Saturday, 10 August 2013

Long Ride, Dose correction and the aftermath

First a bit of good news, I’ve managed to get a recommendation from my diabetic nurse/dietician for an injection pen with half unit scale, which will finally give me the ability to match and adjust doses more accurately according to exercise and other factors and more importantly, with my level of insulin sensitivity I can finally make corrections for high/low levels taking my high insulin sensitivity into account.

 So, today, first long session since last week’s failure in the ultramarathon, this time on the bike.  The plan was a nice 2-hour session on a route I know fairly well and, more importantly, I got to wear my shiny new Team NovoNordisk cycling jersey. Team Novo Nordisk used to be called Team Type 1, as all the riders are type 1 diabetics.  They changed the name with a new sponsor.  As it happens both my insulins are from Novo Nordisk and after a few nice e-mails with their PR people asking where I could buy one as I couldn’t find it online, a shiny new jersey came in the post; sizes are a bit on the snug side though as it’s a large and is fairly figure hugging on my 1.75m, 68kg frame.   

So, to today, as the title suggests, I corrected my morning dosages based on what I’ve learned so far, went out on my ride with no problems, and then while I was out shopping before lunch it all went a bit wrong really, but that’s just another learning opportunity.

 And how did this soap opera of highs, lows, more highs and even more lows unfold?  Well, get yourself seated comfortably and I’ll begin.

Let’s begin at the beginning, as with all good stories, and in this case the beginning is breakfast.  Waking blood sugars this morning of 5.4, right on the button, a nice breakfast of porridge and stewed plums spiced with cardamom, cinnamon and star anise for a total of about 40g of carbs.  My normal dosages in the morning would be 6 units of basal and 2 units of rapid acting for that much carb, but knowing what was to come with an extended exercise session less than 2 hours after eating, that was taken down to 3 units basal and 1 unit rapid acting for the mealtime bolus. The expectation here is that the blood sugars will rise towards the high end of my target range before I set out but that the exercise will deal with that.

So far, so good.

The ride itself went almost perfectly.  The weather was ideal, overcast, slightly on the cool side but warm enough for short sleeves and enough sun to keep you warmed up, light winds and light traffic.  What more could you ask for?

And how did the blood sugars behave, I hear you ask?  Pretty dammned good is the answer, until I got off the bike. The strategy was to test every half an hour (I’ve got no idea how Team Novo Nordisk does this and still races) and to feed in the carbs as necessary, cutting back if the levels went too high, adding more if it looked like they were dropping.  To cut a long story short it went a bit like this.

Time (mins)
BG (mmol/l)
Carbs (g)

 So, I retested just before I started out and you can see that the level has gone up, as expected due to the low mealtime bolus, but still within my normal range of 4-8.  For exercise like this, I’d be happy to run up nearer 10 without taking any action.  I had no carbs for the first half hour and you can see the effect that had, taking me almost down to my lower limit.  A bolus of two slices of nice sticky malt loaf sorted that out nicely.  I then decided to give myself an intake of 15g carbs every 15 minutes, a nice easy round number to think of.  It also happened to be 200ml of my liquid carbs and about 1/3 of my solid energy bars.  By the way, when I set out on something like this, I have a pretty good idea of my caloric needs, which is not far from what it used to be pre diagnosis, so I stock up ready for that, but also tuck a couple of reserve energy gels in one of my pockets just in case.

 As you can see the 15g every 15 minutes did the trick nicely from there on, remembering that there is also some inaccuracy in the test itself.

Overall my stats for the ride were 2hr 6min, 62.04km, 29.5 ave speed, 37.6 max speed, AHR 136, MHR 149, so a nice steady training ride, getting a bit of time in the saddle. The only fly in the ointment there was my left ITB starting to ache about 90 mins in, that’s a reminder of the knee that took me out of Grim, so I need to get that dealt with.

One thing to also note is that I’d be continuing to burn carbs after I stopped, to replenish the glycogen in the muscles, so to take care of that I had another 25gr carbs before my shower. 

A quick cup of coffee and a shower later and I was ready to go out into town, to the farmer’s market and pick up a few bits and pieces, taking my son Rohan with me.  Some time together and a bit of fresh air for him.  As usual, and being a good diabetic I tested before I drove, 8.9,a bit high, but that’s the extra 25g carbs kicking in, at least I’m good to drive.  Off we go, a few stalls into the market, local eggs, tomatoes, a nice sour dough rye bread and look at the next stall as my head is beginning to go a bit fuzzy and sparkly lights appear in my eyes! Time to test I think – 3.7, not technically a hypo, but getting there and a massively rapid drop.  That insulin sensitivity really giving me a kick up the arse.  Like a good T1 I had my test kit and snacks with me at all times, so 20 g carbs and 5 minutes later while also trying to stop Rohan wandering off (special needs and doesn’t sit still easily while I’m testing and eating) and I’m feeling Ok again.  Drop a few things at the car and restest, back up to 4.8, good.  Even so, I snuck in a couple of garibaldi while walking around Waitrose and paid for the opened packet at the till as I left, just to make sure I stayed OK to drive.

