago, and I have plenty to write about it. And I’ll do that soon. For now, I’ll just tease y’all and say my reaction so far is better than Kim’s but not yet as awesome as with the older Sof-Sensor. In the meantime . . .


Lisa and I were in Portland, Oregon, last week for Christmas. I had a good time there and will post pictures as well as an observation or two about running amidst waterfalls soon.

While cleaning up my e-mail inbox this morning, I came across a link to an article from The Onion about Diet Coke: “Man Who Drinks 5 Diet Cokes Per Day Hoping Doctors Working On Cure For Whatever He’s Getting.” It’s pretty clear that the article is satire, but it does include a choice bit or two:

He’s “counting on” scientists to invent a pill, vaccine, patch, or other medical solution in the coming years to prevent people from contracting whatever horrific, life-threatening disease you eventually get from drinking 60 or more ounces of Diet Coke each day. . . . “And I hope they start working on it soon, too, because I’m not feeling so great.” Cowan added that, until that day comes, he could really go for another Diet Coke.

I pretty much quit Diet Coke cold turkey four months ago. The good news: My doctor doesn’t think that I ever had an ulcer; so there’s that. The other good news: I don’t need to be medicated to prevent the nausea that I had been having. At my doctor’s suggestion, I tapered myself of omeprazole without beginning to feel ill again. Which means that the only other change I made—giving up Diet Coke and most fizzy drinks—is likely the main cause of my feeling better.

Giving up Diet Coke was both easy and difficult. On the one hand, the choice between caffeine/Diet Coke/soda and actually feeling good is an easy one to make. I feel so much better now, and on the rare time that my tummy is a little questionable (because I’ve eaten like a crazy man) a couple of Tums makes it all better. I’m drinking more water and lemonade (sugar-free, of course) to keep hydrated, but that took some mindfulness to make happen.

On the other hand, I think I’m beginning to understand addiction. I know, I know. Caffeine isn’t nicotine or heroin or alcohol. It’s probably not even close, although it is definitely addictive. But I did want a Diet Coke a lot after I stopped drinking it. I still do. I like the flavor well enough. I like the way it tickles/burns my mouth. It’s refreshing.

Beyond all of its physically pleasing qualities, though, drinking Diet Coke was something I did. As soon as I quit, there was a hole in my daily routine. That was perhaps the hardest part of breaking the habit. There were triggers everywhere: buying something at the office café, going to a restaurant, having dinner at home, taking a road trip, etc. Whenever Lisa and I would go for ice cream, we would always buy a soda afterward. We still get delicious ice cream from time to time, but somehow it feels incomplete without the Diet Coke. (At least for now it does.) And I will probably always maintain that pizza tastes better with a Diet Coke (or any kind of soda) than without. It might be entirely psychological, but that doesn’t change how real the feeling is.

So there it is. I’m Jeff Mather, and I like Diet Coke even though I don’t drink it any more.

Posted in Diabetes, General, Life Lessons | 3 Comments

How Sweet Are You?

I was inspired by Scully’s post that showed a unit of insulin in relation to a bunch of different things, like a nickel, a staple, and a LEGO man. (It’s pretty cool. You should be sure to go look at it.) Seeing those drops of insulin made me think of the blood sugar that it controls. What would the equivalent of all that blood sugar look like outside of the body?

Let’s see . . . the average adult body has 5 liters of blood, and a typical nondiabetic blood sugar reading might be 100 mg/dL (5.5 mmol/L). That means that there’s about

5 L x 10 (dL/L) x 100 (mg/dL) = 5,000 mg

5 grams of sugar in the blood.

A typical sugar packet contains 2-3g of sugar. So we’re talking about trying to control about two packets (or one teaspoon) worth of sugar with those tiny drops of insulin.

2 sugar packets

But blood glucose isn’t the only “sugar” in the body. There’s also glycogen stored in muscles, ready to be used whenever we start any kind of aerobic activity. Typically, about 40% of a healthy body is muscle, and 1% of the weight of that muscle (according to Wikipedia) is glycogen. So, if I weigh 150 pounds (or 70kg), the amount of muscle glycogen is 70 x 0.4 x 0.01 = 0.28 kg. That’s 280 grams (about 10 ounces, or 107 packets . . . some of which I “liberated” from the office).

107 sugar packets

The average person also has 120g of glycogen stored in the liver. Those 120g are about the same as 46 packets of sugar. This glycogen is released from the liver by glucagon and other “fright or flight” hormones. Dropping insulin levels during exercise also release it. This is the stuff you want to be able to tap into when you’re exercising.

