I’ve not been active on this blog for a while, but to summarize, so far so good. Thus far, I have followed all the recommendations of wearing masks and avoiding indoor crowded situations and have remained negative so far. That said, I did make some other changes, which included: (1) Primarily use regular human insulin for boluses due to it being a better match for most foods I eat. (2) adding 500 mg of metformin per morning to my treatment regimen, (3) eliminating processed seed oils from my diet around May 2020 based upon an expert who was on Real Time with Bill Maher — Dr. Cate Shanahan, who was a guest on his show who recommended eliminating these oils. I’ve never been a person inclined to become a disciple of an author, but in this case, I find her particular piece of advice useful, even though I don’t follow all the other recommendations, which include nasty stuff like bone broth. I can say the same of Bernstein: his general approach is quite useful to me, but I don’t find the need to take my carb intake down to such extreme low quantities that he’s recommending. Plus, I’ve never been a big fan of meat, and that is mostly genetic. I’m not a vegan or vegetarian, but I simply don’t enjoy the taste of meat very much and I think there is a strong genetic reason for that, so I only eat a little of it.
I have diverged, but it turns out that Dr. Cate has plenty of supporting evidence — for example, corn oil is shown to cause insulin resistance in rats. For those of us with type 1 who inject all our insulin, we are basically the canary in the coal mine. In reality, most of the world is fed a shitty diet and repeatedly told it’s “heart healthy”, but it causes insulin resistance and who knows what else. That’s why I was, at times, using 50 units per day of basal insulin and finding it insufficient — due to insulin resistance caused by the shitty oils in the pizza, cookies, etc. that I was eating. I’m currently using around 30 units per day of basal insulin, but occasionally as much as 34 units. That’s still well under the prior doses. My new set of dietary rules eliminates most restaurant food from the menu, but when it works for me, I cannot deny the evidence.
Other consequence of COVID19 — all my registered triathlons were cancelled. However, I did and still do remain as physically active as feasible outdoors. Currently, that’s an occasional paddle board outing as weather permits, combined with running 3 to 6 miles 3 times per week. I prefer trail running over anywhere else and thankfully, the scheduled hunting events the result in trail closure have been cancelled this year.
As a result of these changes I’ve made, there are really 2 benefits: (1) weight is stable (currently 218 after supper) with no tendency to gain even though I can’t use my gym anymore. (2) roughly 40% less hypoglycemia.
Anyway, for all who are reading, stay safe and healthy and don’t succumb to pressure to eat garbage.
I have used Symlin, an injectable diabetes drug designed to slow the release of sugar into the blood after a meal, part of the time for over 10 years. The advantage of using it is the potential for better glycemic control combined with lower caloric intake. From my own experience, it’s a useful and helpful drug with some limitations, but its instructions are poorly written. Manufacturer instructions address the need to reduce insulin dose, but not the timing issue.
My first experience using it was with Novolog and I followed the instructions (reducing Novolog dose by roughly 50%) but using both during or immediately before the meal. The result of this was horrendously low blood sugar beginning roughly 1 hour after eating that was very difficult to correct, but ultimately ended with a spike over 300 mg/dL as both drugs wear off at the same time. In hindsight, this all makes sense because Symlin is a drug that acts quickly to hold sugar in the stomach longer, while Novolog is a fast-acting insulin that peaks at roughly 90 minutes. It was reaching its peak while the Symlin was still very effective at keeping sugar out of the bloodstream.
After lots of trial and error, both before CGM and after, I’ve concluded the right way to use Symlin is as follows:
With meals containing 30 to 80 g of net carbs and low to moderate fat content, since fat also slows down the release of sugar to the blood.
Never immediately after a workout or while recovering. Reason for this is my experience suggests that it can slow down the recovery process by keeping glycogen in the liver, thus less accessible to recovering muscles. I noticed longer-lasting muscle soreness when using it a lot after workouts, and also less weight loss than expected with that combination of exercise and caloric intake, so I recently stopped doing that.
Inject Symlin dose (time = 0) before a meal and begin eating within 15 minutes. A small delay can be helpful because it allows you to feel the appetite suppressing effects before you overeat. I then inject the insulin well after eating at a time between 1 and 2 hours, depending upon type of bolus insulin (regular vs. Humalog or Novalog) and glycemic index of meal. If I’m eating low GI meal with Humalog as a bolus, my bolus delay would be as long as 2 hours. If it’s a high GI meal with regular insulin, I’d only delay 1 hour. What I normally do is just watch the CGM and inject the bolus when I see the beginning of a sustained rise. This approach typically leads to a spike of no more than 40 mg/dL over the baseline. Insulin pumpers would have the option to further refine this as needed with multiple boluses, square wave boluses, etc.
Reduce the insulin bolus by only 20 to 25%, per gram of net carbs consumed. Realize that when one considers the appetite suppression effects, this might well result in using 50% smaller insulin bolus than would otherwise be used.
Be aware of the increased risk of hypoglycemia that typically occurs between 30 and 120 minutes after the Symlin dose. Small corrections with fast-acting carbs (ideally pure sugar) may be necessary even before the delayed bolus is taken.
