Any other day I would have taken insulin, I didn’t take insulin because I was worried about it BG going low due to the race. I’m about 3 months into this diabetic thing, and was very insulin sensitive early on. Next time I race I won’t be as concerned about going low and will take my insulin as usual. Like I said this race and B2B was pretty much an experiment. I’m also aware my BG won’t always react the same but now I have a better idea of what it might do
I had a similar experience when I was first diagnosed. I would take 3 units on insulin for a huge pasta dinner and still end up going a little hypo. That all stopped the first time I got sick- it wasn’t that bad of a cold, but it caused real issues with my BG. After I recovered, I had to totally re-learn how to dose insulin. I went from 1 unit/40g carbs to 1 unit/15g in the period of 2 weeks. It has held steady since then.
Speaking of sickness, does anyone have any pointers on how to handle BG while sick? I have only had two colds since I was diagnosed, but both times have been very difficult to control things short of taking boatloads of insulin.
My insulin insulin sensitivity changed about a month ago. I went about 2 months without really having to take humalog at all because I was going llw like crazy. Now I take humalog with every meal, 1 u for 20g carb.
I dont worry as much about going low now.
Also interested to see how my bg responds to anaerobic workouts as I will start working on my ftp soon
Interested to see responses on bg and sickness because I hear it can be bad!!
I had a similar experience when I was first diagnosed. I would take 3 units on insulin for a huge pasta dinner and still end up going a little hypo. That all stopped the first time I got sick- it wasn’t that bad of a cold, but it caused real issues with my BG. After I recovered, I had to totally re-learn how to dose insulin. I went from 1 unit/40g carbs to 1 unit/15g in the period of 2 weeks. It has held steady since then.
Speaking of sickness, does anyone have any pointers on how to handle BG while sick? I have only had two colds since I was diagnosed, but both times have been very difficult to control things short of taking boatloads of insulin.
Sickness (and stress!) really messes with blood sugar,not much you can do but what your doing. I believe your liver dumps glucose into your blood to create energy to fight infection. Having no insulin means we go high obviously. Hence the boatloads of insulin.
Im finding a few days after a 70.3, despite pulling out on the run, my legs are very sore and as a result im very insulin resistant at the moment. I too am taking boatloads more than normal even post race. You would think it would be the opposite, and we would run into lows. Im not 100% sure why this is, im thinking the body produces glucose to feed into muscles for repair? I actually worry about putting on weight when you have to increase insulin dosage. Im not fat by any means, but increasing insulin dosages always makes me think of it
glad to see this thread continuing and people helping each other. I’m not a big fan of a1c penis measuring as, much like the analogy it’s not about numbers but about what you do with it and how you get there!
WRT your friend do remember that pumps can have site issues, the insulin could be not clearing from the site and thus the BG remains high. One of the nice things about MDI is the ability to change site with each injection. This isn’t an occlusion, the insulin is leaving the pump tube just not being absorbed.
On the off chance anyone is in AZ for IMAZ and still around for El tour we are having a fundraiser, i’d love to have more people from this thread attend (a few already are) and have this conversation over dinner not the internet!
http://volunteers.ayudainc.net/site/Calendar?view=Detail&id=101041
WRT your friend do remember that pumps can have site issues, the insulin could be not clearing from the site and thus the BG remains high. One of the nice things about MDI is the ability to change site with each injection. This isn’t an occlusion, the insulin is leaving the pump tube just not being absorbed.
This is often mentioned with a pump but I wonder how frequently it is a problem. I have been pumping for 4 years and never once had a problem with occulsions or significantly altered absorption rates. I have had times that I needed a lot more insulin but that was due to what I ate.
The canula gets moved every 3-4 days. After several years, I do find that some places are harder to insert the needle than before (feels like a rubbery membrane under the skin) but once it is inserted, I don’t believe it has significantly altered the absorption.
Just sidetracking for a bit.
