Friday, December 31, 2010

History of Insulin - Part 2

After the group of Toronto doctors were able to isolate insulin, treat humans and refine the extract with the help of Eli Lilly; there was still a huge problem.  Supply & distribution.  This area of the exhibit was much smaller than the areas devoted to the discovery of insulin or the advancement of how it was utilized by patients; but had my MBA dork side really excited.

Before a synthetic compound like Novolog or Humalog was created insulin needed to be extracted from the pancreas of a pig.  The below picture shows the number of big pancreases necessary for 1 liter of insulin:
Since everyone loves Wilbur, that was obviously going to cause some supply chain issues!

John Rockefeller then got involved in the process and promised the Eli Lilly corporation $150,000 for the refinement and further development of insulin extracts.  The financing and partnership provided the capital necessary to develop the drug for wide-scale human use and allowed for further partnerships with manufacturing and shipping companies.  Without the wheels of business the discovery of insulin would have impacted the lives of far fewer people.

This part of the exhibit really spoke to me directly.  My professional life has turned towards creating partnerships that allow a product, which I believe will help people lead healthier lives, reach more people.  Until I grasped that I probably would not be alive today if it wasn't for the funding by people like Rockefeller or partnerships between Eli Lilly and Toronto University I don't know that I fully appreciated the necessity of such partnerships.  One can't function without the other and while the discovery of insulin won a Noble prize its reach, scope and impact would have been far less dramatic with the wrong supply and distribution strategy.  This quote from J.K. Lilly to Elliott Joslin kind of sums it up:

"The great and refreshing discovery through this experience
was that the really great men in any line of endeavor are the
most approachable, simple, and direct in their reasoning and contacts.
Both in letter and in spirit, we have endeavored to indicate to you
how precious our relations have been with you and your associates."

Wednesday, December 29, 2010

History of Insulin - Part 1

I had the pleasure of visiting the NY Historical Society's exhibit on the history of insulin with my sister on December 21st.  After some holiday cheer I finally had the time to upload the pictures from the exhibit to my computer so over my next several posts I hope to walk you through how amazing the exhibit was.  The exhibit brought to light how incredible of a breakthrough the discovery of insulin was but also illuminated how the breakthrough would have saved far fewer lives had it not been for the potential profitability of the drug.  From a personal, medical and business perspective I was in awe as I walked through the exhibit.

Part 1 - The Breakthrough

In 1921 a group of University of Toronto researchers were able to isolate the peptide insulin from islet cells in the pancreas.  This would lead to the first partnership between a research university and a corporation, Eli Lilly.  The path to discovering insulin not surprisingly was met with in-fighting, and egos.  Tensions were no doubt raised due to the near death-sentence a diagnosis of type 1 diabetes had been met with to that point.

While the Toronto researchers were successfully isolating insulin in the pancreas Frederick Allen and Elliott Joslin were treating diabetic patients through a near starvation diet.  The idea was to restrict a diabetic to a critically low level of calories so that the body would be forced to accept the calories with a minimal insulin spike.  The diet prolonged the life of some diabetics but did not address lifestyle conditions and was not sustainable.  Essentially the diet bought time as the real treatment was being developed.

Dr. Banting in 1920 was reviewing an 1889 study of Dr. Minkowski and jotted the following note to himself "Ligate pancreatic ducts of the dog. Keep dogs alive till acini degenerate leaving islets. Try to isolate internal secretion of these and relieve glycosurea."  Over that summer Banting and team performed several experiments on dogs and were able to keep Alpha alive for the entire summer with no pancreas.  In subsequent months further tests were performed on dogs using insulin extracted from a fetal calf pancreas with positive results.  This led to the first human test on Leonard Thompson in 1922.  The first experiments proved costly as the insulin was too impure and caused severe allergic reactions in the test subjects.  With the help of Eli Lilly the research team was able to better purify the insulin extract which led to one of the most heart wrenching exhibits:

In 1922, 5-year-old Teddy Ryder was treated with insulin.  The first picture shows how dire his medical condition was prior to receiving insulin; the photograph on the right is Teddy after insulin a cherubic faced  healthy boy.  That moment more than any other during the exhibit struck me as how fortunate we all are that the Toronto based team was able to isolate insulin.  This team is the reason why any of us can function normally in society let alone run triathlons, compete in the NBA, NFL or accomplish whatever we set our minds to.

Teddy's note expresses in its simplest form the impact this discovery has had on anyone who has been diagnosed with diabetes:

"Dear Dr. Banting, I wish you could come to see me.  
I am a fat boy now and I feel fine.  
I can climb a tree.  
Margaret would like to see you.  Lots of love from Teddy Ryder."

Tuesday, December 7, 2010

Exhausted of Explaining

Something odd happened on Friday night when I was out for Korean BBQ with around 15 people, some of whom I knew and some of whom I was meeting for the first time.  Before the food arrived I excused myself to the rest room, tested my blood sugar and pumped off before returning to the table.  One thing I have never done is felt the need to hide my diabetes; I wouldn't help out Triabetes or blog if that was the case.  Rather dating new people, working in a new place and meeting new people has caused me to explain how I compete in triathlon, how I developed type 1 at 27, describe the difference between type 1 and type 2 and explain that juvenile diabetes is the same as type 1 and that it doesn't go away just because you grow up so many times over the past month and 1/2 I just couldn't do it one more time.

Explanation fatigue; I'm sure this is a universal trend for anyone who deals with something that is a bit different than the person sitting next to you.  There comes a point where you just don't feel like talking about "it," whatever "it," may be anymore.  As understandable as it is that I wanted a night where I didn't have to have "the conversation," my decision to test and bolus away from the table really surprised me.  I guess sometimes everyone just needs a vacation from the things they are forced to focus on daily.

Wednesday, December 1, 2010

High fat foods

It has been far too long since I wrote about how various food compositions affect my blood sugar so I thought I'd get back on the d-blogging wagon and talk about something relevant.  Armed with my trust Dexcom again I've been able to analyze how all sorts of foods impact my blood sugar levels.  The really cool thing about a CGM is that you can see the time series trend of how the glycemic index of a food will impact the amount of time your blood sugar spends "out of range."

Normally for lunch I have a turkey sandwich on sprouted grain bread or a salad, I know exciting.  Today I was beyond hungry when lunch rolled around so I opted for lamb shwarma and falafel.  Not the epitome of health but my diet has been super rigid lately so I felt the need to splurge a bit and get in some fats.  The shwarma was covered in hummus and babaganoush while the 6 falafel balls were gigantic.  Since this wasn't a very carb dense meal (although high fat) I assumed there were about 90 grams of carbohydrates.  I took in the approriate amount of insulin and 20 minutes after eating began to see my blood sugar climb.  My blood sugar plateaud at about 290 and remained there for about 3 hours before it precipitously came down to range.

This got me to thinking about the relationship of different nutrition compositions and diabetes.  It is alot easier to understand what a high carbohydrate/ high sugar food is versus a high glycemic food.  Ice cream for example has much fewer carbohydrates than you would first assume but the high fat content of ice cream makes it incredible difficult to manage with artificial insulin.  Understanding the glycemic index takes time and its not the most widely discussed nutrition metric but probably should be.  Counting carbohydrates is important to determine the appropriate amount of insulin but understanding how the nutritional composition is what can really lead to an awesome a1c. 

Oh and since I didn't post last week, Happy Thanksgiving everyone!

Wednesday, November 24, 2010

Seasons? Or Something In The Water?

Over the past week or so my blood sugars have been angry, even with the new pump.  I have been struggling to get my blood sugars out of the 300s even with big boluses, lots of water, a good amount of exercise and an increasing basal rate.  My first thought to get my blood sugars back in line was to have a day of nothing but Ezikuel bread (which is really sprouted grains), salad and quinoa. When a dinner of just quinoa still had me high I figured something bigger wast at play.

Yesterday on Facebook a post by Anne popped up that said, "RAGE BOLUS!"  I e-mailed her and asked if her blood sugars had been crazy for the past week as well.  She told me she couldn't figure out what was going on and that she too was struggling to keep her blood sugars under the 250 mark.  Moreover, another type 1 friend of hers was experiencing the same issues.  WTF!!!!!!!

So either there is a mass conspiracy in San Francisco to drive all diabetic's A1c above 10 or the change in seasons this year is just really weird.  The temperatures in San Fran have dropped pretty starkly over the past week after some unusually warm weather.  My best guest is the drastic change in temperatures has messed with people's metabolisms.  "Normal," people as Lauren Antennucci, my sports nutritionist, used to say will be more tired than usual in the face of a changing metabolism but for someone special, like Anne, her friend and me the repercussions are blood sugars that are totally SNAFU.  Hopefully all the SF blood sugars get under control soon; if not an investment in the companies that produce insulin might not be the worst idea!

Wednesday, November 17, 2010

36 hours of shots....

10 am this morning could not have come fast enough.  For the past 36 hours I've been managing my blood sugars with a combination of lantus and novolog injections.  The last time I was on lantus I was still in the "honeymoon," phase of type 1 so I gave myself something like 13 or 14 units of lantus a day.  Because my exercise rate varies daily due to training I manage my blood sugars with a combination of my basal rate and planned boluses throughout the day.  Therefore, I had no clue how much lantus to give msyelf for the the first 24 hours without my tail.

After Anne gave me the lantus I knew I didn't want to go overboard with my long lasting insulin so I gave myself 11 units and planned to manage any highs with novolog injections.  I woke up with a blood sugar of 255 and had an egg on a small multigrain english muffin for breakfast.  By the time I got into work about an hour later my glucose had popped to 352.  The day was not off to a good start and I was feeling awful, I was thirsty, had to pee, had unclear vision and my head felt like someone was lightly tapping it from the inside.  For the next 6 hours my blood sugar oscillated between 275 and 325 as I gave myself injection after injection.  Finally around 3pm my blood sugar dipped below 100 and then quickly dropped into the 70s.  I had a clif bar to bring my bs back up and then took another injection when I saw my blood sugar rise to 180.

