Diabetes, cycling and technology

Note:  I first wrote and posted this article to my blog at VeloReviews.com on June 15, 2010.  Since then, I’ve imported it back here to JustAnotherCyclist.com to provide more context to posts that will be appearing here.

I generally don’t spend a lot of time dwelling on my diabetes [here on JustAnotherCyclist.com]. It is not that I’m ashamed of my type 1 diabetes, or trying to hide it, but more that I mostly consider it just a part of my life. Thinking of it in that context I’m just not really compelled to post about it on web sites that I frequent, or write about it in my blog. However, every once in awhile something comes along that can potentially make my diabetes noteworthy. In this case, it is a change in the way I manage my diabetes that promises to make my cycling a whole lot better, safer and enjoyable. Well, two things actually.

After a fair amount of research I’ve decided to change from my current management routine of daily insulin injections and move to an insulin pump. To understand how this will effect cycling, I’ll need to give a little bit of background on diabetes and insulin. I’ll keep this very general – just enough information to help non-diabetics understand what’s going on here.

Basically, insulin is a hormone that allows the fuel you eat (food) to get into your cells. Yes – this is skipping over many actual details and steps in the process, but it is sufficient for our discussion. Your body (well, the body of a non-diabetic at least) releases insulin in response to – and in proportion to – the amount of food you eat. In addition, your liver releases a small, steady stream of sugars to fuel the general running and maintenance of your body even whenever you are not eating. As you might expect, your body also releases a small, steady stream of insulin in response to your liver’s small, steady stream of sugar. This background stream of insulin is called basal. It is in the management of my basal insulin that an insulin pump actually offers the biggest benefit.

I take shots of two different types of insulin a day currently. One – referred to as bolus – is taken in direct response to the amount of food I eat. However, since it is very impractical for me to take a whole stream of different shots each day to simulate basal insulin, I instead take two shots a day of dedicated basal insulin. This insulin, unlike my bolus shots, takes some time to “activate” – you can think of it as time-release insulin. I take a set amount in the morning, and a set amount at night, every day, day in and day out. This set amount has been adjusted through trial and error to match my liver’s steady supply of sugar mentioned above.

So far, so good. But there is another variable to throw in – exercise. Exercise actually allows your body to get the same amount of fuel (food, or more specifically glucose) into your cells with less insulin. It quite literally opens up more channels into your cells for sugars to get in and be burned as fuel. So, putting this together, I take a set amount of basal insulin each day that matches my baseline of sugars released by my liver. But then I go out for a nice long bike ride, and my system gets all revved up by the exercise. Suddenly, I’m burning through more glucose for the same amount of basal insulin I’ve taken in and eventually … I run out of available glucose in my blood stream. This is a condition known as insulin shock or, more properly, hypoglycemia. Definitely something to avoid.

An insulin pump alleviates this problem. The issue is that, currently, once I take my basal insulin shot I’m stuck with that amount of insulin until it wears off. However, an insulin pump more closly replicates what our bodies are supposed to do. Specifically, it releases small amounts of insulin slowly over time. That means that, when I go out for a ride, I can immediately adjust the rate of basal insulin released into my body. That’s a huge win – and significantly reduces the risk of hypoglycemia brought on by exercise.

That’s one of the two things I’m doing to help manage my diabetes that I’m hoping will have a direct positive effect on my cycling performance. The other thing – perhaps even more beneficial to my cycling specifically – is the utilization of a continuous glucose monitor. Currently, with traditional glucose monitoring, I have to prick my finger to get a drop of blood and put that blood on a strip that I’ve inserted into a glucose meter. That’s a lot of moving parts to manage, and damn near impossible when you are in the saddle. However, with a continuous glucose monitor, I’ll have a device attached directly to my skin that will sample my blood glucose levels (the amount of available sugar in my bloodstream) periodically and transmit that information to a small hand held device. With information available this frequently, the hand held device can track the trends of your blood glucose and and set alerts when my blood sugar is heading to levels too high (this causes fatigue and a general loss of power) or too low (danger!)

So, the scenarios where blood sugar levels are outside of norms will look like this by utilizing these two technologies:

Glucose Monitor alerts that blood sugar is getting low: Grab a gel from the jersey pocket and keep riding
Glucose Monitor alerts that blood sugar is getting high: Grab glucose monitor hand held unit out of jersey pocked and read value. Grab insulin pump controller out of jersey pocket and give an additional dose of insulin.

And without these devices? How do I deal with these currently?
Feel light headed and have no energy. Suspect blood sugar may be low: Stop riding, get off bike, pull out all the parts of the meter and check blood sugar. Grab gel and continue riding
Feel fatigued and listless. Is it high blood sugar, or just a hard effort: It is almost impossible for me to tell the difference between the two, so stop and check blood sugar with the meter. If it is high, pull the insulin out of the jersey and give myself a shot before climbing back on the bike.