So back home, anticipating that I would stay insulin sensitive for some time, I cut a generous slice of that fresh sourdough rye bread, toasted that with a pile of eggs and some smoked mackerel.  Very tasty.   Overall this bit looks like this.

Time (mins)
BG (mmol/l)
Carbs (g)
+30 mins, after shower
+90 mins
lunch, 1 unit novorapid

As you can see I only had 1 unit of bolus with my lunch.  Normally that much carb would mop up 3 units.  And for the record, my +2hr reading was 6.3, a perfect score when you’re aiming for a post-meal rise of no more than 2mmol at +2hours.

Put this lot on a graph and it looks pretty cool.

I think that shows the roller coaster pretty well.

Taking a step back though, what does this all mean?  Well looking at the insulin profiles, all my breakfast bolus would have been well out of my system when I had the post ride crash, so two things spring to mind; 1) extreme insulin sensitivity and the GLUT4 receptors also playing a role in depleting my cisrulating carbs with the post ride walking around 2) I need to cut the background dose a bit more to account for the post ride insulin sensitivity,  Maybe down to 2 units.  Only further experimentation will tell. 

I can definitely say though, that this was a good learning day.

Wednesday, 7 August 2013

Reset, Rename, Relaunch

Back in July 2011 when I started this blog, it had a purpose, and that was to show how it was possible to go from being a lifetime heelstriker to an efficient minimalist and barefoot runner and improve my running in the process.  I think I managed to do that, and the transition is done and there for all to see.  I’ve gone from running 150 miles in 2010 and being continually injured, to 650 miles in 2011 and my first half marathon (placing 14th), just under 100 miles in 2012 and 650 to the beginning of August 2013.

Lately both me and the blog have been languishing a bit, so time to do something about that.

The new mission statement for this blog is therefore
1) demonstrating that life does not stop with a type 1 diagnosis
2) demonstrating the benefits of exercise for a type 1 diabetic
3) The practicalities of how to go about it, managing training and diet based on my experiment of one
4) report back on my training progress and the occasional race I manage to compete in

I’ve also been rethinking my overall plan and strategy for the rest of 2013 and the targets I want to hit.

Number 1 – Must be to recover from the injury that took me out of Grim and to work to prevent it recurring.

Number 2 – Get back out on the bike
I’ve been neglecting two wheels for the running.  I’d like to be getting back to at least one good bike session a week of 2-3 hours if I’m home for the weekend.

Number 3 – Increase the resistance work
Upper body strength in particular has dropped off since I stopped rowing so much and I also have a notion that it will help me both reduce likelihood of injury, but also improve my insulin management by building more lean mass.  The target is therefore 1 yoga session and 1 weights or bodyweight session a week

Number 4 – target 5 sessions a week

Number 5 – Fill in with running
Keep throwing the running shoes in the suitcase to take with me and pick up the pace a bit when I do, with one tempo or interval session a week as a minimum

Number 6 – Good blood sugar management
Working out the right insulin dosage – for me. Continually re-evaluating my nutritional and hydration needs, particularly trying to get my carbs as clean and natural as I can.  I don’t think I will ever get away from carbs as a diabetic athlete, but they shouldn’t be of poor quality.  A bit of research will be needed here

And getting more specific
  • 10k PB at Ely Runners New Year's Eve Race aiming for sub-42 minutes
  • 5k PB before the end of the year
  • Find a 30-40 mile spring ultra, May, June, July
That’s all working in my mind into a weekly schedule looking something like
  • Sunday - Endurance session - long run or ride
  • Monday – rest or easy day – usually a travel day
  • Tuesday – Club time trial or speed running session
  • Wednesday – HR capped steady day, run or ride/turbo
  • Thursday – Yoga (maybe body weight circuits)
  • Friday – easy day or rest – travel again
  • Saturday – Strength/weights
Of course, that’s just a starting point and will change in response to events, work, holidays etc. As one famous general once said “no plan survives contact with the enemy”, so let’s see what happens when we have the first engagement.  

As for the name, I’ve come down in favour of “Adventures of an Athletic Diabetic” athlete first, diabetic second.

Other suggestions offered were
  • Sweet Feet - Suggests Running only, and I do more than that
  • Becoming Number 1 - doesn't shout Diabetes to me
  • Insulin Athlete
  • Insulin Infused
  • Who needs a pancreas anyway - quite like this one
  • pumping insulin - I'm not on a pump yet, but could be in the future
  • I did it my way - I do like Frank Sinatra
I'm also open to any other suggestions or variations on a theme, but it needs to be relevant to both the diabetes and athletic aspirations.