When I got home at 7:30 pm I took in 14 units of lantus and 4 units of novolog to cover the salad I was having for dinner.  Thankfully my blood sugar finally stabilized as I laid on my bed and watched some Netflix too exhausted to move.  I woke up with a blood sugar of 190, took in 2 units of insulin, had a cup of coffee and rode my bike to work.  Once at work my blood sugar remained at 120 and finally at 10am my new pump arrived.

Today I feel 1,000 times better than I did yesterday; I have no idea how I lived like that everyday for a year as I went undiagnosed.  The headache, the thirst, the muscle cramps, the problems seeing; all those little symptoms that had me so confused from 2006 - 2007 were on full display yesterday as my blood sugar was consistently the highest it had been in many, many years.  With a stomach sore from the # of injections I gave myself yesterday I sit here tremendously happy knowing that my tail is firmly in place and that I'm back in control.

Tuesday, November 16, 2010

Another pump bites the dust

The new purple pancreas was with us for a very short period of time so it will not be receiving the 21 gun salute that the original purple pancreas received.  In fact, if not returning the pump didn't cost $3,000+ for not returning (can you follow all those negatives?) it would currently be somewhere between my apartment and the Pacific Ocean for how far I would have thrown it!  The freaking thing lasted from late August until mid-November; not my idea of a quality built product.  Alas, here I am waiting for my new pump to arrive - it won't arrive until Wednesday, so I'm on lantus for the first time since June, 2008 for 24 hours.

The beauty of Triabetes and the diabetic community was on full display last night.  After my pump would not prime and a ton of moisture was underneath the screen I called Medtronic.  Since my pump died at like 9:15 pm PDT, UPS could no longer ship it out for next day delivery.  Apparently Big Brown says you have to place an order by 11pm central time for it to arrive the next day.  That doesn't sound like just in time logistics to me; but whatever I guess commercials lie. 

I hopped on gmail to see if any of the local Triabetes crew was online, God smiled down on me as Anne of Annetics happily had the green available to chat button next to her name.  The crazy thing is Anne was one of the first diabetics I had ever spoken with, how I became involved in Triabetes and was a guiding light during my early days of both triathlon training and more importantly managing the D. 

Our conversation went something like - "Hey Anne, my pump broke, do you have any lantus or syringes?" Anne replied, "let me check; yep I do, come on over!"  Simple as that I wouldn't have to totally freak out for 24 hours without any tail.  I do feel kind of paralyzed though.  I was supposed to ride in GG Park this morning with a friend of mine from SF Tri Club but I had to bail because I'm not sure at all how my body will respond to lantus.  So for 24 hours I'll be eating pretty light (not that, that's a huge change) but won't have the ability to really work out.  I remember when I was on multiple-injections I was low pretty much all the time so I'll just have to be extra vigilant about that today.

Pretty frustrating that technology failed me again so quickly.  Maybe it's because I went for a run in the rain with my pump; maybe it's because it was a refurbished pump.  I love the purple pancreas but lets just say if any pump manufacturers want to sponsor me right now I wouldn't be opposed to switching.

Friday, November 12, 2010

Finding a Pool - the life of a triathlete on the move

A triathlete faces many obstacles when moving.  Beyond figuring out how to get one's most prized possession (a tri bike) from point A to point B safely, securely and in one glorious piece the triathlete has to figure out where the heck to work out in their new city.  Finding running and cycling routes is one thing; finding a new pool is a completely different story.

I became somewhat spoiled having UVA's pool as my body of water to train in for the past two years.  Having top notch division 1 facilities, a clean locker room; a wall of windows and enough lanes to satisfy all the bike commuters in San Francisco.  The luxury of having that pool for 2 years has left it hard for me to be satisfied of another pool to train in.  Thus far I'm up to trying out three pools in SF and researching about 5 others.

Each pool has had a really interesting draw back:

  • the first was USFs' pool - nice enough, a good amount of lanes, kind of weird because there is no shallow end so during rest periods you have to hold onto the wall for dear life.  The big kicker at this place is to join I have to "try out" for the masters team.  I'm not worried about the try out but am just kind of annoyed by the fact that I have to be "approved" to swim in the pool so I don't have to spend $15 every time I show up.
  • the second was UCSF's Mission Bay Pool.  Really nice facilities although kind of confusing to navigate.  I can join this as a "neighbor" because my apartment is near their other campus.  However the big challenge here is that the pool is on the roof - outside.  An outside pool is awesome somewhere like oh I don't know Miami, but San Francisco gets freaking cold and is wet, ALOT.  Swimming outside in the rain in 50 degree temperatures isn't my idea of a good time.  If this pool had a tent over it or something it would be a great option.
  • Now last night's fiasco.  I was real excited to find a Y 2 miles away from my apartment with awesome hours.  Their website said the pool had 8 lanes (4 split in 2s) and while Ys aren't glamorous they normally get the job done.  I got to the pool last night to swim, each lane was marked for speed, Fast, Medium Fast, Medium and Slow.  Looking over the swimmers in each lane I opted for the fast lane - with 3 other swimmers.  I'm not a huge fan of circle swimming to begin with; if everyone is doing the same workout it's great; it's pretty awful if there are individual agendas going on.  
 To continue.... two of the people in the lane were wearing paddles, one of the swimmers with paddles had a weird tube around his feet that was kind of like a pull buoy but seemed way more bouant and then there was the woman....  I should have known this woman would be a disaster when I arrived at the pool and the lifeguard tried to explain something to her.  So I hop in the pool as the woman continues to just stand in the middle of the lane.  Finally I push off the wall and go to swim; when I returned to the starting wall the woman was still standing in the middle of the lane.  After my next 100 she had finally crossed the length of the pool and stopped in the adjacent half lane (i.e., the one you would kick off from during circle swim) when I asked her, "do you have any idea how to circle swim?"  I know, I know but I was frustrated.

She continued to do bizzare things including just swimming a very slow breast stroke which continued to clog the other 3 of us.  Finally she left to go to the medium slow lane.  Since she continued to clog up the lane the other 3 of us came dangerously close to hitting into each other during the push offs from the wall; at least I thought that was her causing all of it.  But no..... as I continued to try and circle swim one of the swimmers with the paddles would stop every 50 yards and instead of getting to the corner that would give the rest of us more room he would stop short of the wall and kind of take up both 1/2 lanes.  This caused me to almost hit into the dude with the inner tube thing 3 times.  And at one point as the paddle guy was walking between lanes I pushed off the wall directly into him, fun. 

Then inner tube guy had his son also wearing an inner tube on his feet join him in the fast lane.  They decided that chatting along the wall taking up an entire 5 yards of a half lane was ok as they allowed their inner tube feet to float to the surface.  Concurrently paddle guy was standing in the other half lane doing absolutley nothing so as I returned to the wall I literally had no where to push off of or touch.  At that point I had, had enough jumped out of the pool, packed up and went home.  The Stonestown Y will not be my pool of choice.

As it stands now it looks like I'll have to get over my annoyance and try out for the Masters team.  Either that or get over my fear of sharks and swim at Chrissy Field for free year round (although the rain and cold thing would put a damper on that).  Oh the joys of a moving triathlete.

Thursday, November 11, 2010

Returning To Form

Hello again, it's been a while since I've had the time to sit down and collect my thoughts.  Life at a start-up keeps you busy for sure, the frantic pace and constant need to move things forward keeps it interesting and fun but a 36 hour day would help things out quite a bit!  However, now that I'm finally settled into life on the West Coast things are returning to normal.

Late last week I decided to start training again.  My body needed some time to recover from training for CDA and well I overall needed to adjust to the move and new job.  I technically never stopped working out but I hadn't worn my heart rate monitor for a couple of months and really had no structure to anything that I was doing. All that was a nice change of pace but I was craving a direction and some hard core heart pounding work outs.  With that I finally turned the corner on Sunday and found my mojo to push it again.

Sunday was a rainy day here in San Francisco, but I woke up feeling a desire to run that I hadn't felt in some time.  My previous 5ish runs had been cut short because of blood sugar issues but for this run I made sure to prepare my nutrition and to load on carbs pre-run just like I do during normal training periods.  I left my house with a blood sugar of 238 ready to take on the hills of SF.  The goal for the day was to run more than 7 miles.

I headed through Golden Gate Park with fresh legs and a focus in my mind I hadn't felt in a while.  My blood sugar felt stable as I cruised with a really comfortable stride.  The miles began ticking off, my heart rate was staying in zone 3 and I was feeling fantastic.  I ran along the Great Highway cruising at an 8:30 pace, looked at the Pacific and smiled; this was my first real California moment, running the rain with waves crashing to my right - one of the exact images I had hoped to find when I so wanted to move to the West Coast.

I slowed my pace just a bit from mile 6 to 7 as I wanted to push the pace a bit for mile 8.  Mile 8 ticked by with my watch showing an hour and 9 minutes; which left me with a great mile cool down as I jogged back to my apartment.  My first "real run" since CDA, and better yet my blood sugar was a happy 140 when I got out of the rain.

The day after the powers that be at my firm gave the company the day off for a super successful product launch.  So I locked El Bastardo to the roof of my car and drove down to Santa Cruz for what was sure to be some great riding.  Made a blood sugar mistake on the way down as I started the ride with a bs of 392 - scones sure have alot of carbs!  The ride in Santa Cruz was in a word, perfect.

I started my 40 mile loop with a 10 mile beast of a climb.  The climb reached grades of 11% for short stretches and averaged about 6% for the entire climb.  The climb was longer than anything I had done in Virginia and was unbelievably challenging as I couldn't get into my biggest gears on my rear cog (need to make some rear derailleur adjustments).  But I kept a steady cadence (dropping to 45 at one point!) and kept the wheels rolling.  Close to an hour later I had conquered the first 10 miles and faced a crazy steep descent.

The amazing thing about riding in California is the drastic temperature swings.  I was pretty warm on the climb up in my merino wool jersey, warmers and bib shorts.  But I was cold to the point of shivering on the way down!  At one point I had to stop in a patch of sun light to stop my teeth from chattering and warm up a bit.  Once I finished the descent I was greeted by an unbelievable view of the Pacific Ocean and 15 miles of pure bliss as I time trialed it down US 1.  Sadly, my damn Droid didn't save the pictures I took of the ocean so the images are only burned in my mind not on film.