As you can see, this is a huge leap forward. To use a cycling analogy, my current method of diabetes management in kinda like road racing before Mr. Campagnolo invented the derailleur. Back in those days, you had two different gears on the rear wheel, on on each side of the hub. You’d start the race on one. When you got to the bottom of a big climb (when you’d want a lower gear) you’d stop the bike, remove the back wheel and flip it over to make the smaller gear active. At the top of the climb – you guessed it, stop again and get into the bigger gear for the descent. That’s cycling the way I do it now. After Campagnolo’s derailleur, you keep riding right up that climb, changing gears by operating simple controls while you’re still in the saddle pedaling. That’s riding with an insulin pump and a continuous glucose monitor.

If anyone wants more information on this subject, don’t hesitate to get a hold of me, or contact your endocrinologist, diabetes educator or other medical professional.

  • Jay

    Became a Type 1 diabetic after having my bleeding pancreas removed in late July. After recovering from surgery (and using Lantus and Humalog) I cycled until the snow came. Going with an insulin pump soon. Practical choices are Animal OneTouch Ping and Medtronic Paradigm Real-time Minimed. Any thoughts by diabetic cyclists out there.

    • http://justanothercyclist.com/ JustAnotherCyclist

      Personally, given the option I feel that OmniPod is the absolute best choice for cyclists – and probably for any athletes. I currently use one, and have for the last 6 months or so. I wear my pods on the back of my arms. I actually go into some detail about those in my post An open letter to diabetic cyclists

      That being said – I’m going off of the OmniPod. I changed insurance, and my new carrier (Kaiser) won’t pay for the OmniPod. I hate hate HATE the fact that my insurance is deciding the best course of treatment for me – but such is our crappy system.

      I’ve opted to go with the Animas OnTouch Ping myself. The biggest reason is that I believe the workability of a wireless (and tubeless) device that I can hold in my hand while riding and give myself insulin is absolutely critical. I haven’t gotten my hands on one of these yet, but from what I can tell I can’t adjust the basal rate from the remote unit. That really sucks if true. With the minimed, all control is in the device that connects to the infusion set, and thus you’ve got to negotiate all of that stuff out from under your jersey while you are riding.

      I’m really disappointed that I have to make this change – the OmniPod worked out beautifully for me. We’ll see how the OneTouch ping works out going forward.

      Now the fact that my insurance is giving me a hard time and making me jump through a bunch of hoops to even see if I can get my Dexcom Continuous Glucose Monitor supported – well, that just flat pisses me off. I’m still right in the middle of all of that non-sense, so I’ll let you know how it goes. I’m actually preparing a letter that I’m going to submit to them to contest their red tape, and I’ll probably post it her verbatim.

      • Jay

        Thanks. I’m trying out the Minimed continuous glucose monitor during this weekend, just to see if the CGM is worth it for me. If not, it makes the decision between Animas and Minimed a more even choice. I’d appreciate your updates.

        • Jay

          I’m curious about your experience with Dex Com CGM. This Medtronic GCM I’ve been trying out has been all over the place. After finally getting it up and running, the CGM readings sometimes have been the same as or within 3-4 points of my finger sticks, but sometimes from 20-50 points different! For instance, at 2 a.m. I got an alert that there was a weak signal. After getting the signal back, I found that my glucose reading had dipped on a diagonal graph from from 238 (finger-stick read 286) at bedtime (big meal, lots of carbs, but 6 units of humalog beforehand) to 110 at 1:30 a.m. Concerned, I did a finger-stick and got a reading of 86. Ate a glucerna snack bar to make sure I didn’t go hypo.

          Are you having that kind of variation between your CGM meter and finger-sticks?

          Jay

          • http://justanothercyclist.com/ JustAnotherCyclist

            Yea – there is variation – especially after first changing the sensor. It takes a few hours of calibration (2-3 finger pricks) before I trust it to be “in the ball park”

            The other thing is I see a 10-15 minute lag between blood sugar levels and CGM readings. This is normal – as the GCM measures blood sugar indirectly via interstitial fluid.

            More than the specific numbers, for me the GCM is valuable for trends. I check my GCM while riding and it shows me falling – and I haven’t eaten anything since it started falling – I know I need to take on some carbs or I’ll be hypo shortly.

          • Jay

            Thanks. That’s what I’ve been thinking as well.

  • Jay

    Just made the decision to go with the Animas One-Touch Ping. Not an easy decision, but my week with the Medtronic CGM left me cold. According to the Animas rep, when FDA approves the Animas/Dexcom joint device, I’ll be able to upgrade to that new unit – with the Dexcom transmitter – for $299. Maybe less, since my insurance company will pay for CGM.