Avoid using Symlin if blood sugar is low before a meal or there are indications of excess basal insulin (meaning you realize in hindsight that you used too much basal insulin, but haven’t yet had the opportunity to correct it).
With respect to weight management, my experience tells me that Symlin is effective at preventing weight gain that would otherwise occur while recovering from an injury, while doing a job where you don’t have the opportunity to exercise, etc., but despite its strong appetite suppressing effect, it’s a not drug that will enable you to achieve a large degree of weight loss.
One viable option that I’ve occasionally used for combining Symlin with exercise is to simply use it with a smallish meal, then begin the workout 1.5 to 2 hours later, either skipping the meal bolus entirely or greatly reducing it beyond the normal 20 to 25%. The disadvantage of that approach is that any delays can ruin it because you either have to begin working out at the right time or bolus, but not both. Working out with any significant dose of fast acting insulin in your system that hasn’t passed its peak puts you at a greater risk of hypoglycemia.
Here’s an example of a day where I did the right things with Symlin, aside from using it after a workout.
Here’s my list of sugar / carbs that I use before, during, and after both workouts and races. I’m not suggesting anyone make a meal out of these things, but for anyone on insulin, some carbs are necessary to either prevent or treat low blood sugar. As a non-pumping, long-term type 1 diabetic, these are critical to surviving my workouts. Here’s my list:
Sugar Cubes
Domino Sugar Cubes
Advantages: cheap ($0.0043 per gram of net carbs.), ideally sized at 2.2 g per cube. Environment-friendly (no plastic in the packaging). Convenient to carry in a pill bottle to the gym, on a bike, kayak, etc. Dissolves quickly. Raises blood sugar quickly. No added calories from fat.
Disadvantages: crumbles easily. Doesn’t travel well when running unless something is done to stop them from shaking.
Advice: this is my primary method of both treating low blood sugar and preventing it during workouts. They are effective and fairly precise. DON’T OVERTREAT! These dissolve in your mouth much more quickly than hard candy. These are not monoliths or solid crystals of sugar, but blocks of granules that have been pressed together. They can be swallowed after dissolving completely or even if they’ve only crumbled to powder.
Oreo Double Stuff Cookies
Oreo Double Stuf.
Advantages: tastes good, cheap ($0.0093/gram of net carbs), ideally sized at 10 grams of net carbs per cookie. Slower release of blood sugar makes it suitable as a pre-event food. Reduces hunger during longer events.
Disadvantages: 72% more calories per gram of net carbs than pure sugar due to fat content. With each 10 grams of carbs, you also get 3.5 grams of fat. May not the be most suitable carb for treating severe or rapidly falling blood sugar due to slower absorption.
Advice: beware of the caloric content and glycemic properties of these cookies. Yes, they do have lots of sugar and binging on them is bad, but at the same time, beware they can produce delayed hyperglycemia if eaten late during lighter exercise or swimming. For me, swimming tends to rapidly decrease blood sugar while I’m doing it, but doesn’t have that effect afterwards like many other exercises do. That said, they are great for long bike rides and long runs.
Various Types of Energy / Carb Gels
Power Gels and GU Gels
Advantages: convenient, portable, good shelf life, suitable to use during races, easy to store in a pocket, under a swim cap, etc.
Disadvantages: very expensive ($0.0624 per gram of net carbs). Some formulations may be high in fructose, which isn’t as effective at treating low blood sugar. Environmental issues with package, which doesn’t degrade easily.
Advice: use these sparingly and only when no other feasible alternatives are available, such as for open water swimming or actual races. I put one under my swim cap and up the sleeve of my wetsuit while open water swimming. Use other carb sources before and after the races.
Here is a quick summary of my experiences with placing the Dexom G5 and G6 sensors on various parts of the body — the abdominal area, upper arms, and upper buttocks. These are the only areas I’ve tried. There are some who’ve successfully placed them on their legs, but I don’t see any advantage in that, so I haven’t tried it.
Site needs to be an area with subcutaneous fat. Since both body fat percent and distribution vary, some sites may work for some, but not others. For example, bodybuilders might not have enough fat to place sensors on their arms.
Another issue is protection against aquatic shear. Simply sitting in the water with a “naked” sensor is fine, but swimming, water skiing, jumping or diving into the water, or letting one get blasted by a high-pressure shower is a bad idea. It’s a good way to lose both the sensor and transmitter. Also, letting one be submerged in a hot tub isn’t a good idea either, since the combination of heat and chemicals can cause it to degrade more quickly.
Final issue is comfort and appearance. If you’re a model, dancer, body builder, performing artist, etc., you may have aesthetic reasons for placing them in more discreet locations. Also, sensors are subject to bounce no matter where you put them. This may cause discomfort, but can usually be relieved by wearing some sort of compression clothing. Good news is that you have plenty of options with respect to where to put them and how to protect them.
Abdominal Area
G5 Sensor Placed on Abdominal Area
General Considerations
Sensor needs to be placed in a location that avoids creases in the skin that form when you bend over, do sit-ups, etc. Placing it too high (just below rib cage) can hit a nerve and cause persistent pain. Placing it on a skin crease can cause it to fall off prematurely.