For 15 miles I jammed along at a 24 mph pace and my legs turned the pedals seemingly like they never forgot how.  Riding along the Pacific, enjoying the view was the happiest I had been since I moved to California.  I couldn't have asked for a better loop.

The ramp up in exercise has of course begun dropping my basal rates like a lead balloon.  One of the many reasons I hopped back on the saddle was an escalating basal rate and some blood sugar numbers I wasn't happy seeing.  The combination of commuting by bike and my daily workouts has me exercising close to 2 hours a day which has brought my basal rate from a high of 17.5 back down to 15 in a 10 day period.  That has translated to blood sugars that were hovering around the 160 mark to blood sugars between 100 and 120.  My basal rate still isn't as refined as it should be, the move and recovery took its tool.  However, slowly everything is returning to form.

Friday, October 29, 2010

Diabetic Recovery

Yesterday a really good friend of mine got some fantastic news.  My friend who is an incredible athlete, former NCAA all-american, had gone through several hip surgeries to repair a chronic condition.  For the past three years she thought she had to give up being competitive, something that was so integral to how she had defined herself for more than 20 years.  Yesterday a visit with her incredible team of doctors yielded the result that she can get after it again!  When she called me to share the news I about wanted to jump out of my chair and do a jig; having been in the same situation after surgeries I know how incredible the feeling is when a surgeon says - let it rip.  But her situation was a bit different, she still has to take it easy on the run and went through years of slow rehab - it actually got me thinking to how that parallels diabetes.

When I was first diagnosed with diabetes I had no idea what it meant to my life.  One of the reasons I signed up for my first Ironman was to prove that I was still the same idiot meathead I had always been and that the disease wouldn't take away my ability to use determination to accomplish my goals.  I would think much like any child, parent of child or person who is diagnosed none of really knows what this disease means for our lives. 

Over time we learn how to adapt our lifestyles to blood sugar management.  I've learned over time what is required to swim, bike and run as well as I can.  I've learned over time how to function as well as possible at work without going low or going high.  I've learned over time what to look for when I'm going low or high and learned how to control the symptoms when I can't just bury my head in the sand. 

As a diabetic we never receive the words from a doctor that "you're you again," but with every passing day and every passing experience that lets us control this disease a bit better we reduce the limitations this disease places on our lifestyle.  I know how big a smile my friend will have on her face the first time she really races again; it's alot like the smile I have each time I run because I know, like all of you know that a run for us isn't "just a run." 

Wednesday, October 20, 2010

The New Endo

As the knowledge of my disease has progressed the importance of my endo has decreased.  Now that I'm pretty patched into the diabetic network I can get the support and knowledge I need from a community of patient and care giver support rather than having to make an appointment to see a white coat.  This has created a weird situation where my endo has become more of a gateway to a prescription rather than my outlet of all things diabetes.

On Monday this relationship became abundantly apparent as I met my new KP endocrinologist.  Dr. Kantor seemed like a smart enough doctor but when I left the office I had this weird feeling that he could have been a robot and that would have been fine too.  He asked me a series of questions about my basal rates, disease progression (to clarify if I had traditional Type 1 or the more recently claimed Latent Adult Onset Type 1 - I'm a traditional T1) and queried me for my bolus ratios.  When I told him about my basal rate which is now about 17 units a day of insulin I mentioned that when I did IMCDA my basal rate was closer to 11.  He asked about my job, so I told him I now work for a healthcare tech start up and also do work with a non-profit devoted to revolutionizing blood sugar management.  At that he realized that I kind of have my sh*t together when it comes to all this and said something like, "it's amazing when a diagnosis like this happens and kind of transforms someone's life."  After that it was just all about the prescriptions.

In the hallway I heard him tell his nurse that "I had everything under control and that I even do Ironmans so all I needed was my scripts."  But that also brought up the question in my mind - what if I didn't have it all under control.  What if I do triathlons, devote my life to healthcare, know my basal rates inside and out but have zero command of blood sugar.  This isn't the case but very easily could be.  I was surprised my A1c wasn't taken to confirm that I have transformed into this machine of blood sugar management. 

I left the KP facility with 9 vials of insulin and 900 test strips realizing my brain had become a walking encyclopedia of type 1 diabetes knowledge.  I can tell you the glycemic effect of just about any food, analyze the fat content versus carbohydrate amount in a given item and have full working knowledge of what exercise will do to my metabolic rate.  Three plus years of constant knowledge seeking has made me my own walking white coat.  Now the challenge is to stay as aware of my body and my disease as I have been so that the I continually expand my ability to manage my disease no matter how solid I have become at that task.

Monday, October 18, 2010

Insulin - a Great Forecast of Future Healthcare

A week or two ago the NY Times had an amazing article on the history of insulin.  Some time ago I wrote about advancements in medical technology that allow me to pursue some of the crazy athletic things I do; but I had kind of taken the discovery of insulin for granted.  I forgot that at some point isolating the compound that allows the body to use glucose has allowed all type 1s to live past their first few years with the disease.  The article discusses how viscous a killer diabetes was in the early 1900s and basically states insulin was one of the few "once in a generation," drugs that truly changed the world.

The description of children with type 1 in the article is tremendously heart wrenching.  The mental image of a 10 year old who is nothing but skin and bones really made me realize how incredible it is that I control my disease with a pump and about 90 years after the discovery of the drug am able to be a muscular 31 year old.  None of that would have been possible without a team of canadian doctors - so my heartfelt thanks to that team!

What was really shocking about the article was how strongly it parallels what is occurring today.  Much like the treatment for the biggest health risks of the 2000s (obesity, type 2 diabetes, high cholesterol, etc), the management of type 1 required doctors to loosen their grip on the patient and allow them to treat themselves at home.  Doctors were terrified that letting their patients inject themselves with insulin would lead to all sorts of down stream ramifications (thankfully I can get an infusion set into my butt cheek as well as a guy who went to Harvard med!).  Today, although Doctors are all for eradicating the greatest health risks we face the medical business model doesn't let them be treated as effectively as they otherwise could be.

So anyway, overall a really interesting article that is a great read.  The article was written in concert with the launch of a new exhibit about the drug at the New York Historical Society, 2 West 77th Street.  "Breakthrough:  The Dramatic Story of the Discovery of Insulin," runs through January 31; I'll be sure to get to it when I'm home for the holidays!

Tuesday, October 5, 2010

Ed's adventures in prescriptions fills

As most of my loyal readers know by now I've since left the east coast and the world of PCs for the open air of California and a Mac loving industry (for the record I lasted 12 hours on a Mac!)  With the big move came switching pharmacies and transferring my prescriptions from VA to NY to CA.  I've also switched insurance and pharmacies so the idea that all of that would have gone smoothly for someone who has encountered more problems with prescription re-fills than NASA does testing flight equipment was probably a stupid thought.

For the past couple weeks I have been getting everything set for my first insulin pick up at Kaiser Permanente (KP).  I contacted my new PCP to let him know I would need insulin for October 1st, contacted the KP pharmacy to ask what the protocol was and followed up with CVS to initiate the transfer.  Through a series of e-mails, phone calls and follow ups I was assured that I would have a 1 month supply of insulin by September 25th and that not seeing my doctor for the first time until the second week in October was not a problem. 

So I hopped on the 38L from work last night and anxiously awaited to hop off the bus at Divisaderio and Geary.  An aside, it is really hard to tell what street you're on while riding the bus in SF; I constantly have to look at google maps on my Droid because the street signs aren't consistent and have names, not numbers so I can't just "count."  I'm sure eventually I'll know landmarks and stuff or figure out the mystical language other SFers use to know when to get off the bus but for now I rely on technology. 

Once off the bus I walked into the KP building, found the pharmacy and got into line.  The pharmacy is freaking huge and feels more like a DMV than a CVS, there were about a dozen people waiting in chairs staring at some screen that apparently tells you when your script is ready for pick up and there are windows of tellers - not a nice open desk for you to drop off your script, pick up or pay for stuff I guess.  This pharmacy also had the most robust section of contraceptives I've ever seen - no problem with that, KP just offers quite the variety!

Finally I got to window 5, handed the clerk my drivers license and KP insurance card and then I saw her inquisitively looking at the screen.  Uhoh, the trouble begins.  "What medicine do you need?" I respond insulin - Novolog.  "Hmmm, ok there is a note from your doctor but CVS hasn't transferred the scripts yet."  I responded, I confirmed everything with my Doc and CVS and have e-mails following up with each, yes those scripts have been transfered.  The really nice (seriously) clerk then said "ok let me talk to the pharmacist."

After a couple minutes the clerk came back and said "we would send you up to emergency care to get a script but they are closed."  I responded ok, I'm just about out of insulin and will be by tomorrow morning, this is kind of a necessity right now.  For the record this was the first time I could actually go to KP to get my script filled, I didn't intentionally wait until I only had 30 units of insulin left - all in my pump.  "Ok let me get the pharmacist to talk to you."

Evil pharmacist comes to greet me.  "We can't refill your script, it doesn't exist."  I responded in a non-elevated tone, that of course it exists, I have e-mails saying so, can pull my old scripts on and have an e-mail from my doctor.  Evil pharmacist of course doesn't budge so I then get a little agrivated but didn't raise my voice (I'm learning!).  So I asked her this; KP is supposed to be all about patient centered care, right?  she responds "Yes," and I am the patient, right?  again she says, "Yes", so then if in the morning I'm in the hospital because I don't have insulin how does that possibly equate to patient centered care?, she looks slightly annoyed so I close with; I'm pretty sure a dead patient doesn't equal patient centered care.  At that she replied "we can't fill your prescription you have to talk to your doctor," and walked away.