    I’ll let you know how it all works out.

    • http://justanothercyclist.com/ JustAnotherCyclist

      That makes two of us. After the insurance fiasco, I’m now sportin’ the Animas OneTouch Ping on my belt now too.

      • Fromkin

        Just got my insurance determination yesterday that they’ve approved me for the insulin pump. Hoping to go on soon. How’s the Ping working out for you?

        • http://justanothercyclist.com/ JustAnotherCyclist

          It is working. I don’t think I can honestly give it an unbiased assessment at this point since I was kinda forced to it. I still like the OmniPod better – but do keep my previous sentence in mind before you give too much weight to my apparent anti-Ping sentiment.

          I’m very glad to hear that your insurance is covering what you want though. That’s great news!

          • Jay

            UPS brought my pump and supplies today; going for education on it Tuesday.

          • http://justanothercyclist.com/ JustAnotherCyclist

            If you’d be interested in writing a guest post about your experiences with the new equipment, I’d love to post it here.

          • Jay

            You bet. Went on the pump yesterday. Interesting experience. Hooked up easily at the diabetes center. But my educator suggested clipping the pump to the small fifth pocket on my jeans rather than my belt. While shopping, the pump fell out and dangled by the infusion set before I could pull it back up and clip it to my belt. Had a slice of pizza at COSTCO and gave myself a bolus with the remote. Everything seemed fine until I got home a couple of hours later and took my BG – 408! Gave myself 4 units of HumaLog and changed the infusion set and canula, which I assume pulled out of my body when the pump fell. BG started going back down through dinner to 124 before bed (my target is 120). Had a Glucerna mini-snack bar before bed, and woke with a BG level of 147. I suspect that we might have to jigger the basal rate during the next couple of weeks. Sleeping with a soft-belt pump pack went OK. Last thing I wanted was an occlusion or another pull-out. Looking forward to my next finger prick.

          • Jay

            You bet. Went on the pump yesterday. Interesting experience. Hooked up easily at the diabetes center. But my educator suggested clipping the pump to the small fifth pocket on my jeans rather than my belt. While shopping, the pump fell out and dangled by the infusion set before I could pull it back up and clip it to my belt. Had a slice of pizza at COSTCO and gave myself a bolus with the remote. Everything seemed fine until I got home a couple of hours later and took my BG – 408! Gave myself 4 units of HumaLog and changed the infusion set and canula, which I assume pulled out of my body when the pump fell. BG started going back down through dinner to 124 before bed (my target is 120). Had a Glucerna mini-snack bar before bed, and woke with a BG level of 147. I suspect that we might have to jigger the basal rate during the next couple of weeks. Sleeping with a soft-belt pump pack went OK. Last thing I wanted was an occlusion or another pull-out. Looking forward to my next finger prick.

  • Fromkin

    Well, it’s official, our 14 year-old part-Siamese cat, Blue, is diabetic. I know it’s not a contagious condition, but what the hell? Now, I’ve been diabetic since the end of July, when my surgeon removed my bleeding, tumorous pancreas. Yesterday, we took Blue to the vet for some tests. He’s been lethargic, drinking a lot of water and urinating frequently. Kerry thought it might be the result of Mirolax, which the vet suggested to help with his constipation. After looking up Blue’s symptoms on the Internet (a great electronic encyclopedia of everything), Kerry concluded he was diabetic, and asked me to take his blood sugar. I used my old meter and test strips (I’m on a pump now), and sure enough, it was nearly 400 MG/dl at one point.

    So, we hustled him into the vet yesterday, and the results came back today. Not only is he diabetic, but also he has a basal cell carcinoma on a back toe (we’ll have that removed when the diabetes is under control. So, he’s on Hill’s M/D wet food ($31 for a case of 24 cans), and tonight I start giving him Lantus, 2 units twice a day.

    By coincidence, I went to see my endocrinologist today, and after explaining about Blue, he gave me a sample bottle of Lantus; I already have a boxful of syringes I don’t need since going on the pump. So, we’ll try this for a month. Our vet thinks it’s possible that he’ll be OK by then and not need continuing insulin. We’ll see. Poor Kerry, having to take care of two diabetics in the family.

    Anyway, I’m doing fine. My A1C is down to 6.8, my blood pressure is down to 117 over 79, and I’m feeling great. Once the snow and rain stop, I’ll be back out cutting wood. And once he’s feeling better, Blue will be back taking walks with us.

  • will1

    Thank goodness the bike was OK.

    Any word on if you’ll need surgery for the collar bone?

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  • Jay Fromkin

    Anybody taking Norvasc for high blood pressure? Any impact on diabetic symptoms or cycling efficiency?