46 sugar packets

Adding all of that blood glucose and glycogen together, you get about 400 grams of sugar (280 + 120 + 5). That’s about 9/10 of a pound of sugar, which looks a little like this:

That's roughly 400 grams of carbs

But all of this carbohydrate pales in comparison to the amount of energy stored as fat in even the leanest body. It’s not only more plentiful; it’s also more energy dense, containing more than twice as many calories. The four hundred grams of sugar in an athletic 150 pound body stores only about 1,600 calories, which only lasts a couple of hours in an event like a marathon. (That’s why it’s necessary to take on extra carbohydrates during exercise.) That same athlete might have 15% body fat. So that healthy person’s body has 70 kg x 0.15 x 1000 = 10,500 g (or 23 pounds) of fat. There’s an almost infinite amount of energy stored in body fat. And by infinite, I mean about 94,500 calories. That’s a lot of energy. About 60 times more than carbohydrates.

Each package of 4 sticks contains 360 grams of fat


So let’s recap:

Blood Glucose 5g 20 calories
Liver Glycogen 120g 480 calories
Muscle Glycogen 280g 1120 calories
Fat 10,500g 94,500 calories
Posted in Diabetes, Photography | 2 Comments

That Diabetes Feeling

A couple days ago Scully suggested that I write about how diabetes feels. It’s an interesting question, and the answer is hard to put into words.

I’ve written before about how diabetes is both part of who I am and something that feels separate and foreign. Managing this disease wasn’t something I did for the first twenty five years of my life, and now it’s something that I do all of the time. But really it’s not something I think about every moment of every waking hour. And yet diabetes is always there, whether I’m actively doing anything about it or not. In some way it’s always on my mind. “How am I feeling? Is everything normal? Do I need to eat? Do I have the supplies I need? Am I going to do something out of the ordinary, and what do I need to do to make that work?” Some of these thoughts are automatic and happen without me actually thinking about them. Others are really more of a gut feeling, literally. Blood chemistry affects brain chemistry affects mood, and I’ve learned to recognize some of my moods as originating from unbalanced diabetes. From time to time, the feeling are very conscious, especially when I’m having trouble influencing my diabetes to go where I want it. At those times, I feel frustrated, angry, despondent, inadequate, incapable. Sometimes diabetes is a motivator, and I feel an obligation to myself to do well despite/because of it.

This kind of omnipresent state of feeling or thinking about something is almost like any other relationship or obsession. When you’re falling in love, you think about the other person all the time. He or she is always on your mind, even when you’re not actively thinking about them. If the relationship goes bad, you can’t stop thinking about it. Sure, you’re making spreadsheets at the office, but you’re also thinking about the current troubles and how it was better and why can’t it be great now and can it ever really be great again and was it ever really that great to begin with or was it all just a big mistake. The same thing happens when a friend or loved one is hurting; you go about your day mostly doing what you always do but sparing some extra thoughts and effort trying to make things better, trying to soothe the hurt. Occasionally obsessions turn bad and you can get caught up in patterns of self-destructive thinking and actions. Thoughts can become disordered and distorted. We can lose perspective on what’s really happening or what’s the most important thing for us to be doing. We can get a little lost to those around us while we try to figure things out, sometimes because we assume that no can really understand what we’re going through or because our thoughts seem so unusual. And then things change; thoughts change; feelings change.

That’s pretty much how diabetes feels to me . . . but different.

Posted in Diabetes, NaBloPoMo, NaBloPoMo 2013 | 3 Comments

Working on the A1c

I was really early for my endocrinology appointment this morning. It was one of those “arrive really early or struggle to make it on time” choices that had me sitting around in the hospital cafeteria, leisurely eating a muffin and reviewing my diabetes data. The hospital has free Wi-Fi, so I uploaded my data from my pump and meter into CareLink and then exported it from there back to MATLAB. (It’s an inelegant process, but it’s the best I can do . . . for now.) My endo’s staff was going to download all of it again when I got to her office, but I wanted to look it over myself so that we could talk about what’s going on.

My last couple of A1c blood draws have been near all-time (that is to say, “post-diagnosis”) highs. My endo is remarkably judgement-free, and she’s really eager to help me figure out what’s going on and what changes to make. It’s a partnership, and we both bring our own perspective and fresh ideas. I have the context behind the numbers, and she has experience with other type-1 patients.