My clerk in shining lab coat was way more empathetic and tried to help me out; she asked me what the CVS phone # who held my scripts was, and if I had the RX number in the e-mails from my Doc.  I then brought up the e-mail from my Doc on my trusty Droid and showed her the CVS script on the same gift of technology.  My CVS script said refills "transferred out," proving they did their job and the e-mail from my Doc said "you are fine to pick up your one month script before seeing me, the endo nurse will follow up and confirm," which she did.

The clerk in a stroke of genius then went to talk to a different pharmacist, this one with a brain, who understood the importance of insulin for a T1 and who realized that this was a system mistake and not some dude on the street trying to score some insulin (because nothing says a fun night like going hypo).   After 45 minutes everything was resolved and I did in fact receive the goodness that is synthetic insulin that keeps me going day after day.  Sampson hadn't lost his hair.  Welcome to a new pharmacy - my adventures continue.

Monday, September 20, 2010


Adaptation has never been something I've been particularly adept at; take one look at my nutrition plan for race day and you'll realize I try and figure out every variable known to man and prepare for it. It's one of the reasons why I manically studied metabolism and nutrition when I was first diagnosed with nutrition, the inability to control my fate has been something that has always bothered me - that may be one of those reasons I always work so hard.  But I think my move to California may just hint towards a more mature Ed, an Ed whose willing to flow with things a bit more and not freak out over time zone changes, an inability to find things 100% organic and a workout schedule that has been schizophrenic at best.

The first year after my diagnosis I had tried to control every variable that went into my blood sugar management.  I would freak out if a friend made me eat an hour later than I had planned, would all but lose it if someone wanted fast food instead of something healthy and god forbid a workout started 20 minutes late.  I had tight control over my A1C but probably wasn't the most pleasant person to be around.  During my first season of triathlon I was so worried about hitting my nutrition protocol to a tee that I kind of forgot to have fun during alot of my races.  Fast forward a year and I was still pretty nervous about my pre-race routine but started to loosen the reins on other parts of my life.  Then at the start of IMCDA I had lost that gel, a year earlier and I wouldn't have started the race - this time around I had a super solid swim.  Baby steps towards the willingness to adapt added up to a huge change.

Tonight after work I was planning on going for a run; I had no idea the exact time I'd start or even how far I would go for (I know, shocking).  I left work at about 6pm, and turned my basal rate down to 40%, when I finally got on the N to head to my super sweet new pad (more on that below), I opened up my Clif Bar wrapper and munched away then got home tested, tossed on my running shoes took a swig of Odawala Super Food and off I went.  At some point during the run I decided a 7 mile Monday night jaunt was solid enough.  No planning, no fuel belt, not even a heart rate monitor!  I did wear the Garmin though - I mean I can't just go technologically nude!

And now about the place.  In year's past I was terrified to live with people I knew, let alone people I had only met for 10 minutes!  But on Sunday I moved into my humble new abode with 2 roommates whom I've spoken with a total of 30 minutes, maybe.  I have none of my own stuff here (that comes the first week in October), am making due with the food I could find at the local market and am just enjoying my first place in California.

So how's all that relate to diabetes?  I've switched time zones 8 times in the past month, that hasn't been great for blood sugar management - but rather than freak out about it I'm adapting.  Yes I have to take in a bit more insulin than usual and yes it has been frustrating that my blood sugar is bouncing more than I would like.  But... freaking out about every second of every day isn't going to help my A1C.  I think I'm finally at a place where I can sit back and know that I have tight control of my disease and know that I'm taking the steps necessary to control diabetes as best as I can.  The learning continues - or maybe I've just become mellow since I'm off the East Coast!

Thursday, September 16, 2010

Mobile Health & Diabetes

Through my awesome new job I'm going to have an opportunity to attend some great healthcare related conferences.  Last week I was in San Diego for the MHealth conference which focused on how mobile technology can improve the efficacy of medical treatment, adherence to protocol at home and improve the overall heath outcome of a patient.  One of the subjects that came up alot was home biometric devices.

To aid in adherence biotech companies have come up with an idea to attach band aid like sensors to people to monitor everything from blood sugar to cholesterol to hydration.  I love the idea of body sensors and to have a ton of metabolic information at my finger tips.  I'm a data dork and the more information I can get about my metabolic rates the better I can manage my blood sugars and the better I can perform everyday activities.  However, this technology relies on one huge assumption - that it's accurate.

A few presentations I saw talked about constant glucose monitors, and Dexcom was mentioned!  I love my Dexcom, having the CGM gives me much tighter control over my blood sugars - but it's not accurate all the time.  A while back I talked about the night time low alarms that were occurring for no reason; for home medical technology to really drive great care those problems need to be resolved.  Accuracy needs to improve to a point that shows true trends and presents actionable data in the absence of a manual confirmation.

I do believe that home biometric devices will be a large determinant of improving medical outcomes in the future.  However, the accuracy of that technology needs to increase a great deal before home biometric monitoring becomes a driver of health.  For a pretty healthy 31 year old who understands data a false alarm on my Dexcom is no big deal, for a 70 year old on blood pressure meds a false alarm could be deadly.  Once the technology improves home biometric devices will be awesome; hopefully that day comes sooner rather than later.

Sunday, September 5, 2010

California Dreaming

After close to five years of trying to move to the west coast I'm finally following the advice of Horace Greeley and heading west.  Prior to leaving Manhattan for Darden I was emphatic about working for a small start-up on the west coast where I had control of my own destiny.  Over the course of my 2 years in business school that plan shifted and bent at times but when I returned for my second year in VA I had a firm resolve to make it out West.  One characteristic that has defined who I am is perserverance - my path to a healthcare technology start up demonstrated that quality ten fold.

At the start of b-school there were two career paths I was considering, both slightly non-traditional for a post-MBA career.  I was trying to decide if my skills and passions were a better fit for socially sustainable international development or if following my love of athletics and wellness along with the nerdiness I bring to data analtyics made healthcare technology a better fit.  Since my resume is pretty strong in financial services it was easier to figure out if the buy side of finance would let me pursue a msision that satisifed me both professionally and personally - by the end of the summer that answer was a resounding no.  So when I returned to Charlottesville I was hell bent on getting into health and wellness no matter what.

Over the course of my second year at Darden I tried to start my own healthcare technology company that could be implemented in a corporate envrionment.  I did this with a small intent of getting funding but mainly to gain experieince in the industry.  Creating my business plan and value concept gave me enough cache to get on the schedules of executives at various healthcare firms around the country and demonstrated a passion to actually work in the field.  The hours I spent laboring on my idea proved to be one some of the best time I spent academically at Darden.

From September until August I talked to anyone who would listen about my ideas behind health and wellness and what I could bring to the table.  There were tons of bumps in the road, a start up that had flirted with me lost their funding, a large medical group misled me during the recruitment process, a research grant was refused (still slightly bitter about that one), and I turned down a couple offers that wouldn't have let me fulfill my career aspirations even if the I loved the personality of the companies.  Then this summer hit and I had informational interviews with Microsoft, in person interviews with Amazon.  Those discussions continued to fortify my desire to work for a small start-up who got my ideas so our mutual passions could create growth.  My continued outreach finally paid off in late July.

On a whim I e-mailed the head of the Pioneer Portfolio of the Robert Wood Johnson Foundation to pick his brain about the industry and to find out if they needed an intern for the summer (I was starting to need cash in a bad way!)  The Pioneer Portfolio is RWJ's investment arm that funds disruptive technologies in healthcare innovation - totally the type of stuff I wanted to be doing; although my ultimate goal was to get on the product side of things.  After pitching my ideas behind Perform Wellness and asking Paul about his thoughts on the industry I swung for the fences and asked him to name some firms he thought were really pushing the envelope on healthcare innovation.  One firm he named was Keas.

After doing some google searching, Keas seemed like a totally kick a** place to launch my career or hell to become a lifer at.  At its core Keas is a technology platform that transforms content from healthcare experts into actionable care plans that are personalized for the patient's disease, lifestyle and personality needs.  Keas and my ideas behind Perform Wellness had so many similarities that I thought I was dreaming when I first read their product descriptions.  Not only is the product awesome but when the company launched they made the front page of the NY Times and were recently recognized by Time Magazine as one of the 50 best consumer websites out there - tops in healthcare.  At this point I was pretty much salavating like Pavlov was ringing a bell in my ear then I came to learn that their founder was the previous head of Google Health. 

I calmed my nerves, collected my professional thoughts and shot an e-mail to the career address for Keas.  Within a few hours I heard back from HR asking some clarifying questions; our dialogue led me to the Director of Business Development.  After a quick e-mail the DBD and I had a close to 2 hour conversation about our thoughts on healthcare technoogy, my ideas on corporate strategy and on competitive intelligence - by the end of the conversation Ms. DBD asked me to come out for an in person interview.

The following Wednesday I was on the first flight I could find to San Francisco, had my game face on and knew it was now or never to break into the industry I was dying to get into for a firm that I thought I could really crush it at.  From 9am until 3pm I met with the CEO, COO, DBD, Head of Product Management, and HR.  Each conversation had me more impressed with the firm, not only did I love their thoughts on the industry but I felt like it was a fit; I felt like the people involved in this company really wanted to create change, not just talk about it.

The wait that weekend was agnoizing, I had sent them my references and knew they had contacted at least one, but I was dying to know if I had finally landed the gig I was dreaming of.  All signs were pointing to yes but after more than 9 months of hard core job searching I was starting to lose faith in the process and confidence that I would ever find a job outside of finance.  Then finally at 7:30 pm on Thursday August 26th, Ms. DBD called me to offer me the position of Manager of Business Development!  I started on Monday remotely from NY and spent the last half of the week working in San Francisco for what was without question the best first week of work I have ever had.  Working for a start-up is totally different than the buttoned up culture I come from, but I freaking love it; I'm free to think how I think, be creative and just get after it - there aren't floors or ceilings to navigate, simply a hunger to get the job done lets you feel empowered to take on the challenge. 