Has any of you type 1’s struggle with weight or notice they put it on quite easily? Im 71kgs at 5’10 but i did get up to 75 easily at one stage. I asked my GP if more insulin = weight gain. He said flat out ‘yes’. My endo said ‘not necessarily’. I understand insulin, in part, is a storage hormone. However, as mentioned previously, what about the times when one is sick? Or goes through a taper and insulin needs increase? Does anyone hate having to up their insulin because they think its ‘going to their thighs’? or am i just being a little bitch.
Or, are we governed by the same rules of calories in vs calories out, even if it was all carbs and a lot of insulin to cover?
Hi Folks - great thread. Type1 diagnosed 3 yrs ago. Playing at Triathlon and have done a few marathons.
I find the same happens after a long endurance race. I recently ran Chicago marathon and for a week afterwards my blood sugars were elevated, not dramatically, but certainly a bit higher than normal. The main cause of this is inflammation & stress on the body which increases the amount of cortisol & other stress hormones being released as they help to reduce inflammation. This floods the muscles it with glucose (from liver), to supply an immediate energy source to aid recovery. Also, its worth noting that Cortisol also suppresses the immune system which can cause an increased susceptibility to colds and other illnesses. I’ve found that a good way to minimize the impacts of this are to take a good Omega-3 Fish Oil supplement to help reduce inflammation, and take a combination of an Immune Boosting Multi-Vitamin Supplement and high dose Vitamin C to help the immune system. Its worth considering doing same during high mileage training weeks before the race.
Wrt to weight gain, Cortisol is a definite driver of fat storage , even in non-diabetics - primarily by driving hyperinsulinemia. Overall for weight management minimizing insulin levels as much as possible are a good thing, through both reduction in stress (mental & physical) and through use of appropriate nutrition as outlined by Vinnie. High levels of insulin are BAD. The last thing we want to becomes is insulin resistant & Type1 diabetics. I’m not going to kick off the Ketogenic debate again - but I’ve definitely seen huge benefits in from a low(er) carb nutrient dense way of eating. Better recovery, stable weight, good energy levels & improved cholesterol profile.
Hello, ST
I am posting / giving back a schedule I use with my athletes, mainly to advertise my diabetic coaching services and reach a greater audience of T1 athletes. This is my full time job and what better way to interest new athletes by giving away some of the “secret sauce”!
Here are fueling suggestions for you to try out if you are using an insulin pump. Please keep in mind these are NOT the same as raceday. (A completely different metabolic state) Also keep in mind that insulin on board and types of carbs consumed (slow vs fast) can have a great impact on how things play out prior to exercise and during. To learn more about the decision support system I use with my athletes day to day and on raceday please contact me directly. (Cliff@tristarathlete.com)
TIME 3+ HOURS OUT
FUELING 3+HOURS OUT FROM WORKOUT
BOLUS AT 100%LEAVE BASAL RATE ON AT SUGGESTED NORMAL RATE.DETERMINE FUEL STRATEGY DURING WORKOUT AS DESCRIBED IN “O HOURS” OUT STRATEGY BELOW.
TIME -2 HOURS OUT
FUELING 2HRS PRIOR TO WORKOUT
BOLUS AT 100% 2HRS PRIORLEAVE BASAL RATE ON UNTIL START OF EXERCISE, THEN TURN BASAL OFF AT START OF EXERCISE.CONSUME 30G OF CARB AT START OF ACTIVITY (NO BOLUS TO COVER FOR THIS)BOLUS SCHEDULE WHEN BASAL IS OFF………CONSUME 30G OF CARB AT 45MIN AND ADDITIONALLY 30G EVERY 30-45MIN WITHOUT A BOLUS TO COVER)AFTER 2HRS OF ACTIVITY - DURING THE THIRD HOUR BOLUS AS FOLLOWS……3RD HOUR AT 30% FOR “X” CARBS4TH HOUR AT 20 % FOR “X” CARBS5TH HOUR AT 10% FOR “X” CARBS6TH HOUR + AT 10% FOR “X” CARBSABOVE ASSUMES CONTINUOUS ENDURANCE SUSTAINED ACTIVITY.