For this visit, I decided that Saturday and yesterday were two good case studies that we might investigate.

Saturday was a typical weekend day: sleep in a little, clean house a bit, have lunch out, do some shopping, etc. The thing that made it interesting was that I slid into lunch a bit low and then I had a lot of trouble getting myself out of the hypoglycemic zone. We decided that it may have been because my Indian food lunch was rather “complex,” causing the carbohydrates to take longer to get absorbed into my bloodstream. She also noticed that I have a lot of “bolus stacking” going on, which I had also seen from my graphs. (She observed a lot of stacking on Halloween and the day after, too. “Yeah, you can see when the Tooth Decay Fairy showed up,” I said to much amusement.) The stacking isn’t a problem per se, but it does make digging myself out of an insulin hole harder.

Yesterday was typical of some of the other issues I’ve been having. I had good BGs overnight and before swimming. I ate a little bit before heading to the pool and finished my swim an hour later at about the same place I started. So far, so good. But then I didn’t bolus enough for the extra muffin at breakfast. I knew the amount was probably too little, but even with all those carbs it just felt like a lot of insulin. I was going to be walking around the campus a fair bit, going to meetings and preparing for a very important meeting of my own later in the day. I didn’t want to go high, but I also couldn’t afford losing time to the lows. Not surprisingly, I went way up before lunch and then really had to work to bring it back down. By dinner I was in a happy place, except (once again) I was worried about lows, so I delivered less insulin than required. This time it was totally the right thing, since I kept sliding lower throughout the evening, and I ended up in the low 60s (3.3 mmol/L) twice overnight.

That story garnered some more suggestions, and I have a bolus test or two to do. In a couple weeks I will send her more data.

The interesting thing, we both thought, is that if you look at the last two weeks (and take out the 24 hours after the trick-or-treaters left) my BGs look pretty good. We think that with a few changes, my next A1c will be much better. Let’s hope so.

Posted in Data-betes, Diabetes, NaBloPoMo, NaBloPoMo 2013 | Leave a comment

JDRF Nashville

You are all very generous people. Close to one hundred people supported JDRF on my behalf, donating $12,275. That’s a lot of money to help develop new treatment options and find a cure for diabetes. I just can’t say exactly how appreciative I am for all of your generosity, but I am just so deeply moved by what you’ve done.

A JDRF ride is never just a ride. It’s also a chance to meet other people touched by diabetes and to reconnect with old friends. This weekend Lisa and I met up with Victoria, Ross, Sarah, and Greg, who were all at last year’s JDRF Death Valley ride. I spent some time with Steve Berube, the New England coach and all-around great guy, who lives a couple towns over from me. I even saw Rebecca out on the Trace just before the turnaround point.

This year I met a bunch of new people, including some that I had already “met” online or known through reputation: Becky Furuta, Chrysa Malosh, and Joe Eldridge (plus a couple of other Team Novo Nordisk riders). The Novo people are great, and Chrysa told me to join them on the tune-up ride Friday morning, when we decided that daylight was burning and it was time to get on our bikes and ride. It was great being out on the road with them, even if it was just to do a few 2.5-mile loops near Vanderbilt University.

Before and after the big event, the JDRF riders spend a lot of time together celebrating what we’ve accomplished and what the money we’ve raised—over $1.5 million just for this one ride—is working to accomplish: the artificial pancreas project, smart insulin, a true biological cure, a vaccine, etc. We share great stories about the ride and the people we ride for. This year (even more than last year it seems) we also celebrated the people with diabetes who were on the ride. At Nashville we totaled more than 100 of the 515 riders, and we had our own snazzy blue jerseys. It was nice to be get a little extra love when people saw us out there on the road.

The ride itself was good. JDRF seems to always put on a terrific event, and the course was challenging and fun. We rode a bit more than fifteen miles from Vanderbilt University in Nashville to the Natchez Trace. Once on this limited access parkway, we rode 35 undulating miles before turning around to retrace the Trace. The route, with its 5200 feet of climbing, reminded me a lot of the terrain near my house, and I should have had no problems with it. However, a couple of things conspired against me having my 100% best day.