It's funny, without having been diagnosed with type 1 in 2007 I'm not sure I would have ever realized that health and wellness was the way my career should go.  I had always thought I had so much freaking fun playing football because I was pretty good at the sport and loved the competition.  It turns out helping my teammates become better and challenging myself to be a better athlete were the things that got me going.  As I continued to write this blog and continually applied my analytic geekiness to sports nutrition and blood sugar management that I was deveoping some intresting ideas on how to help people become healthier.  Since 2007 I've been on this crazy quest to figure out what stuff meant for me, where I fit in and how to become succesful not defined by the amount of money I had in my bank account but by the level of personal satisifaction I felt from my job.  I think that quest got alot more clairifed on August 30th, that whole perserverance thing turned out to be pretty important in all of this.  The next chapter begins in San Francisco, I have no idea what this book will look like but if it's anything like the journey I went on the past 4 years I'm in for one hell of a ride.

Monday, August 30, 2010

Choosing Health Insurance

For the first time, either in a really long time or possibly ever, I have a choice as to what health insurance I will use.  When I was first diagnosed with T1 I was already enrolled in Aetna while working at Brown Brothers and there was no way I was going to try and change insurance plans.  At Darden my coverage with Aetna continued under their student health plan and really it was either use that plan or go it alone and try and buy something off the street (not really an option).  However, now that I've FINALLY FOUND POST-MBA EMPLOYMENT (more on my dream job later this week) I need to figure out which insurance plan to go with.

The choices:

  • Anthem Blue Cross PPO - $20 co-pay
  • Kaiser Plan 20
The most important part of my coverage is prescription cost.  The Anthem plan will have me paying $15 for generics (does Novolog even come in generic?), $25 for brand name with a $250 annual deductible.  Kaiser's cost structure is $10 for generics, and $60 for brand name at a 100 day supply through their mail order service.  

Does anyone have experience filling Medtronic or Dexcom orders with these plans?  Anne of loves her Kaiser plan but its a different one than what my future employer (unveiled later this week) is offering.  Not sure what else I need to look out for - any advice would be awesome!

Wednesday, August 25, 2010

The Little Things

NPP and I have been getting along very well over the first week of our relationship.  My blood sugars have been incredibly steady and my bolus ratios actually work like I expect them too again; I fear that OPP was on the fritz for the better part of a year.  I really wish there was a guide book for all the little things that a diabetic encounters during the course of their disease.  Most of the daily adjustments we make become second nature, but every so often I am reminded of how much thought and practice it took to get accustomed to this new way of life.

Tuesday evening after physical therapy I met my sister out for dinner at Suenos, a tasty Mexican restaurant in the Chelsea area of Manhattan, for taco night.  We started the night with some guacamole and then split a delicious trio of taco meats and we made our own tasty delights family style at the table.  With the massive amount of corn I was about to consume I started plugging away on NPP to pump up the bolus.  I figured that my meal would be about 160 grams of carbohydrates, but for the life of me couldn't figure out where my dual wave bolus function went.  I also could not fathom why my pump kept locking me out of administering a regular bolus saying I had exceeded my mass bolus limit!

Now a step back, due to all the medical regulation required for medical devices the device pretty much has to be error proof.  Additionally, tons of children use insulin pumps so there need to be a ton of fail safe mechanisms so a 5 year old does not inadvertently give themselves 20 units of insulin.  So on each pump there are settings that open up more menus for a higher level of customization of insulin infusions.  It's kind of like unlocking a secret level on a video game except in this case it lets me eat, not just spend more hours getting callused thumbs.

After staring at NPP for a good 3 minutes I finally remembered that it came with factory settings - not Ed customized settings!  With that realization I began beeping away expanding my max bolus from 10 units to 25 units and unlocking the magic menus of square and dual wave boluses.  Had those two functions not been available to me there was no way I could have eaten the meal we ordered.

Over the past month I have gotten just a small taste of what blood sugar management must have been like prior to pens that could give you lantus or novolog in micro-adjustments or insulin pumps that can change the level of insulin in your body at the push of a button.  The advancements in medical technology have made it possible for me to eat a carb-riffic meal of tacos, compete in Ironmans and go about my day like any other 31 year old would.  And the amazing thing is, it's not the big advancements that have helped totally change blood sugar management, it's the small things that let insulin calculations become more precise.  I know that the advent of insulins that react differently in the body (i.e., lantus v novolog) revolutionized care but the incremental changes to deliver that insulin more precisely has provided alot more freedom.  From a 30,000 foot level we all manage this disease pretty similarly but when you get down really close to individual management you see how unique this disease is for each person who has it.  The past few weeks have made me realize how much all those little things add up and reminded me why it's so important for our collective experience to be shared.

Monday, August 23, 2010

Re-Birth! The New Purple Pancreas Arrives

I anxiously waited by my front door on Tuesday morning hoping to see Big Brown making its way up the hill my parent's house is on.  I sat by the door like an anxious puppy with my head turning at each passing car.  After less than 24 hours I couldn't handle shots anymore.  I had bruised my stomach twice, had a rapidly escalating blood sugar and overall just felt lousy from the worst control I had over my blood sugars since day 1.  My knight in shining brown could not get here with my package fast enough.

Just before 10:30 am I was in my driveway to go pick up my Dad from the auto-mechanic shop where he had dropped a family car off for new brakes.  As I opened my car door I heard a rumble at the end of the driveway - Big Brown had finally arrived!  I signed for the package and called out for my Mom, I couldn't wait, it was time to put my tail back on!

Giddy with joy I opened each box, removed my remarkably similar new pump (there was some anticipation that there would be some distinguishing characteristic).  I had hoped for a slightly different colored "ACT" button, maybe a slimmer profile, but NPP looks identical to OPP - I guess while OPP was not original in looks he was original in spirit.  I take solace in the fact that on my belt NPP is OPP's twin.

I found my settings on my Minimed Connect site, loaded them into NPP, felt the oh so familiar sting of inserting an infusion site and was off to pumping again!  By the time I had NPP up and running my blood sugar was up to 279.  To manage my blood sugar while tail-less I set my alarm for 4am so that I could get some mid-sleep fast acting insulin into my system.  At 4am my blood sugar was in the 250s, I took in 3 units of insulin and woke 3 hours later with a blood sugar of 215.  At 8am I took in another 3 units of insulin but by 10:30 am without any breakfast I had hit the 279 mark.  With my pump attached I bolused away but my blood sugar was still on the rise.  Due to the lack of insulin in my system my bood sugar continued to climb into the 300s until I had enough insulin in my system to reach a homeostatic state.  Around 5pm I finally had control over my blood sugars again.

Over the past few days I have noticed that the control I have over my blood sugar levels has been much tighter than what it was with OPP.  During OPP's final few months I had to fight off low after low and often encountered an unusual high that made no sense.  Foods that I would bolus for one day under the exact same environmental factors (exercise, temperature, etc) would require a totally different insulin amount the next day.  I probably should have called Medtronic as soon as I noticed my blood sugars doing weird things because it was probably a warning side that OPP had gone crazy.  NPP has worked like a champ and my bolus calculations have returned to what I expect them to be and my blood sugars are reacting like they should.  I guess I'll take this as a lesson to never be too cautious when it comes to my blood sugars and when I notice something is repeatably out of line to take action and find out what's up.

Monday, August 16, 2010

Obituary: Original Purple Pancreas

On August 16th at approximately 4:10pm on the 5th floor of 60 East 56th street in Manhattan the Original Purple Pancreas experienced a fatal button error. After numerous attempts to revive the Original Purple Pancreas through a series of battery changes, rapid button pushing and the seldom effective slap on the side, Minimed Paramedics called time of death.  The Original Purple Pancreas was born on June 12th, 2007, lived a full life and is survived by 6 boxes of infusion sets, 5 boxes of reservoirs and 17 needle marks on Ed L’s posterior.

The Original Purple Pancreas truly gave life to all those he came in contact with.  The Original Purple Pancreas was a warrior insulin pump having survived two Ironman triathlons, including one in the pouring rain, five half-iron, 2 Olympic and 1 sprint triathlon.  The Original Purple Pancreas was no stranger to foreign cultures having visited Costa Rica, Sweden and Denmark as well as spending time in no less than 15 US States.      

OPP three times survived extensive security screenings at airports and was known to perilously detach himself from the safety of its belt clip to dangle life and limb from nothing but an infusion site tube; OPP was truly a thrill seeker.  OPP with a series of beeps, calculations and corrections was always fond of low glycemic foods but gave its best to counteract the sugar spike of the occasional pizza. OPP unfortunately never was able to achieve its life’s dream of testing its carbohydrate counteracting abilities versus Wylie Dufresne’s molecular gastronomy however. OPP’s last great triumph over blood sugars was at Jonathan Waxman’s Barbutto, 6 days before OPP’s passing.

OPP will sorely be missed by those he supported and allowed to thrive.  On countless bike rides, through questionable placement during debaucherious pursuits, and steadfastly fighting the fight against type 1 diabetes OPP was always there.  He will be most fondly remembered for his remarkable ability to face carbohydrates and allow those he supported to live their life to the fullest. 

Tribute to Original Purple Pancreas will be paid during his long lost twin brother’s first priming on June 17th, 2010 at 10:30 am in Upstate NY.  Sarah McLachlan’s I Will Remember You will be played during priming simultaneously on all connected Itunes libraries at that time.

The Nutrition Protocol Drawing Board

My attempts at exercise starting at a lower initial blood sugar has been going on for about a month now.  At times the process has been tremendously frustrating, like getting to the pool parking lot with a blood sugar of 75, sitting there for 15 minutes and then realizing a swim just isn't going to happen.  Or going out for what you hope will be an 8 mile run and having your blood sugar drop into the 40s during the first 20 minutes of the attempt.  However, I totally expected this to run into some really frustrating moments as I attempted to tweak my nutrition.  After a month I've noticed some trends and am getting more comfortable taking insulin before I workout.  Also, thanks for some of the great suggestions with my last post on this topic, please keep the ideas coming!