TIME -1.5 HOURS OUT
FUELING 1.5HRS PRIOR TO WORKOUT (ALLOWS FOR FUELING OF 150CALS PRIOR, ~300CALS AT START,
BOLUS 100% FOR ‘X’ CARBS, (NO MORE THAN 150 CALS OF CARB (~<1.5U)
CONSUME “X” CALS AT 1.5HRS PRIOR.LEAVE BASAL PROGRAM ON UNTIL STARTING WORKOUT THEN TURN BASAL OFFCONSUME CAL AT START OF WORKOUT. (BASICALLY DOUBLE WHAT YOU ATE 1.5HRS AGO.)HIGH BG CORRECTIONS (BOLUS AT 40% OF SUGGESTED CORRECTION PRIOR TO START OF EXERCISE)1HR INTO WORKOUT - CONSUME ONE GEL.EVERY 30MIN OF ADDITIONAL ACTIVITY CONSUME ( ex: 100CAL OF CARB FROM 300CALS AT START).NEED MORE CALORIES AT 1.5HORUS PRIOR TO WORKOUT? CONSUME PROTEIN OR GOOD FATS.
TIME 0.0 HOURS OUT
FUELING AT START OF WORKOUT (5-10MIN PRIOR)
BOLUS AT 40% OF “X” CARBS 5-10MIN PRIOR TO EXERCISE. (MAX CARB TO INTAKE AT START = < 300CALS CARB.TURN PUMP OFF.AFTER 1ST HOUR CONSUME 1 GEL EVERY 30MIN.HIGH BG CORRECTIONS (BOLUS AT 40% OF SUGGESTED CORRECTION PRIOR TO START OF EXERCISE)BOLUS SCHEDULE WHEN BASAL IS OFF……… 1ST HOUR AT 40% FOR “X” CARBS2ND HOUR AT 35% FOR “X” CARBS3RD HOUR AT 30% FOR “X” CARBS4TH HOUR AT 20 % FOR “X” CARBS5TH HOUR AT 10% FOR “X” CARBS6TH HOUR + AT 10% FOR “X” CARBS
HOW TO MANAGE DIABETES DURING EXERCISE?, ITS ALL ABOUT “TIMING”.
Prior to Exercise
Prior to activity there can be a mental gymnastics to determine the right amount of insulin and carbohydrate necessary to fuel the body but at the same time prevent low blood sugars or highs. The question that needs to be asked is where am I now and where am I going? If you are going to drive the car just down the block and back, you probably don’t need to fill up the gas tank to full. However, if you were to drive out of state you certainly would not leave home with the light on “empty”. The next thought is how much do I need to stay fueled up and sustain during my activity, and how long and hard is that activity?
As a diabetic, you must ask these questions but also at the same time know the answer to the question of how much carbohydrate do I need to offset current insulin on board. Depending on when your last bolus was (one or more and how many corrections + current basal rate), this for a diabetic determines how much you will need to put into the tank, besides needing gas to go for a drive.
The following paragraphs provide guidelines for how to fuel or not fuel prior to a workout from different time points out from your intended exercise. Options will be provided for fueling up and not fueling up based on goals. I decided to provide this information as well, as more times than not diabetic athletes or those simply wanting to do safe exercise are forced to eat when they do not want to. This can make it difficult to maintain weight and also capture the benefits of key workouts or activities.
Three hours before a workout
Three hours before your workout is a fairly long time away from the actual workout itself. Any insulin you take at this point will have minimal impact on your actual workout or activity planned. The duration of activity of most insulins are between 3.5 and 4hours. (Most rapid acting insulins) Insulin takes time to get rolling, and in the first 15minutes the action on blood sugar will be very little. Novolog, Humalog and Apidra have similar curves where the peak is approximately 50-70min post bolus. From there the insulin falls off rapidly and has a tail of “lowering action” for up to 3.5-4 hours.