First off, it’s possible that I switched over from cycling to marathon training a little too effectively. I had plenty of endurance, but I felt like my cycling legs were just a bit tired. I kept getting dropped by Greg whenever we got to a sizable hill, and I just couldn’t seem to will myself to catch him again. The upside of this is that I fell in with a bunch of different riders in small groups until I would catch up with Greg at the next rest stop. One of the riders in one of these groups put his hand on my back and gave me a little push up the hill to help keep me in touch with the riders ahead of us. It was a very kind gesture, and I appreciated it.

I also had a whole bunch of diabetes-related nonsense going on during the ride. Despite starting out at a very comfortable 220 mg/dL (12.2 mmol/L) before the ride, I dropped to 140 (7.8) within the first hour. I spent the next 70 miles eating as much as I could just to stay inches away from hypoglycemia. It sapped my energy and beat up my confidence and left me riding more conservatively than I wanted to, lest I actually push myself to a place where I needed to stop. Eventually I made it back to Nashville a bit tired but feeling very strong. Like last year, I rolled into the finish without the people I had ridden with on-and-off for six hours. Greg and I lost each other a few times, but somehow I passed him when he stopped at the final break point.

Some people I’ve met go for blood during a century ride. (Overheard on the course: “It’s not a race; it’s a ride.” “No way! It is too a race.”) Other people’s main objective is to beat the time cut-off before being forced to turn around short of the half-way point. Having done five century rides in the last few years, I can say that I’m somewhere in between. I’m not worried about finishing, but I don’t feel the need to find out how fast I can ride 100 miles. (It was six hours and eight minutes of riding time yesterday, BTW.) Going for speed can wait until I start Ironman racing. When it’s not a race, I want to have a good time and see stuff along the route, to stop and take in the historical markers and scenic overlooks and roadside parks. (I’d love to come back and ride more of the Natchez Trace, perhaps even the whole thing.)

When it comes right down to it, sometimes I’m still just a guy with diabetes on a bike. When I’m out for a ride, I don’t need to be the fastest guy out there, and sometimes (like yesterday) diabetes is going to make sure that’s what happens. But all in all, it was a really good ride, and I’m so glad that I had the opportunity to do it.

Thank you all again for supporting this fantastic cause! If you feel like you missed out on your chance to support JDRF, don’t worry! You can still contribute.

Posted in 101 in 1001, Cycling, Diabetes | 4 Comments

There’s still time!

Hey, readers!

It’s almost time for the inaugural Nashville JDRF Ride to Cure Diabetes. In fact, a week from today, Lisa and I are flying down to Tennessee for the event. I’m very excited!

Last year, we raised over $12,000 for diabetes research. I’m hoping we can do even better this year. No amount is too small, because every bit helps. I am just as appreciative for the $5, $10, and $25 gifts I’ve seen as I am for the $100 and $500 ones.

If you’ve already contributed, you have my deepest thanks. If you would like to donate, it’s fast and easy: Just click here.

Thanks again! I know that with your help we can really improve the lives of millions of people with diabetes.

Posted in Cycling, Diabetes, General | 1 Comment

14 Years, 14 Miles, and No More Diet Coke

Today is a big day. Fourteen years ago today I was diagnosed with diabetes. And this is my 1,000th post here.

I. A D-Day Run — Last year, I went trail running on the 13th anniversary of my diabetes diagnosis. It was fun . . . and difficult. This year, I’m marathon training, and I did another long run. (Next year, it’s my diabetes’s quinceañera, so who knows what will happen.) I started training a couple weeks ago, and my race is six weeks away. It’s a bit of an accelerated schedule, but I think I can manage.

Today I went for a 14-mile run, my longest run since Around the Bay a year and a half ago. It felt pretty easy. Actually, it was the best long run I’ve ever had! My pace was a very consistent 8:35-8:40/mile for the whole outing (including hills), my legs felt pretty good, and I was trying to practice a few things that I’ve read about recently.

It seems that one of our key limiters for athletic performance is the brain. It performs a vital function in keeping us athletes from doing serious damage to our bodies by throttling down our effort when we’re working too hard. That also means that we often give in when things seem tough, even if we have plenty of energy left over. Basically, we give up even when we don’t want to. (That doesn’t mean we’re weak or that we can all be Olympians, but it does mean that maybe we have extra greatness in us.) Today I worked on some of the mental things I read about: believing in my abilities, feeling relaxed, and (yes) even smiling. It seemed to work. It’s nice to be past my runner’s block.