Thus far swimming has been the easiest thing to change my nutrition protocol for.  For swimming I can take in more insulin than for biking or running pre-workout and my blood sugars seem to be more stable for the duration of the effort.  It also seems I need a lower level of initial carbohydrates for swimming than I do for the other two disciplines.  Not sure how that will play out in a race but as a stand alone the new protocol is helping alot.  In the past I would start a swim with a blood sugar upwards of 220 and that number would continue to rise throughout my warm up.  During the early part of my main set I'd often be dizzy or just not feel that great.  Now starting at a blood sugar of 140 - 160 allows me to feel much more fluid in the water, concentrate to a higher degree and feel much stronger at the end of my set.  I've been taking in about 35 grams of carbohydrates pre-swim with 1 unit of insulin compared to 60 grams of carbohydrates pre-swim with no insulin; the protocol still needs some tweaking as my blood sugar is dropping into the 70s or 80s if I swim for more than 1,500 yards but at least I am avoiding the massive blood sugar spike post swim that I had encountered in the past.

I have only been on my bike 4 times since IMCDA but 3 of those times came in the past week.  My physical therapist wanted me to hold off on biking as we've been working on my back but having made some progress I was comfortable enough to get back in the saddle.  Last week had mixed results for blood sugar management on El Bastardo.  Monday I threw my bike onto my trainer and was set for an hour long effort.  I took in 1.5 units of insulin for a clif bar about 40 minutes prior to my workout.  20 minutes into the ride my blood sugar dipped to the 60s which required a 20 minute break before my blood sugar came back up.  Thursday I attempted the ride again this time taking in 1.1 units of insulin for my clif bar and was able to hit the ride out of the park.  Confusing the issue has been a major basal/ bolus rate problem I've had since diagnosis. Almost everyday sometime between 4pm and 5:30pm I know I'm going to go low.  No matter what I do, what I change, what I eat, I go low.  A future post will feature that issue since I have no clue what the heck is going on in the afternoon.

The run has been by far the most frustrating part of the nutrition tweaking idea.  I know for certain taking in insulin greater than 1 unit in the 40 minute window prior to running will make my blood sugar go way low in over the first 2 miles of a run.  I have also realized that when I run with a blood sugar between 130 and 150 I feel freaking awesome, especially when compared to running with a blood sugar near 200.  The stomach issues and cramps that I normally associate with a run are absent when exercising at a lower bs.  There is a really delicate balance between insulin intake, carbs or board and running duration to my blood sugars though and I just don't have it dialed in yet.  I'm getting closer - on Saturday I headed out for what I hoped to be an 11 mile run (bonked at mile 9.85, fitness has left the building!) by mile 4.5 my blood sugar was in the 90s and I felt a little low - in the previous attempts I'd get that feeling around mile 3.  I was able to recover my blood sugars quickly and continue the run with a stable blood sugar in the 120s.  There however is a huge mental hurdle to get over to have the confidence to run at a stable 120 when you have spent 3 years freaking out if your blood sugar was below 160 for a run.

The quest continues; a few more weeks of this and I'll hopefully have everything locked in.

Thursday, August 12, 2010

Dropping Knowledge About My Dexcom

I still need to finish my long overdue full review about my Dexcom.  But honestly the thing has been amazing and well my long self-directed job search has been taking up the bulk of my time.  While I know that going the off-grounds route for my post-MBA job will prove to be incredible rewarding does not make networking my butt off on a daily basis any easier.  But enough of the whining, onto some knowledge about the Dexcom.

My one big frustration with my Dexcom has been its uncanny ability to wake me up at 3am proclaiming that I'm about to go into a hypoglycemic coma with nothing but an announcement of LOW on the screen.  The vibrations and beeps are enough to wake the dead; the tones are especially nice when I accidentally hit the Dexcom next to my pillow while I sleep.  Now if my blood sugar was in the 40s or 50s each time the alarm went off during prime sleeping hours I'd be ecstatic.  However, alot of the time the alarm is going off even though my blood sugar is somewhere in the 110 to 130 range.  Getting woken up at 3:30 for no reason = not cool.

Then during a run the other day I had an epiphany.  My blood sugar started to drop quickly and I could feel some of the symptoms of a bad low coming on so I plopped my butt on a bench.  Since I was looking at my Dexcom every 30 seconds waiting for the trend arrow to change (it takes 7 minutes btw) I decided to clip it off of my shorts and put it on the park bench next to me.  Even though I was just inches away from the Dexcom the out of range icon popped into the status box.  Hmmm..... weird.....

At that moment I realized that the sensor for the Dexcom is probably on the back of the device (I have no official knowledge of the engineering specs for the CGM).  So that when the back of the device was laying flat on a solid wood park bench and my sensor site was above the receiver the transmission got lost in space.  when I flipped my Dexcom face-side down it quickly picked up a signal again somewhat confirming my hypothesis.

It then dawned on me that the same thing is probably happening while I sleep on my mattress.  My big ol' butt is making the sensor site higher than the receiver and if the receiver is face up its receiving nothing but transmission from my mattress.  I've noticed when the Dexcom picks up an intermittent signal it can start to do wacky things - which is what I believe was happening each night.  Now that I keep my Dexcom face down on my mattress I'm getting an "illegitimate" low maybe every 3rd or 4th night - way better than being startled awake up to 3 times a night for false lows.  The small change did the trick and now I'm getting much better sleep!

Monday, August 9, 2010

MacGyver Like Diabetes Management

Each year my Uncle throws what he calls the "Sweeney Bass Tournament," at his lake front cottage just North of Albany, NY.  The origins of the name are a bit confusing, in the 20 or so years that the family BBQ has been going on a total of zero bass have been caught and well I'm not sure anyone has actually seen a bass in the lake, ever.  But I guess Bass Tournament sounds alot better than Sunny Tournament.  The family get together was held this past Saturday and marked the first time I was able to make the party in about 3 years.

Besides some great highlights, like my sister's boyfriend and 2 of our cousins flipping the canoe over in the lake, my first match of can-jam and running the fastest 3.5 miles and longest distance (7.5 miles) I have run since prior to IMCDA, one diabetic incident almost soured my day.  In my temporary stay at my parent's house during my quest to launch my ideal post-MBA career my diabetic supplies aren't in the nightstand I normally keep them in; since the stand is in storage.  So, about a week ago my Medtronic Inserter fell into the vortex of lost things in my parent's house forcing me to put my infusion sites in by hand.

The Medtronic Inserter makes putting a silhouette infusion site in way easier than putting it in by hand.  The "gun" controls the speed and angle the needle punctures your body at creating an optimal insertion.  When inserting a site by hand I never know how hard or deep to push or what angle I should ultimately put the needle in at. Plus, the "gun" is considerably less painful than putting a site in by hand.  With that history, on Saturday I had to change my infusion site by hand and hoped that I had put it in at the right angle.

When I finished my 7.5 mile run on beautiful country roads up at the lake house I hopped in my Aunt and Uncle's shower. When I removed my running shorts I looked down to see a bloody infusion site hanging at my waist - it had completely fallen out of my butt.  I quickly showered, got dressed, and then found my Mom to say "ummm, I have a problem."  Normally I bring an extra site with me when I travel but for whatever reason I didn't have one in my bag of blood sugar doom.  I then tried to call Medtronic to see if there were any reps in the area I could grab a site from but after 20 minutes on hold with no answer I went to plan C.

I had remembered sometime ago reading on another diabetic's blog that they used their pump reservoir as an insulin source and inserted their novolog with a syringe.  With that faint memory my sister and I headed to CVS to pick up a package of syringes.  Once in the car I took the reservoir out of my pump, tried to calculate 2 units of insulin on the 50 unit syringe and for the first time in over 3 years stuck the needle into my gut to manually give myself insulin.  The day was kind of saved and we wouldn't have to leave the party early.

For the next 5 hours I kept a close watch on my blood sugar levels but knew there was no way I could be as precise with a 50 unit syringe as I could be with either a novolog pen or especially my pump.  For dinner I ate as carb light as I could passing over the meatballs, pasta, steak and fried chicken for quinoa, salad and green beans.  Even with a super careful eye for carbohydrates my blood sugar was just not stable, the difference between giving myself 3 and 5 units of novolog is huge from a blood sugar perspective, but on the syringe each looks about the same.  So for the next 2.5 hours I battled a bunch of lows, but had an ample supply of clif mojo bars and Erin Bakers brownie bites to stave off the glucose deficit.

Once home I happily put in my infusion site and once again had my tail attached to me.  Sleep Saturday night/ Sunday morning was a mess however.  The combination of my attempts to work out last week at a lower blood sugar target and my non-precise insulin calculations during the day had me wake up four times with blood sugars in the 40s!  After some extra eating on Sunday including a flat bread pizza, ice cream and a delicious avocado and potato salad my blood sugars have stabilized and I'm back to normal. But my day of MacGyvering out blood sugar management was an interesting one.

Wednesday, August 4, 2010

Tweaking Nutrition

Any change to a type 1 diabetic's exercise nutrition plan takes a ton of practice and bit of patience.  I'm awesome with the practice part; patience, not so much! For the past few weeks I have been attempting to start my work outs with a blood sugar around 160, rather than the 220 I had been aiming for the past couple years.  The new target is for both performance and health.  It's probably not healthy for me to intentionally spike my blood sugars into the 200s once a day to get in a workout. Also, spikes that high in blood sugar can really degrade performance. So in addition to trying to get my weight down to 175 this off season Coach E and I set a lower pre-workout blood sugar target as priority A.

My first big experiment with the new target is to take in insulin with my pre-workout food.  Historically I had eaten a Clif Bar 30 to 45 minutes prior to exercising to spike my blood sugar for the start. If I was just munching on a Clif Bar as a snack I would take in 3 to 3.5 units of insulin (a carb ratio ranging between 1:11 and 1:15).  Now I'm experimenting with taking in 1 to 2 units of insulin for the deliciousness that is a White Chocolate Macadamia Nut Clif Bar.  I'm then taking in some liquid nutrition right before the start of my workout so that my blood sugars don't plummet during the first 15 minutes of output.  So far, so good.