Monday, 5 August 2013

Caught by the Grim Reaper

So, this time last year, give or take a month I toed the line for my first ultramarathon in an absolute downpour and ran 40 miles on a quagmire before DNF at 40 miles.

Three days ago in overcast conditions, threatening to get very hot later and nice and dry underfoot, I toed the line again to run the same course and to try and beat it this time.  The only difference was this time I was running with a camelback with hydration bladder whereas last time I used a waist pack with one handheld bottle as well; and one other thing around 8 weeks before the race I was diagnosed as Type 1 diabetic.

To be honest, yes it did interrupt training a bit leading up to the race, but no, I didn’t feel unprepared. I actually felt fairly well trained and well tapered and I had a plan.  The thing that was bothering me more was the blood sugar management but as with everything else plan, plan, plan and it should not be a problem.

I’ve spent the last 8 weeks trying to understand this condition and how it affects me, and then plan a strategy to deal with it, including training runs of 2 and 3 hours going into it, but your guess is as good as mine in terms of what was going to happen over the next 14 hours plus.  That wasn’t going to stop me trying though.

The plan needed to take into account two main issues:-
1) Exercise induced high insulin sensitivity – as you exercise your endocrine system makes several changes to improve the transport of circulating blood glucose to the active muscles.  One of these is to activate additional transport mechanisms such as the GLUT4 pathway, but the other is that you become much more sensitive to insulin i.e. you need much less to do the same job. Normally your pancreas does this automatically, but my pancreas comes in a syringe these days.
2) increased transport of glucose to your muscles is pretty much at its max when running in steady state at close to your aerobic threshold. Again as a T1, your body is no longer as effective as it used to be in maintaining homeostatis by dumping glucose from stored glycogen into your bloodstream.

That, and experimenting gives two main parts to the plan
1) reduced morning insulin doses – Basal (levemir) down from a normal 6 units to 3, breakfast bolus (novorapid) down from 2 units for the meal I ate to one.
2) during the race, monitor blood glucose every 6km (approx. 35-60 mins), trying to run slightly high at 5-9 vs the normal 4-8mmol/l
3) steady intake of carbs throughout the race
4) if blood sugars are drifting higher >12mmol/l twice, then consider taking a unit of rapid acting insulin next time I come back round to the tent

pre-race briefing with Rob Bryn (fell asleep on the course) and Jane Benson

The Tent Farm

So, with that in mind I got to the start line amongst the biggest entry for this race so far. With adrenaline and low dosages in the morning, my BG levels had drifted up a bit to 8.7, but I knew that would come down quickly enough. Quick couple of photos and we’re off. Familiar territory with the long drag down the hill past the lake on tarmac, before turning left up the first gentle hill on a bit of roughed up old tarmac (which I swear was a limestone trail last year) and then onto the first trail for real.  The field is of course now starting to string out so I can see a line of bobbing lycra and dayglo shirts and jackets in front of me.  As normal the first lap is going a bit faster than the plan by the time I stop to take the first test.  Lots of other runners checking that I’m Ok as they pass me, a few even know me from past events and online, but all routine so far.  5.7, well within the range, but keep eating regularly and keep the fluids going in as it’s starting to warm up.

At the bridge, courtesy of Kev Taylor, lap 1 feling good.

That was the pattern for the rest of the lap, on a mostly well remember course, but with a few alterations for this year, dib the timing chip at the right points and keep going.  Last year’s slippery mud hill of scrambling and sliding was an easy walk and the long grassy stretch afterwards was dry and firm underfoot before getting back onto the long tarmac drag with a great view of the castle and back down to the final field section and then through the woods.

Back to the start/finish straight to find mum and dad there waiting to take a few photos.  Quick visit to the tent to replenish supplies and take stock.  Fluid intake was lower than intended, carbs intake a bit lower than intended, but broadly in the right place.  Plan error number 1 – too much choice of stuff – even though it was clear in my mind beforehand what I was going to take, I’d packed extra and ended up giving myself too many choices.  Result – dithering at the tent after a quick first lap of 1hr 40.  

End of Lap 1

The only soggy bit of the course

Blood sugars still OK, testing at the tent each lap as well as every 6km, dib out again to start the next lap.  1hr 46 on the Garmin, so around 7 minutes taken at the tent.

At this point I was in Merrell Trail Gloves, with injinji socks and a few toes taped to prevent blisters and with an ankle KT taped against an old injury.  The Trail Gloves are great in dry conditions on light trails with small stones underfoot.  They don’t do well in mud as the tread is not particularly aggressive, but for the conditions today that was not a problem.  What was a problem was where someone had dumped a load of fist-sized lumps of rubble and limestone in all of the potholes along one section of the course about 2-3km long all ready to turn an ankle and also spikier than the rock plate on the Merrells could really handle.  But that in itself was not a problem as the plan was two laps in the Merrells and then switch to the Inov-8 X-Talon 190s, with the possibility of change back later, or a change into my Altra road shoes.  The latter was dismissed early; the Altras would just not take the trails here.