On this D-Day, my diabetes plan worked very well. I started running at 135 mg/dL (7.5 mmol/L) and finished at 123 (6.8). That’s about as close to perfect as I can imagine! I was a little high overnight, and I had boluses some insulin about five hours before running, so I had some insulin on board. I ate a banana along with a couple of glucose tablets about five minutes before starting, and then I ate a gel (20g of carbs) every 25 minutes. That worked very well today . . . and last week, too. Next week is a recovery week, and my long run is only seven miles long. I wonder if I can reproduce this again. We shall see.


II. Marathon Training — I’m intrigued and perplexed by marathon training. I’ve never done it before, but it doesn’t seem that different from preparing for a half marathon. There’s a weekly long run (currently 14 miles and building to 20 a month from now), a 6-ish mile tempo run, and another “regular” run. The long run makes sense. While I’m 90% sure that I could run 26.2 miles next week if I had to, I see value in building up distance to make it easier. And the tempo/speed work is all about becoming faster.

But I just don’t get the regular run. From triathlon training, I’m used to every workout having some purpose. It builds endurance or strength or speed. So what does a low intensity, 40-60 minute run do? What’s it for? Why do it? Is it just because you have to run at least three times a week? But what if I’m already cycling and running a couple of other times?

We shall see.


III. Real People Sick — On my previous long run (12 miles on Tuesday) I thought a bit about having been sick recently. Last Thursday I had what I thought was food poisoning. Maybe it was. But I’m starting to suspect that it actually is a different, more long-standing issue. Here’s my thinking on the matter.

Exhibit 1: I’ve been anemic for several years. I used to have a very high hematocrit (red blood cell volume) after years of living at altitude and being athletic, but about 7-8 years ago it dropped into the anemic range.

Exhibit 2: There are three broad categories of anemia. Some forms are essentially due to blood loss. Another kind is because of slow production of RBCs. And the last kind is because of ineffective RBCs. (Think sickle cell anemia or low iron-binding.) My doctor thought that I had the second kind due to a vitamin B12 deficiency.

Exhibit 3: Taking extra vitamin B12 didn’t do much for my hematocrit, and I’m still more out of breath than I think I should be.

Exhibit 4: For a while I’ve had feelings of nausea in the afternoons, especially around the time that I go home for the day. I haven’t eaten in three or four hours, although I’ve been drinking Diet Coke. At first I thought that it could be the beginning of a gluten allergy, and I thought that changing my bread helped a bit. But I didn’t have any other celiac-like symptoms, and I could eat the same thing on two days and feel symptoms some days but not others. A couple weeks ago, I had a lot of nausea after getting home. I took a nap, and it went away.

Exhibit 5: Last week I was actually sick, and (let’s just say) I’m pretty sure it involved some blood loss. On the day I was sick, I had persistent low BGs, and my first thought was gastroparesis, a diabetic complication. But after bit more reflection I doubt that. I just don’t have enough other symptoms.

Exhibit 6: I had heartburn for days after being sick. It’s never been bad before, but a mild version does seem to accompany my nausea.

When I add it all up—the persistent low-grade anemia, indigestion, and blood—I think I might have an ulcer. Obviously, I’m going to get this checked by my doctor, but I’m making some changes in the meantime. I started taking a course of Omeprazole, and I gave up Diet Coke. I miss it, but it was the one thing I noticed that really made a difference in how I feel. If I finished the bottle on the way home, I felt bad. If I didn’t, I didn’t. So I’m giving it up and drinking more water and feeling better. But I do miss it.

Time will tell if any of this is true and (if it is) whether it will actually improve my anemia. But if it does, I really wonder where I can be athletically at this time next year. We shall see.

Posted in Diabetes, Running | 2 Comments

This Is Triathlon. It’s What You Do.

I was walking my bike to the shuttle after the the Timberman Ironman 70.3 race yesterday when I had a “moment.”

I had just talked briefly with Patricia Brownell‘s husband at her team’s tent. Once again—as seems usual for us—we missed seeing each other in real-life, despite having been internet acquaintances for a couple of years. She was the first triathlete with diabetes I had heard of, and her success was very encouraging as I was just getting into the sport. The first race I did I saw someone in a Team Type 1 tri-top, but I never got the chance to see if my diabetes radar was working correctly.