The results have been pretty good thus far.  I haven't yet tried any workouts longer than an hour with the new plan.  The big workouts I've been doing over the past few weeks are a 5 mile trail run in the Ward's Pound Ridge Reserve (awesome park if you're in the Westchester area) and a 1,500 to 2,000 yard swim set.  For the past 2 weeks I have been consistently starting my workouts with a blood sugar between 140 and 170 and ending with a blood sugar right around 90.  I've noticed that this has helped my speed towards the end of my run but has really hurt my effort during the swim.  I'm not convinced that my blood sugars will hold up during exercise of longer than an hour yet but this will be an iterative process with alot of trial and error.

Also, a huge shout out to Triabetes Captain Annie who broke 6 hours in her first Half Iron this past weekend!

Friday, July 30, 2010

More Abnormalities!

Recently I went to see Dr. Jordan Metzl, sports doctor for the stars, about the chronic back pain I've been having during cycling.  Dr. Metzl is a contributor to Triathlete magazine, Ironman finisher and all around awesome advocate and supporter of athletic pursuits.  I knew him from my days with Terrier Tri in Manhattan and had visited after him IMLP to talk about the stress fractures that I developed in each shin during that race.  This time around the situation was a bit more serious as my chronic back issue has seriously been affecting race day performance.

On my flight back from Seattle a week or two ago after having made my appointment with Jordan, I came across one of his articles in Triathlete magazine.  The stars were aligned as his most recent article was on pain in the sacroiliac joint; the article described the issue I was having perfectly!

The great thing about Dr. Metzl is that during my appointment prior to asking me any medical questions or rushing me out of his office he took the time to ask me how triathlon was going, talk to me about my latest races and tell me about his pending plans to compete in IMLP.  Then after a quick examination (his article made it pretty easy to tell him my problem) he triumphantly shouted - I can fix you!  Gave me a fist pump and was off to get me the info for the physical therapist who would put me through pain towards health.

I've now been to Chris and Ali at Vitaris Rehabilitation a couple of times.  They diagnosed the cause of my problem as a leg length difference!  Currently we're working through determining if the leg length difference is an anatomical or functional problem.  The functional issue of a pelvic tilt needs to be addressed first this requires a ton of stretching that has me sweat like a pig and put my abs into spasms but all that is an effort to level off my pelvis.  After a few weeks of torture Chris and Ali will re-valuate the problem to determine if there is an anatomical difference between the bone structure in my legs.  If so I'll need to wear a lift in my left shoe while running and biking so that I'm on a level surface.

The leg length discrepancy has caused my right side to basically compress on itself to artificially level off my pelvis during exercise.  This compression is causing my sacroiliac joint to spasm which starts as an ache in my    lower right back, turns into a shooting pain and then eventually the pain radiates from my back to my right hip.  When that happens I loose the ability to generate power with my right leg on the bike and it kills my speed.  The off season is time to fix stuff so hopefully I can get this leg length issue taken care of and then really get after cycling!

Tuesday, July 27, 2010

Huge Shout Out - Jon Paladini

For the past year or so I have been helping out my younger sister's best friend's younger brother, Jon, prepare for Ironman Lake Placid.  Jon was diagnosed with Chron's Disease when he was just a kid and really struggled to get the disease under control as a youth.  Over the years he became really interested in fitness and nutrition and will soon graduate from SUNY Cortland with a degree in nutrition and physiology (or something close to that).  Anyway, just over a year ago I received an e-mail from him on Facebook asking me about Ironman Lake Placid and telling me he was thinking about signing up for the race.

I had warned Jon about the time commitment training for an Ironman takes and that the Ironman won't go anywhere but you're only in college for a finite period of time.  He was fully prepared for the commitment and seemed hell bent on crossing the finish line so I told him I'd help with whatever he needed during his preparation for the race.  With that he drove up to IMLP last year to sign up for the long journey to the starting line.

Over the course of the year Jon prepared for the race all on his own.  From training to nutrition he read books, found outlets online and asked questions to develop his own training plan and nutrition protocol.  I was a bit worried when he told me his main source of nutrition on the bike would be Fig Newtons, but hey if it worked for Dave Scott in the 80s' I guess it was "ok" to break out the history books and try it again.  We went on a couple rides together, I talked to him about cadence, gave him a set of my old clip on aero bars and discussed how the Ironman is way more mental than physical.

Leading up to the race we continued to exchange e-mails, he told me about sleeping on an air mattress in his friend's apartment on weekends because there were too many parties on his floor, asked me what the worst long training ride I went on was, and picked my brain about running form and things like that.  All in all I think I was just a resource for him not to feel like he was the only person who had thought "what the hell did I get myself into."

Knowing how much work he had put into the race there was no way I was going to miss cheering Jon on at IMLP this year. The Friday before the race I sent some text messages to people who were going to be at the race to see if I could find some floor space to crash on.  Of course Jon's sister came through and away I was from my parent's house to Lake Placid to watch the race as spectator for the second time.

Heading into the race I was worried for Jon.  Like I said he had the 1984 nutrition plan and he had only done two sprint triathlons prior to the big day.  I knew he would cross the finish line but wondered if the Fig Newtons would give him the energy needed to perform well.  Holly Cow did he SHOCK ME!!!!

Although he had won his age group in his last sprint triathlon I never expected him to lay down a 12:31 FOR HIS FIRST IRONMAN!!!!!!  On a training plan all his own, dealing with the stresses and weird schedules of college life, on a nutrition plan to fit a college budget Jon freaking crushed the Ironman Lake Placid course; 12:31 is a great time for any Ironman, but freaking incredible for a first one!  Congratulations Jon, you've come a really long way since you started to win your fight against Crohn's disease!  I'm incredibly honored that you let me be a small part of your journey to the finish line - you are an Ironman!

Tuesday, July 20, 2010

IM Aftermath on Basal Rates

For the past few weeks I've been traveling between the East & West coast interviewing for jobs that will be the first step in my post-MBA career.  Over that time I've had to pay extra special attention to my blood sugars as breaking out in a full sweat while interviewing with a Senior VP at a multi-billion dollar company isn't the best way to make a first impression!  That's given me the opportunity to really see what effect recovery from an Ironman has on blood sugars and basal rates.

In the week following IMCDA my basal rates slowly climbed from the 11ish units per day my basal was set at on race day.  Towards the end of the week my blood sugars were consistently in the mid 200s to low 300s.  As my muscles recovered from a brutal training year and arduous race alot of insulin was needed to transport glucose from my blood to my muscles for the recovery.  8 to 10 days after the race my basal rate had jumped about 5 points to 16 units per day.

As I began to do some unstructured workouts and my sleep schedule returned to normal my basal rate started to slowly fall.  Last Monday, some 2 weeks after the race I started to encounter low after low.  My Dexcom would wake me up several times a night with a low alarm, and during the day I'd constantly be fighting my way out of the 70s.  Finally my metabolic rate had returned to normal, my body finished it's aggressive recovery and I have reduced my basal rate to about 13 units of insulin per day.

The variation of blood sugars and basal rates has all sorts of short-term consequences on one's mood and energy.  All the lows I encountered as my basal rates returned to normal forced interrupted sleep and had me exhausted in the mornings.  Additionally, the high blood sugars after the race increase irritability and really just made me feel kind of "icky."  Active management of my blood sugars with a focus on basal rate patterns was necessary to get back to feeling like myself as quickly as possible.

Monday, July 5, 2010

Compete Each Mile: IMCDA Race Report

Determined not to have to borrow just about every piece of triathlon gear imaginable like I did for California 70.3 I flew out to Coeur d'Alene the Wednesday before the Ironman with a death grip on my triathlon back pack.  I figured I had built up enough goodwill points with the airlines by always stowing my carry on under the seat in front of me to have one flight where I could jam a big backpack into the overhead bins without feeling guilty.  With my triathlon gear in hand I arrived at my beautiful lake front condo on June 23rd feeling amazingly confident and calm.

As the week progressed I was shocked at the contrast in my attitude and demeanor towards my second Ironman than at IMLP in 2008.  It's not that I didn't feel nervous, it was more that I felt like an athlete and less like someone to prove.  I was excited to take on the distance, to strut my stuff for 140.6 miles and was determined to give the race everything I had.  In speaking with Coach Orton in the days leading up to the race my only goal was to compete for every mile.

The days leading up to the race had my blood sugars doing some really funky things.  E had warned me that I might become extremely hungry during my taper as my body recovered from a years worth of the training hell he created for me.  In the 10 preceding days to IMCDA it almost seemed like I didn't need any insulin to cover the food I was eating.  Of course this would be a welcome gift to any Type 1 but..... in the week leading up to an Ironman I'd rather have business as usual with the blood sugars.  Even though my training volumes had dropped way down my basal rate went from about 13.5 units per day the Monday before the race to 11 units per day the Saturday before the race.  Just something I was going to have to deal with, no freak outs were allowed.

Race Day

After a week of doing pretty much nothing I was itching to go on Sunday morning.  I woke up at 4am, had my fruit shake, hopped on a boat with my flippy floppys (Arrowhead resort made my race day commute the easiest I've ever had!) and headed over to transition.  At transition I popped on my race day Ipod play mix and got deeper into my own world.  Calm, confident and anxious were the 3 words that described me best in the hours before the race.  I knew I had put in the work, now it was time to have some fun.

I unfortunately was not able to drop the kids off at the pool prior to the race.  As hard as I tried nothing would happen.  As much as I try and practice race day bathroom habits I just can't seem to get it right.  So after 20 minutes in a port-a-potty and nothing happening I figured I'd have to take a quick break at some point during the race.  After my trip to the plastic throne I stripped out of my morning clothes, donned the Triabetes jersey, lubed up with some body glide and was off to the beach.

The Swim

My only complaint about the race organization was that the path to the swim start was not sectioned off from the spectators like it is at IMLP.  2,700 athletes had to fight their way through friends and family to make it to the one entry way that activated our timing chips; nothing like adding a rush hour bottleneck to the high stress environment of a IM swim start.  The first time I made it through to the timing mat pretty easily; I made my way from transition to the entry way at 6:15 am; but much to my surprise I couldn't find a medical needs table at the swim start or finish so I had to return to transition to put my blood sugar meter and Dexcom in my swim to bike transition bag.  God however was smiling down me, threw the throngs of people and faceless crowd I spotted a "Ring The Bolus," t-shirt on my walk back to the transition area.  Serendipity was in full effect as I ran into my parents and friends on my hectic fight to find refuge for my diabetes gear; with a bear hug for my Mom and high-five for my Dad I smiled at this awesome stroke of luck.