The only swimsuits that sufficiently protect abdominally-placed sensors from aquatic shear are women’s one-piece competition style suits, triathlon style suits, and wetsuits. Those with any other type of swimsuit will need to wear full-length compression tops that cover the abdominal area while swimming. Finding tops that accomplish this can be expensive and challenging. Most el cheapo rash guards you find in a surf shop are way too baggy to be comfortable to wear while swimming laps. They become drag suits in their own right. Please note, this isn’t necessary just to get in the water, but only for actual swimming.
Advantages (a) This is the only sensor insertion area officially approved by Dexcom and the FDA. (b) Location is secure and suitable for most sports and physical activities including running, weight training, boxing bag type workouts, and paddle boarding. (c) Discomfort or irritation caused by bouncing is least likely to happen at this site for most activities.
Disadvantages (a) Location can cause false reporting of low blood sugar when biking. In one instance with the G5 system, I noticed it reporting an off-scale low, when in fact it was around 140 mg/dL while riding my road bike. I now use the G6 system, but haven’t done any road biking while using it. (b) Sensor signal may be blocked by the body if phone or receiver is placed in the back of a jersey while biking. (c) A properly worn seatbelt can put pressure on and/or cause discomfort with a sensor placed in this area. (d) Not a good location for rowing, whether in an actual boat or machine because you tend to hit the sensor with the oars or machine handle at the end of the stroke. Other problem is the compact body position at the beginning of the stroke, which not only stresses the adhesive, but could cause false reporting of lows as it does on the bike. (f) Not a discrete location to use while engaged in outdoor, shirtless activities.
Upper Buttocks Area
Dexcom G6 Sensor (and Transmitter) under Speedo Endurance Swimsuit. As can be seen, the sensor is very discreet and well-protected in this location.
General Considerations
This may not be compatible with all body types and clothing style preference. Proper placement may be difficult and may require assistance, though I did mine alone. Sensor needs to be well below belts and waistbands, but well above the part of your butt you sit on. The upper bound is your lowest waistband and the lower bound would be the part of your butt you sit on. It should be roughly in the middle of those bounds.
Depending upon what’s in your gym bag or wardrobe, one option for optimal placement is put on your smallest swimsuit bottom and mark its boundaries with a pen. Place sensor so that it’s well within the bounds.
“Cheeky” styles of swimwear or underwear should be avoided, since their seam is very likely to put pressure on the sensor. Most full coverage bottoms should be sufficient to cover the sensor. Thongs will not interfere with the sensor, but they won’t protect it either.
Baggy bottoms or sagging pants/shorts should be avoided at all costs. They can put pressure on the sensor or catch on it and rip it off. When changing pants, using the bathroom, etc, you must train yourself to pull your waistband away from the sensor before pulling them down.
If using a sensor in this location to monitor your blood sugar while swimming, you must somehow get your butt and the sensor above the water line every 5 minutes or so while it’s sending a signal. If you miss a few, no problem — the transmitter actually sends the last couple of hours of data every 5 minutes. If you want to do intervals longer than 5 minutes, you’ll get the data when ever you rest and get the sensor above water level while its transmitting. Depending upon which lane I get, I’ll either climb partially up a ladder, or just climb out of the water and sit on a kickboard between intervals while the signal is sent.
Advantages
(a) Sensor is adequately protected from aquatic shear and uncomfortable bounce by virtually all competition-style men’s and women’s swimwear and athletic compression shorts. (b) Completely discrete location. (c) Good adhesion, since there aren’t skin creases in this area.
Disadvantages
(a) Of all locations I’ve tried, this one is the most prone to signal being blocked by the body. I’ve had this happen while driving with the receiver placed in the console and also while sleeping. (b) Poorly placed sensors may cause discomfort while driving, sleeping, sitting in certain chairs, vehicles, etc. (c) Little or no documentation is available online to help you with placing a sensor on your butt.
Upper Arms
Dexcom G5 Sensor on Upper Arm
General Considerations
Sensor needs to be placed on a soft and high part of the arm, but not between the arm and the body and not too lateral (outside) in position.
Advantages
(a) Discrete, comfortable location that is compatible with most sports, work, and leisure activities.
(b) Use of this location is well-documented on the web with many successful examples.
(c) Appears to be preferred by the majority of users
Disadvantages (a) Despite its popularity and an abundance of successful examples, location is not approved by Dexcom or the FDA for anyone. (b) Tight-fitting, sleeved compression shirts are necessary for some activities, such as swimming, while wearing a sensor on the arm. Wetsuits with sleeves are sufficient to protect the sensor, even though they’re not always suitable or permitted for some sports, such as triathlons with warm water swims. I have tried swimming with stand-alone compression sleeves, but the problem is that they slide out of place, often putting pressure on the sensor. (c) For those with little body fat, this location may not be suitable or it may be difficult to find just the right spot. Placing sensor too low or too much on the side as opposed to back, of the arm may result in hitting a nerve and/or getting unreliable readings. Some expensive trial-and-error may occur if you get it wrong.
Turner72 