The knowledge that there are other people out there with diabetes who do athletic things was extra meaningful to me yesterday afternoon as I walked along with my medal around my neck. I’d just finished the hardest single thing I had ever done. The distances—a 1.2 mile swim in beautiful Lake Winnipesaukee, 56 mile bike ride, and 13.1 mile run—weren’t new to me. Nor were the occasional chop and currents in the crystalline lake enough to keep me from having my best pace over that distance during a race. And even though it was quite hilly, the steep rollers and the long climbs didn’t do me in on the bike or run. I kept my pace and effort in check, and all things considered, I even nailed my hydration and nutrition strategy. I was even feeling good on the run, which was quite relieving after a couple months of runner’s block.

You see, despite all of those things, yesterday’s race was all diabetes.


As each starting wave got into the water, the announcer read off interesting things about some of the participants. This guy lost 150 pounds and is doing his first Ironman. That woman was diagnosed a few months ago with breast cancer. He almost died during a training accident. She trained for Timberman in Kandahar while on active duty with the Army. They were all very inspiring stories that in many ways described the best parts of the “Ironman lifestyle.” I vaguely remember filling out this part of the online questionnaire when I registered months ago. My head was underwater as I swam out to the starting line, but Lisa said lots of people clapped when the announcer said this:

“Jeff Mather was diagnosed with type-1 diabetes in 1998, and in 2009 he taught himself how to swim. Now he’s doing his first Ironman 70.3.”

I’m kind of glad that I didn’t hear that. When I race, I like to think that I’m doing what everyone else is doing, and I often feel the most diabetes-free during an event. Obviously, I have to think about it, but none of my fellow competitors have to know that I’m in some way “challenged” as an athlete. I was deeply moved after the race to hear how people responded to knowing that people with diabetes can be real athletes, but before the race I think it might have gotten into my head a little if I’d heard it. Plus, as I was bargaining with myself on the bike about whether to finish or not, it might have enticed me to make a different decision so that I wouldn’t (in some unknowable way) let those people down, even if it might have been a very dangerous thing to do.

I swam well, but my BGs had risen steadily throughout the swim. Although they started in a really good place (135 mg/dL, or 7.5 mmol/L), I suspect I bolused too little insulin for my ClifBar breakfast. About 5 minutes into the ride, I tested and saw a “286″ (15.9) staring back at me. I bolused a tiny amount of insulin, ate a gel (20g of carbs), and decided to wait an hour until my next one. I almost always try to eat 20g every half-hour—and I can’t skip too many without the risk of hitting the wall, like any other athlete—but if I was that high, I could hold off. A little less than an hour later I was at 367 (20.5).

Exercising while having high blood sugar (hyperglycemia) is painful. Imagine having your whole body full of lactic acid and not being able to clear it out by slowing down. I can almost feel my muscle fibers rubbing against each other as they try to contract. Muscles I don’t think about while on the bike got in on the painful action yesterday: My back, shoulders, hips, arms . . . they all hurt, and I found it difficult to stay in my aerodynamic tuck. Not only was I having a painful time getting from here to there over the long, shallow grades and the short, steep rollers, I was doing it more slowly than I knew I could, thus prolonging the agony.

“Do you have a pump?” asked the guy who rolled up next to me and then proceeded to stay in the drafting zone. It was technically against the rules, but he wasn’t getting any advantage from me, and if he had a mechanical problem, I wasn’t going to begrudge helping him. Alas, I did not have a hand-activated air-pump. No. Sorry. “Really? I saw the tubing and I just thought, well, maybe. . . .” Oh, you mean an insulin pump! Yeah, I do. Sorry, I wasn’t expecting that. We chatted for a minute, the Omnipod user and I, before he took off to rock the bike while I plodded along at my more leisurely 19 mph.

The other thing about high blood sugar that you should know is that it’s a sneaky, lying bastard. When the human endocrine system is out of whack, it messes with other parts of your body, including your mind. For me, it amplifies feelings of frustration, helplessness, and despair. Fortunately, I’ve come to see these lies for what they are, and I was able to hold off the voices that told me it was okay to roll into an aid station and call it a day. While that was true—it would be okay—it wasn’t what I wanted to do. I wanted to do what I knew I could do. I wanted that finisher’s medal.

Around the 30th mile I made myself a bargain. I was going to try to make it back to transition, eating and dosing small amounts of insulin (like 0.2-0.3 units) the whole way. If I was over 400 mg/dL (22 mmol/L) when I got there, I was going to say that discretion is the better part of valor and not risk going into DKA on the run or hypoglycemia by trying to treat a super high BG with too much insulin during exercise. It kept me focused on something I could do. That’s about the time, as I was talking to myself out loud, that I invented a new mantra:

This is triathlon. It’s what you do. Sure it’s painful sometimes. You’re almost three hours in to something that’s going to take six or seven hours today, but you knew that. You knew it would be hard. You’ve been here before, and you’ve done this. This is what you do. Everybody knows that. People think you’re touched, and they might be right, but you like knowing that you can do this crazy thing. It’s why you do it. This is triathlon. It’s what you do.