I returned to the beach, got into the water for a quick warm up and was kind of surprised at how cold my back was.  After a 10 minute warm up I got out of the water and realized that the zipper on my wet suit had fallen down, no wonder I was so cold!  However, the open zipper caused the gel I had planned to take between lap 1 and 2 of the swim to fall out of my wet suit so I had to adapt my race day plan.  I wasn't too worried about the short fall in carbohydrates.  Prior to leaving my bs meter in my transition bag my blood sugar was 285 and that was prior to my final liquid fuel up so I was pretty sure my bs would be in the 300s at the swim start; high but I'd rather be high than low during a swim.

Coach Orton wanted me to start in the front 1/3 of the field for the swim.  I stupidly took this to mean to start in the second row.  As Mike Riley got the athletes and crowd pumped up with his unreal enthusiasm and energy I wondered if I should move back just a bit.  Too late!  Before I knew it the gun went off and I was charging into the water ready to get the day underway.  For the first 500 meters I totally got my a** kicked in the water; even though I'm a strong swimmer I'm not one of the fishes so for a brief moment thought of bowing out of the race before my day ever really started.  I slowed my breathing, cleared my head, remembered that I had started way too far up in the field, found some open space and regained my composure.  Freak out # 1 of the day was under control and I was settling into my race.

The IMCDA course has 2 turns during the swim in pretty close proximity.  If you want to know what the turns feel like, cram yourself into your washing machine and have someone hit you over the head with a rubber spatula.  50 at a time we bobbed water around the turns and laughed together that this was more like a pinball machine than a swim.  Finally able to get horizontal again I finished my first lap right around the 35 minute mark - perfect, just where I wanted to be!

After a short beach jog I returned to the water for my second lap.  The water was pretty rough for the second lap and on the way out I had to fight swells and waves to make it to the turn around.  Although it wasn't overly windy the water still felt pretty angry, so I shortened my stroke and kicked a bit more to combat Poseidon.  This time around the 2 turns had a bit more space but were still crowded.  I took two good kicks to the chin around the turns, one of which had me seeing some stars.  Eric had told me to embrace the physical nature of an IM swim rather than getting pissed off about it, so rather than bite the dude's ankle who kicked me in the face I decided to blow by him and beat him out of the water.

I finished the swim in 1:14, 7 minutes off my dream goal but more than 5 minutes faster than my IMLP time; the day was off to a great start.

The Bike

After a T1 which took an eternity; taking my pump out of its water proof case, reattaching my pump clip, drying my hands to test, attaching my Dexcom, and taking in a gel, I grabbed El Bastardo and was off.

Coach E had laid out an awesome bike plan for me; take the first 8 miles to settle into the race at zone 2, don't get caught up with people hammering past me, spin up the hills, elevate my heart rate on the flats and stay within myself.  I stuck to this plan as closely as possible and felt outstanding.  I was in my own world on the bike, I was having fun, smiling and treated it just like another training day.  When I had driven the course prior to the race I was pretty uninspired, but driving and riding the course were 2 totally different worlds.  CDA is an AWESOME bike course, it doesn't have a consistent personality and you need some serious handling skills to attack some of the descents so the course requires a ton of focus but is fun enough to keep your mind fresh - it's alot of fun.

I started on the bike well out side of zone 2, the adrenaline from my swim and normal race day jitters had my hr elevated.  About 2 miles into the bike I settled in, got my heart rate into the 130s and just cruised.  My cadence was high, my back felt great and I was having fun.  I easily spun up the first hill towards Higgins Point, and the second felt even easier.  On the downhill I started to dig into my aero position, tucked a little tighter and opened my legs up just a little bit.  At that point I started to reel in some people but continued my somewhat casual effort.

Finally, I reached mile 10 and was thrilled to up my effort to zone 3.  Now, it was time to race!  I felt freaking awesome, my heart rate was below 145 and I was actually passing people on the up hills.  Apparently all those rides that almost made me throw up on the Blue Ridge Parkway paid off.  I would spin up hills only to have 3/4 of the people who I had passed on the uphill bomb past me on the downhills.  I knew by the second lap their strategy would take a toll on their legs so I continued to stay the course and stick to the plan.

Around mile 35 my back started to tighten up.  I wasn't super worried about my back at this point but am a little aggravated that no matter what I do to try and solve my back issues on the bike I just can't seem to get it right.  Since the off season is all about fixing things I'm seeing an orthopedist on July 19th to figure out what the heck is going on.  I finished the first 56 miles of the bike in just under 3 hours and made it to the special needs area of the bike in 3:06 - 60 miles in 3:06, not too shabby!

At special needs I made my first major mistake of the day.  My blood sugar was 256 and I knew I needed to get it down so I took in .3 units of insulin.   For me exercise essentially makes a bolus 2X stronger than normal so I figured the .3 units would bring my blood sugars down to the 170s.  In my special needs bag I also had a Snickers Bar.  During all my century training rides I have a Snickers bar around the half way point. However, during training I normally take a break, and sit in the shade for a few while I chomp on the nuget and caramel.  I took in .6 units of insulin for the chocolate but then forgot to continue with my regular scheduled feed intervals.  Around mile 70 or 75 I started to feel really sick and my effort dropped way off.  At that point I realized I was trending low as I checked out the pattern on my Dexcom and started to take in nutrition like a mad man.  To combat the adversity I made a promise to myself to work as hard as I could to get to the bathroom at mile 90.  My bowels finally decided they wanted to make a move around the same time I was trending low so I thought I'd play the 2 against each other to save me from a really painful and dark period of the race.

Finally I reached the porta-potty, got off my bike and dropped the spandex.  Stomach relief at last!  I tested and had a blood sugar of 160 and then started to feel alot more stable.  10 minute later (literally, I timed it) I was back on my bike and off to finish up the final 22 miles of the bike course.  At this point my back really started to act up.  The only way I could get relief going up hill was to pedal with my hands on top of the pads on my aerobars.  This took some of the power out of my legs but I was able to climb the hills pretty effectevley.  Headed back into town the wind had picked up a bit so the stretch along 4th St. and Gov't  Way was a bit slower than in the first lap.

I finished the bike course in 6:09, slower than I know I'm capable of but still pretty solid.  I averaged 18.2 mph on the bike, the goal was 19 but with the blood sugar mistake and bathroom break I couldn't be happier with how the bike went.

The Run

T2 went much more smoothly than T1 and I was off to the races.  I came off the bike with a blood sugar of 158, took in a gel to start my run, tossed on my fuel belt and was ready to rock n' roll.

The goal for the run was to get my legs back over the first 4 miles, run at a steady pace from mile 4 to 20 and then empty the tank for the last 10k.  Mile 1 and 2 were run exactly to plan.  I opened up in an easy zone 2 at a 9:30ish pace.  But as I passed by the 2 mile mark my legs started to feel like they were stuck in mud and my mind became fuzzy - I knew what that meant.  I took in a gel, stopped for a quick bathroom break and tested.  My blood sugar had dropped 70 points in the first 2 miles of the run, but I caught the low before any real damage was done.  I grabbed a gatorade, polished off a fuel belt bottle, had a quick stretch and walked for the next mile.  After a mile I tested again and had a blood sugar of 170 - I upped the pace but just couldn't get my mind into it.  I tested and had a blood sugar of 295 - the more than 300 point yo-yo had me feeling awful but I was determined to keep moving forward.

For the next 8 or so miles I ran at a 10 minute pace and walked each aid station to take in as much water as possible.  It also didn't hurt that CDA has some of the best looking aid station volunteers of any race I've done!  I was a particular fan of the aid station captain right before the uphill at the mid-point of the run; even gave her a high-five which during an Ironman is pretty much as good as getting her number, right?

Slowing my pace over that 8 mile stretch worked, my form returned and my blood sugars became stable.  From mile 14 to 22 I was able to run at a 9:30 pace; Coach Orton had me prepared for this race, all that training, all that work was paying off.  Around mile 23 my tank was pretty empty, as hard as I tried to crush the last 3 miles my legs couldn't muster up much more than a 9 or 10 minute pace.  It didn't matter though - when I turned the corner into downtown CDA I can't remember a time that I was happier.

The Finish

Running down the crowd lined blocks was flat out awesome.  I entered the finishing shoot, flapped my arms to the crowd, gave some kids a high five and nearly had my muscles pop out of my arms as I crossed the finish line.  My only goal for the race was to compete within myself for every mile and I did just that.  I took an hour and 16 minutes off my Placid time and while my ultimate time goal was to break 12 hours, finishing in 12:42, 916th overall is just plain awesome for me.  I'm not sure after Placid I had the respect for the Ironman distance the race deserves.  I knew that covering the distance was an incredible feat but I didn't know what it meant to be able to compete for the entire distance.  I had, had so many blood sugar issues during Placid and was so new to the sport I didn't know what it all meant.  At CDA I wanted to really see what I was capable of, I wanted to test myself and just get after it.  I left everything I had on that course and know I have a ton of work left to do to get to where I want to be in triathlon.

Coach E wanted me to have a mantra on race day; I had 4 quotes written on an index card in my tri jersey:

"Success is not final, failure is not fatal, it is the courage to continue that counts."  ~ Winston Churchill
"He is able who thinks he is able."  Buddha
"You can't cross the sea merely by standing & staring at the water."  ~ Rabindranath Tagore

and my personal favorite from the day that I repeated every mile of the run:

"What lies behind you & what lies before you pales in comparison to what lies inside of you."  ~ Ralph Waldo Emerson

I have some long conversations to have with Coach E in the next couple weeks to determine what direction we'll take my endurance sport career.  I might try my hand at track cycling but at this moment I still can't stop smiling because for each mile of that race I competed the way I wanted to and gave it everything that I had.