At this time you can take a full bolus amount and eat normally. The food choices here should be a combination of short acting and slow burning carbohydrate. The proportion may be 80% slow burning or low glycemic in nature while 20% may be fast acting or high glycemic. As an example, a cup of steel cut oatmeal (Slow burning) and quarter cup of raisins (fast acting) with two tablespoons of agave nectar would suffice for a morning breakfast pre workout. To add additional calories for a longer effort, add a quarter cup of almonds and quarter cup of protein powder.
Three hours later at the start of your workout you would then have the option of a “bolus exercise strategy” or “basal exercise strategy” for the intended activity. (Explained in the upcoming sections below.)
3 hours Before workout Recommendation Summary
Bolus normally Fueling Up: Consume a meal with 80% slow burning carbohydrate with 20% slow. A protein component or good fat component may also be added to the meal. Keep baseline basal rates running normally at this time up and to activity. Fueling Down: Consume no food, no adjustment needed prior to exercise. (Note 3 hours is a long time prior to activity) Prior to exercise select a basal or bolus exercise strategy.
Two hours prior to exercise
Two hours prior to exercise is still considered a fairly long amount of time. The reason being is that the food you would be consuming and insulin as well would be mostly cleared prior to activity. However, compared to 3 hours prior, the insulin would now have a direct impact on exercise when you start.
Many diabetic athletes (From now on you will all be called diabetic athletes, since you are at the highest levels of diabetes exercise management)! …will be tempted to take less of a bolus resulting in somewhat high blood sugars for 90min prior to activity. I believe this is less than optimal strategy as high blood sugar dehydrates the body and also forces the body to urinate out the precious electrolytes and carbohydrate consumed prior to exercise, rather defeating the purpose. Raising the basal rate may be another option but not a great one. Given the amount of increased basal, it will not be enough to cover the food from the meal but enough to cause a low BG during exercise. The result is a high prior to exercise and a low during activity within the first 30-60minutes.
Its at this point that a little math comes into play and some exercising diabetic rules that can be applied each time you bolus or use basal within the 2 hours prior to activity. Many pumps can calculate the insulin on board from basal, bolus and any corrections for highs. This information is valuable as the total amount of insulin on board prior to activity has a direct amount of carbohydrate that must be coming in to prevent a low blood sugar. I sometimes refer to it as the Insulin on board to carb on board ratio. (IOB :COB)
The strategy below is for all activities that are non racing scenarios (ie not a 5K or triathlon race) but rather a level of sustained aerobic activity. For race specific insulin plans and day to day management, the strategy is distance dependent, and heart rate driven as well. Contact me directly for specific race insulin plans or global insulin strategies. The plans are as unique to each sport as they are unique to your own physiology! (Ie no quick math ; )
The relationship is as follows; to prevent hyperglycemia, the total insulin on board must have two times the amount of carbohydrate consumed at the start of activity. At this time a temporary exercise basal of no insulin is selected for the duration of activity.
Total IOB (Insulin On Board, at time of start of activity, including all boluses, current basal rate and any corrections for highs.)
I:C (Insulin to Carbohydrate Ratio, where 1u covers X amount of carbohydrate. Common calculation needed for all pump bolus calculations.)
Ex: (Total IOB) X (Grams Covered by 1u) = carbohydrate to be consumed prior to exercise.
2.4u X 16g = 38.4grams X 2 = 76.8grams (Simultaneously at start of exercise, consume 76.8grams of insulin and apply a temp basal rate of zero units per hour or “OFF” or lowest setting for duration of exercise.