Despite backing off the pace early into the ride, I was still passing people. Don’t get me wrong, I did get passed by a lot of men and women, but I made up a lot of time on the uphills, especially the steep ones. The steeper they were, the better for me, it seemed. And I made up time on the downhills, exceeding 50 mph (80 km/h) in aero at one point. And on the corners, where I knew what my bike could do and where the line was and where others around me were not willing to go. And I made it back to transition in just under three hours.


327. The 327 (18.2) reading was enough to get me back out of transition. I was standing in front of my freshly racked bike after walking from the dismount line to my spot. I wasn’t going for a time goal any more. If it took me three hours to walk the half-marathon, what was another couple of minutes of leisurely bike-to-run? I took a drink, I put on my shoes, visor, and race belt, and I tested. 327.

As I ran onto the course, I saw Lisa and stopped. “This is going to be s-l-o-w,” I shouted to her across the road. “That’s okay. I love you!” she shouted back.

A little less than an hour later I was running past her again, smiling and blowing kisses. I hadn’t expected it, but the first couple miles felt good. I planned to run/walk again, thinking I would run a mile and then walk two minutes. But the first mile was so easy that I decided to go for two. The course was hilly, but I was running strong up and down them. I swear I could feel the insulin moving blood sugar into my sore muscles, giving them a fresh bit of juice. Yes, the first loop of the run was very good, all things considered. The second lap was a carbon copy of the first, albeit slightly more painful.

I even talked to a few people as I passed them. One guy told a teammate he was passing that he thought he could break six hours. A few moments later I told him, “I did that on my first tri, too. It was the best feeling ever.” We shook hands, and he told me to go rip shit up. For the first time in a long time, I enjoyed running. I was doing better than I thought I would, and it felt like the good ole days. My legs knew what to do, and my mind was free to consider other things . . . like whether I wanted to high-five that life-size plastic bear that I saw near the end of the first loop. I did. Oh yes, I did!

I decided to give everything I had once I figured out the run was going to be a good one, and I didn’t have much left by the finish line. My best 70.3 time was 5:38:42 for the mostly flat Patriot Half back in June. When Andy Potts (the men’s overall winner) put the finisher’s medal around my neck I was trying hard not to puke all over him, and I wasn’t even thinking about my time. Only after we got home did I realize that I ran a 1:56 half-marathon to finish the whole triathlon in 5:39:49, good enough for 112th of 231 in my age group and a very lucky 777th overall. Five minutes after I finished, my BG was a perfect 104 (5.8).


I don’t know how to end this except to say that I’m very, very grateful for all of the camaraderie and encouragement that I’ve gotten from everyone along this journey. Some people I train and race with know I have diabetes, and many don’t. Even amongst those who do, they don’t make a big deal over it. They nod and say, “It sucks that diabetes robbed you of some minutes during your race, but I’m impressed with what you did regardless.” To riff off what one person said to a family member before the start, “Don’t look for me at the end of the swim. You’ll never pick me out. We’re all wearing black wetsuits.” Most of the time, the combination of diabetes and triathlon is like that; you’d never know. It’s just what I do.

Posted in Cycling, Diabetes, Reluctant Triathlete, Running, Swimming, This is who we are | 7 Comments

All Together Now: Integrating the Diabetes App

Hey, y’all. Sorry I’ve been mostly absent recently. I’ve been making stuff, and it feels pretty good. I don’t get to code quite as much as I used to at work, and this (*ahem*) little project has been giving me the outlet I need.

I started building an app to integrate all of my diabetes and exercise data right after my last endocrinology appointment, when I decided I finally wanted to do something about (1) the abysmal lack of context in the data I share with my doctor, despite having so much of it automatically logged for me, and (2) the highs and lows that I see associated with exercise. I’ve had a bad track record with personal software development projects, but I was able to get some good traction with this one. After some early brainstorming and design sessions, a couple of productive plane rides, numerous conversations with a few coworkers, one Boston Quantified Self meet-up, and many evenings of hacking/coding/fixing/designing/refactoring/playing—including not a few where I stayed up way past “pumpkin time”—I feel like I have something I can actually use to start making real conclusions. Of course I’ve been using the data throughout the project, leading to a few “Ah ha!” moments, but the last bit of integration makes it so easy to really see what’s going on.

