You’ve read about my diabetes here on JustAnotherCyclist a couple of times.  I’ve even claimed to not write about my diabetes much on this blog (as I write about diabetes on this blog – yet again!)  Nonetheless, it is a huge part of my life by necessity.  So it was with some interesting that I happened across another cyclist and diabetic – and blogger.

I have to admit that the title alone got my attention – Pedal Pumper.  A blog by a diabetic cyclist that uses an insulin pump? Well that’s just brilliant.

It was especially poignant to see him speaking about his OmniPod and Dexcom – two devices that were instrumental in my own diabetes management.  This all came about at a time when health insurance and health care costs were at the forefront of my mind.  I had changed insurance after changing jobs, and found myself without one of the devices at all (the Dexcom) and forced to change pumps away from the OmniPod – as Kaiser doesn’t list the OmniPod in their formulary of supported equipment.

If nothing else it was reassuring to know that there was someone else out there in my situation that arrived at the same solution.  It justified the efforts and expense that I am going through to get back to the solution that worked for me.  Changing health insurance 3 times in 4 months is no easy task for someone with a chronic illness to manage.  It is easy for doctors to tell me that they know what devices will help me best.  It is frustrating to realize that those doctor recommendations are based mostly on financial concerns.  It is even more frustrating to have someone tell me what will work best on the bike, when they are neither diabetics nor cyclists.

And finding another great cycling blog – well, that was just icing on the cake.  You can bet that Pedal Pumper is now on my list of blogs to watch.

It is an unfortunate necessity of being a cyclist with Type 1 diabetes that a fair amount of thought goes into blood sugar levels on the days before, during and after major rides.  Despite all the warm fuzzy “Diabetes doesn’t stop me from doing anything” sentiments – which I in fact do agree with – there is still an inescapable fact of life: Diabetes is a big pain in the ass.  I’ve talked before about some of the challenges that cycling, or any athletic endeavor, can present to a diabetic.  To that end, I’ve decided to share some of my methods of managing my diabetes while I’m riding, and ask for your stories to help me address some of the areas I’m struggling with.

First off, the all important disclaimer: I am not a doctor.  I don’t even play one on TV.  Instead, I’m just a guy with diabetes trying to find out what works for me.  That means that anything I say about what I do is just an opinion and not a suggestion to do anything in particular.  Your diabetes management strategy is a choice that you must make for yourself, in conjunction with a qualified health care provider.

I’ve been thinking about writing this for some time, but decided that today was the day.  I’m recovering from my Tahoe ride yesterday and for the most part  I actually feel pretty good.  I’ve surprisingly got absolutely no leg pain or stiffness, due in large part to the great massage I got post-ride yesterday.  However, I am currently struggling with an issue that I, for lack of a better term, will title the “Post ride diabetic hangover.”

The post ride diabetic hangover is the situation that happens the day after a significant ride.  You’re body seems to think you are still climbing the hills or sprinting to the line.  Normal basal rates and carb/insulin rations keep your blood sugars at dangerously low levels.  You find yourself constantly treating hypoglycemia.

This can be a tricky and annoying situation to deal with.  For me today, the problem actually started in the middle of the night.  I’ve been running at a 50% reduction in my normal basal rate ever since then, and I seem to be holding steady.

I tend to deal with these days by the “constant correction” method.  I intentionally reduce my basal and bolus doses.  Hopefully I get the adjustment numbers right.   If I don’t and my blood sugars start to climb I correct.  I always favor slightly higher blood sugars to hypoglycemia.  This, of course, requires constant blood sugar checking.

All of this would be a lot harder to deal with if it were not for my Continuous Glucose Monitor (CGM). I personally use the Dexcom Seven Plus – and it is worth its weight in gold to me, not only for recoveries like I mention above, but while I’m actually riding.  Trying to stick your fingers while juggling a meter and a test strip is downright dangerous in the saddle.  And if you’ve reached any level of seriousness about your riding, you’re probably not going to be coming to a complete stop each and every time you need to test.  This is why, in my opinion, a CGM is one of the most important purchases that a diabetic cyclist can make.

A little tip about the sensor (which almost universally seem to attach to the belly) and cycling bibs, however.  Bibs can be the enemy of your sensor.  I suspect those of you running MiniMeds or other pumps with a separate infusion set might be in the same situation.  There are a couple of times I’ve stopped to use the restroom and ended up with part of my bib shorts caught on the sensor without me being aware – eventually resulting in the sensor being pulled off enough to stop functioning.  Either get in the habit of placing your sensor much higher or lower than the band of your bibs, or just be conscious of this whenever you adjust your bibs.  I tend to keep my sensor lower on my abdomen and just try to be conscious of snags.  It has been working out so far.

Insulin injections are challenging on the bike too – especially basal shots.  Just like with the GSM, switching to an insulin pump made things vastly easier.  The fact that basal is delivered slowly over time (like your body is supposed to do) also means that you can adjust dosages down on the fly and have an almost immediate effect.  I’m an OmniPod user myself.  I just find it much more convenient to have the controlling unit completely separate and wireless – makes it easier to move the display to a position that is reasonable for me to read and operate while still pedaling.  I’ve also heard a couple of times that the Dexcom sensor and OmniPod pump are soon to be merged into a single controlling device – reducing two devices down to a single one.  Now if only I could get that data to my cycling computer!

Above all, though, just be aware of how your body reacts on the bike.  Even if you don’t have the luxury of a CGM, pick days where you do a normal training ride, or simulate a scheduled ride, and stop frequently to check your blood sugars.  I know that I personally often have a really hard time telling the difference between the feeling of low blood sugar, and simple fatigue from pushing really hard through a difficult effort.  It would be awesome if more of us could get access to the amazing information available to the diabetics riding with Team Type 1.  Just imagine having someone there to help you manage your blood sugars.  Someone that knows both cycling and diabetes.  Well, you’re going to have to become that person for yourself – at least until the team decides to pick you up!

So here’s some advice I will give my fellow diabetic cyclists.   This advice is disclaimer-free and I actively encourage you to do this.  Educate yourself, know your limits and don’t assume that diabetes will prevent you from riding your bike.

And spread your experiences!  I know there are numerous hints and ideas about dealing with diabetes while riding – post them in comments here.  Tell others what works for you, or perhaps more importantly what doesn’t.  The cycling community is a close family – the diabetics in that family an even tighter group.  Share and share alike!

There are lots of us out there riding.  I ran into many on my Tahoe ride, as it was also a benefit for Juvenile Diabetes Research Foundation.  And I know from direct conversations I had with many (Hi Dave!  Hi Randy!) they were out there riding with Type 1 diabetes just like I was (and a couple kicked my ass on the climb to Spooner Lake too.)  The stories say that the whole Team Type 1 pro group started when one amateur rider happened to see another checking their blood sugar before a race, realized they were both diabetes and struck up a conversation.  Let’s repeat that.  Share what you know with others.

Safe Riding,

Ross Del Duca – JustAnotherCyclist

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

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

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

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

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

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

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

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

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

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

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

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

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