Fueling options two hours prior to exercise are still the same as three-hour recommendations. No adjustments are necessary only the impact the bolus and basals have prior to the start of exercise. You may want to slightly reduce the amount of good fats at this time from your meal so as not to delay the absorption of carbohydrate in the stomach. (Heavy fat meals tend to slow carbohydrate absorption rates and can cause high blood sugar hours after a bolus. Protein has a similar effect except somewhat less pronounced depending on the nutrients in the gut)
At this point you may or may not have realized that there is a maximum amount of insulin on board that you could have at any given time… In general, most GI systems (ie your stomach) can only absorb between ~200-375 calories per hour of carbohydrate. Small individuals may be less and larger individuals more.
Interestingly, this means that the total amount of insulin that someone could have on board would be limited to this bottleneck of carb ingestion. By way of example, if I were to have 4u on board at the start of exercise I would need to consume 128g of carbohydrate or 580 calories. (which may be possible but certainly would not feel very good or allow for performance!) This would cause a low blood sugar for sure.
Therefore based on the examples above, I should not undertake exercise with >=3u on board. Instead I should wait until some of the insulin has passed from my system before exercising.
One hour before a workout (The Insulin “blackout period”)
Getting closer to the time you will exercise, any injections and corrections at this point will have an increased effect on blood sugar lowering. The reason being is that insulin taken < = 90minutes prior to activity will have a greater lowering effect due to its peak effect at ~60minutes from a bolus or correction.
The goal should be to not take any insulin during this time and sustain or fuel yourself with alternate foods that are not carbohydrate based. A source of protein and good fats to satiate you would be best. Examples would be lean turkey meat, egg white, low carb or no carb protein bar, low fat cottage cheese for protein and avocado, almonds, almond butter, and flax seeds. The impact of these foods is little to no raising of blood sugar and no supplemental insulin is needed prior to a workout or activity. When < 90minutes and > 60minutes prior to exercise approximately 50-400 calories of good fats or proteins is possible depending on how hungry you are and the duration of your intended activity.
The reality of diabetes and working out is that “life” happens in a much less structured way. Its quite hard to always start and stop a workout when you want to and its more about fitting in workouts when and where you can. For this reason, there may be times when you are in the 60-90minutes window and you are carb deficient. For whatever reason, lunch was lighter on carbs, or you are just plain hungry and need carbs for energy; what can you do?
Your options are;
Take a small shot to cover a smaller amount of carbohydrate (Ideally < 30g, since you will need 60g to start your activity. This based on keeping 2 x the carbohydrate on board to insulin on board as previously discussed. Any more than this may cause GI distress. Note you are not discounting the bolus in any way but keeping the IC ratio substantially constant.) Consume a VERY slow burning carbohydrate. In my experience, one such carb that would qualify for this would be UCAN. This product is a powder that can be mixed with water and has the ability to be absorbed over 2 hours. This delay is enough time that no insulin is needed prior to working out. Ucan can be ingested anytime prior to exercise, ~60minutes and less. (The insulin strategy would be take no bolus and leave basal rate “on” until just prior to the workout and then turn the basal rate to “0” or “OFF”.) Based on the fact that most cardiovascular activity that you will be doing will be less than two hours, a consideration for how much carbohydrate on board must be determined. Meaning, at the end of the workout how much carbohydrate is still yet to be digested. This carbohydrate would need to be accounted for and an appropriate bolus taken. Take no insulin and consume lean proteins and good fats to satiate as desired for the current level of hunger and or upcoming duration of activity. (This in my opinion is the most “easy” way to entertain the 90-60minutes window)
The third option also has better metabolic benefits if the intensity levels are low (Fat burning is going to be higher since less insulin is on board).
The third option can also provide much needed flexibility to when you start your workout. Rarely does it happen that we say we will workout at 5pm on the dot and it does. A phone call comes in, work, chore, or a closed pool?! …can lead to disruption in a workout and its timing. If you use option #3, if you need to change the start time there is not pressure to do so. Contrast this with the other options where you are consuming more rapidly absorbed (simple carbs) and blood sugar is sure to rise with every minute that passes.