Here’s what I’ve got. (Click for a larger image.)


You’re looking at four windows in my app. There will probably be more, but this is all I can really wrangle now. Soon I will figure out how to use the awesome, undocumented stuff under development at work and put these parts into a more polished application. (This project is really helping me know more about the bleeding-edge parts of MATLAB. While I’ve worked with it more or less every day for the last fifteen years, I never really had the chance of use many of its newer features.) Here’s are description of the four parts.

(1) The upper left-hand window is a data browser, focusing on the highest level details for each day. This should look pretty familiar to most of us with diabetes. This part and the next one are the most quantitative, and I’m trying to work more contextual, qualitative information into the other pieces of the app. Clicking on any cell in the table changes what is shown in the other windows, and it’s possible to compare multiple days at once.

(2) The lower left window presents more details for the selected days: minimum, maximum, average, and standard deviation for both blood glucose readings and CGM data; the estimated number of carbs I ate (including the ones, like glucose tablets and food during exercise, that I didn’t bolus for) and the amount of insulin I dosed; and the amount of exercise. I have also thrown in a couple of computed values: my average blood glucose divided by the number of carbs and my effective carb:insulin ratio for the day. They might be useful as I look through the data. Or maybe they won’t. We shall see.

(3) The graphs in the upper right are the big picture view of the data. If you’re a visual person (like me) and want to see how the parts fit together, this is it. It’s all there: sensor and BG data, carbs, insulin, temporary and regular basal rates, . . . even the estimated amount of insulin concentration in my bloodstream waiting to be used. The bright blue boxes are exercise. They’re not the most beautiful graphs (yet), but I’ve already managed to see some trends in them.

(4) While looking for these trends, I found myself always going back to the raw data to see exactly what that number was or exactly when that other thing happened. So I made the fourth window—the one in the lower right—which contains the actual events logged by all of my devices. It’s the rawest form of the data that I’ve exposed in the app. (There’s even more “raw” data stored in what I’m calling “the timeline,” or database, but it’s so hard to use as-is. That’s why I wrote the app, eh?)

And that’s the big picture of what I’ve made.

Oh, I guess there’s also this other stuff, just in case you think I’ve been slacking:

  • There’s a nice box plot tool that can be configured to show averages, distributions, and other statistical goodies for different times of day. When I threw enough data at it, it became pretty clear where the most challenging part of my day are (blood sugar wise, at least).
  • It integrates with Dropbox, so I can use it wherever I have both MATLAB and Dropbox installed. The data is always sync’ed up.
  • It has one of the fastest .fit file parsers around. :-)
  • There’s a good deal of date-oriented subsetting functionality. Maybe I want to look at what happened in the last 90 days since my endo appointment. Perhaps I just want to examine weekdays . . . or weekends. I might only be interested in seeing the five hours before and two hours after exercise. Easy peasy.
  • It’s possible to look for and report specific kinds of events. Only want to see CGM or pump alarms? Okay. Want to see all the details about swims lasting longer than 30 minutes. No problem.
  • I liked the free-form nature of Microsoft Outlook’s date/time entry so much that I implemented the same thing for myself. I like saying “yesterday” or “tomorrow” when talking to MATLAB’s datenum function.

There’s more stuff, but they are mostly building blocks.


Now the really exciting work begins to automate the search for trends. . . . finding those insulin needles in the haystack, if you will. I hope to be able to answer questions like these soon: What is happening on days when I climb wicked high in the afternoon? What happens on days when I don’t? How much does my blood glucose typically drop when I ride my bike in the afternoon? What did I do on afternoons when my blood sugar was really stable while I was out running or cycling? What is my actual carb:insulin ratio on days where my blood glucose is well-managed? How does my overnight basal rate look?

I’ll let you know how the data mining turns out!


p.s. — Yes, I’m thinking about how to share this functionality with the whole world (or at the very least the MATLAB-speaking part). But before I do that, I need to ruminate much, much, much more about what it means to provide the building blocks for medical analytics to people (like me) who have to make most/all of our medical decisions without much decision-support tooling and yet are expected to get it right most of the time. It’s not something I take lightly.

Posted in Data-betes, Diabetes, Software Engineering | 7 Comments