In hindsight, I’m not sure if my eventual troubles were caused long this stretch with any kind of twisting on one of those rocks.

End of second lap, a bit slower at 1hr 50, nicely to plan, now much closer to the target place, but still a bit quick.  Took more time at the tent this time though, planned sock change, foot check, shoe change, all OK. Unplanned toilet visit but I may as well do it here as on the course.  Hydration and nutrition better this lap.

About three km into the lap my left knee starts twinging.  As I’d had no hint of any knee trouble in any training I assumed it was just one of those slight niggles that runs itself off.  But in this case it didn’t.  As I went round the lap it started to get progressively worse and worse, affecting my run walk plan and getting seriously painful.  I’d gone from run 3km, walk 2-3 minutes to run 1km walk 300m and by the halfway point was down to around equal walk:run.  After that it took a serious downhill turn and as I hit the long stretch of tarmac back down the course I was down to around 200-300m running before the pain got too much and then walk the rest of the km.  The knee was now also starting to pull on other things with the left ITB now also starting to get painful as it started to take some of the load in compensation for the other bits of my leg that were not working properly.  Pace as expected was going well out of the window now, and I was thinking about whether I had enough time to finish the course walking the rest of it.  With about 5km of the lap to go though, the pain was just getting too much and mentally I had pulled out, but I was definitely going to complete the lap.  I even called home to tell them I’d see them later that day instead of Saturday morning as planned.

Walking in after lap 3, that's a grimace, not a smile

I walked the final km across the start/finish line half an hour slower than the second lap at 2 hours 30, well behind any original pacing plan.  Luckily I bumped into Gary Benson, there to crew for his wife Jane, eventual first lady in the 100mile race. Gary did a quick assessment of my leg and applied a KT taping on the ITB and I tried to set out again.  I got about 200m down the course before the pain in the knee stopped me again.

That was it, for the second year in a row I’d been beaten by the Grim Reaper. First time by the conditions, this time by injury.

Importantly though, I had not been beaten my diabetes.  My blood sugars were in good control for the 6 and a bit hours I was out there with only two readings lower than 5 and those being followed by readings well within the target range.

A ten minute chat with Gary helped in that he couldn’t point to anything in my training that might have been an issue, and that he thought that it was just one of those things, an injury picked up on the day.

For those that are interested, here’s the BG record throughout the race, as sent by e-mail to my specialist diabetic nurse/dietician at Addenbrookes.

Waking, 3 units Levemir, 1 unit Novorapid, a bit low but not outside my normal range on waking
After Bagel and eggs, coffee, OK to drive
pre race
16km lap 1
32km lap 2
48km, lap 3
post lap 3, after bagel with PB,
Ready to drive home again
back home, pre dinner, pasta and veg at 8pm, 55g carbs, 2 units Novorapid (would normally have 3)
2 hours post dinner, 1/2 bagel eaten to prevent an overnight low, should have only had one unit Novorapid at dinner.
4 units Levemir vs the usual 8.


And here’s the Garmin trace

Overall I took in about 310g carbs over the 6 hours plus another 40 or so directly afterwards, plus protein and fats from nuts with three hard boiled eggs straight afterwards.

The other thing to note, for any other T1s or insulin injecting T2s is that you will stay insulin sensitive for a while afterwards.  I took my usual basal dose on Saturday morning, but took only half or less of my bolus doses and still experienced a drop in blood sugars after some meals.  By Sunday I was still not quite back to normal and needed to snack twice to avoid low blood sugars.

Learning points from this?

1) I truly think that I need to moderate my ambitions here.  Both this year and last, I struggled to fit in the required training just because of the travel with work, and in this case my pre-diagnosis diabetic symptoms and then post diagnosis learning curve

2) my nutrition strategy needs tightening up

3) shoe choice?


Actions arising

1) find a 30-40 mile ultra next spring and complete it.  Get the monkey off my back. Think about the Grim Reaper 40 next year.

2) Nutrition – give myself less choice; one of the other competitors had planned in detail with each lap’s nutrition pre-defined.  I like the idea of that, defined nutrition, defined carbs, protein etc, but with a buffer included as well and enough post race recarb and protein.

3) Shoes – the Inov-8s were the best shoe for that terrain, they were a great shoe on the Yomp as well.  I like Inov-8s, need to look at more of their lighter trail shoes as well as my Trail gloves need replacing through wear anyway.

4) get the fluids going in earlier – I had a litre on the way home and my wee was still very dark.

In some ways quite disappointed with this, my second DNF on this course/this event, but in other ways quite excited knowing that it was injury that took me out, not blood sugar control.