In option three, since you are simply turning your basal rate off when you begin exercise, you can do so with some timing flexibility since there are little to no carbohydrates entering the blood stream.
Option #1 may be a better option for someone who is highly active, and is considering being active two or more times in one day. This will help keep fueling up so that you dont “bonk” during a workout.
To learn more, please visit us : ) or contact me directly.
Cliff@TriStarAthlete.com
★★★TriStarAthletes.com
would love to see something like this written for MDI folk!
Cliff, you mention not to take any insulin around 1hr before a workout. I agree and dont take insulin during training at all.
Would you take insulin during a race? At what distances?
this looked good …
And then you tagged Ben Greenfield in your Facebook post…
Thanks! Tri gear being designed and will be available for 2014 !!
Just wondering how people go with CGM’s in tri’s? are they helpful at all? how long is the delay? Thinking of getting one and taping it to the bike so i dont have to keep pricking my fingers mid ride, and then peeling it off and taking it on the run portion in a spi belt. I am in australia and these are NOT covered by any insurance, so im talking 1500 bucks to pony up. Are they worth it?
As an aside, how do you pumpers race with those things attached? especiialy in a wettie? very curious about where you put them in a wettie, on the bike etc?
i found a CGM to be “too much” diabetes, it’s delayed which makes it pretty meaningless in terms of alerting you to potential hypos and looking at it rarley told me what i didn’t know. Sometimes you’ll be high, or low and you don’t need a little vibrating box to remind you of it you just need to HTFU and pedal!
hey James, cheers mate. Thats what i was curious about re: the delay. I understand the dexcom 4 platinum is 5 minutes, i guess my plan was to stop testing and pricking my fingers all the time from the bike onwards and just attach this to the bike and run with it in a belt. Its all about the trends i guess, to keep it in that ‘sweet spot’.
I don’t think the monitor is waterproof so most people sync the sensor and the monitor out of the water…I think.
I don’t see how it could hurt to have a CGM like Dexcom G4, especially for racing and training. I think the sensors is where you will see biggest cost, pretty sure a monthly supply is about $300
I am likely going to get one in 2014…ironically my deductible is $1500 and so is the unit…so I will be shelling out $1500 either way but at least if its 2014 it will satisfy my deductible as well
oh ok. So you cant sync the sensor and place it on your bike in T1, then go swim and it ‘detects’ it when your in range?
I think that my Dexcom has been a tremendous benefit when racing. I have it attached to the top of my stem and can view it easily between my arms when aero. I agree that many of us can use our experience to know what our BS is currently, but 20+ years after diagnosis and still I can’t accurately predict with consistency which direction I’m trending, and that’s where the CGM earns it’s keep! - KP
There’s a sensor that secures to you. YouTube it, looks kinda painful but hear it’s not. The sensor is attached by some sort of adhesive patch your the abdomen (or possibly other areas). The sensor is waterproof (I believe) w dexcom G4. The monitor unit is not water pproof. Think the range is like 10th or something between monitor and sensor. So I think most folk just sync the monitor and sensor in to a bond attached the monitor to the bike
I’ve been using Dexcom for a few years now, so I’m experienced with it. The new G4 Platinum has a range of about 20 feet. The sensors are designed to last 7 days and the adhesive they use is good, but depending on your skin, it may not last the full 7 days. My race routine is this: I put on a new sensor two days prior to race day (Sunday race = new sensor on Friday). As a general rule, you should calibrate at least twice per day, which requires nothing more than using a standard monitor and entering the result into your Dexcom. On race morning, I wait until the last moment before transition closes and then test with a monitor, enter the result and then attach my Dexcom to my bike. I put it in a snack sized zip lock back and it stays dry. After the swim, it takes about 5 minutes for the receiver to connect with your sensor…after that, you have your Dexcom with you for the duration. In T2, I simply pull the Dexcom receiver off my bike and stuff it into the pocket of my jersey (still in the zip lock bag).