Saturday, November 26, 2016

Grazing at holiday parties: How to safely manage blood sugars this holiday season.


Not much is worse for blood sugars than grazing. Whether its eating Pringles on the couch all Saturday long watching football or the new seasons of Gilmore Girls on Netflix with your fiancé or grazing at holiday parties, its all difficult to manage. Diabetes educators and dietitians will tell you how to avoid this: count your chips or crackers and put them in a bowl, measure the hummus, bla bla bla….

Yes! That's exactly what you should do! For diabetes! For health! For weight! But... we don't. Especially at parties. I don't know what you are into but I don't go to parties to count carbs, I go to mindlessly eat carbs!—and socialize of course.

[Disclaimer, these content of this article should not be interpreted as medical advice. Consult with your healthcare provider before making significant changes to your diabetes management routine.]

There are three results to grazing at parties: Under-estimation of carbs consumed, over-estimation and right on target.
-Being on target… Lets just call that luck.
-Under-estimation results in sustained highs, often overnight paired with multiple overnight bathroom visits. 
-Over-estimation is dangerous. Often I find myself on-target or a little high during the party/grazing period, and then, just as I'm about to go to bed, my blood sugar begins to drop, like a rock. Or, even worse, the drop can happen after I'm already sleeping. 

That happened once. I woke up to my fiancé, friends and EMS standing over me. I regret to inform you that this is on the top of my "most embarrassing moments" list. It had a debilitating effect on my fiancé for months. But most importantly, seizures can jeopardize mental and cardiac health.

I never want that to happen again. And I never want that to happen to you. So I have some easy options that will keep you free of dangerous lows and out of the bathroom peeing out annoying nighttime highs.

I give you the four step plan managing blood sugars at parties:

Step One is programming a temporary basal rate (if you use an insulin pump). Assess the situation before you even start. If you are walking into a party where you see lots of delicious fatty food and will be sitting, this is what you need. I choose a basal rate of 150-200% that will end at least 2 hours before you plan to leave the party.

Side note: If I am hosting the party, I will actually decrease my basal rate. Hosting not only requires the physical exertion between cleaning, cooking and prepping it also requires a drastic amount of mental energy through stressing, planning and managing multiple conversations at once. Remember: pound for pound, the brain is the largest pound for pound consumer of glucose.

Steps 2 and 3 are more of a rule: NO MORE THAN TWO BOLUSES AT A PARTY. Why?: 
  1. Less decisions to make. - Bolusing is decision making. The more decisions you make in the day, the more likely you are two screw one up. Thats why the president doesn't pick his own tie in the morning.
  2. Fully engaged bolusing. - While you are deep in conversation with a scotch in one hand and that pile of cookies within arms reach, it's tempting to do a no-look bolus a.k.a. Russian roulette. Don't do it. Follow the two bolus rule.
  3. Avoids stacking insulin. - This is what will make your blood sugar bottom out right after your fall asleep. 

Step Four, analyze your night and make any corrections needed before bed and set an alarm for the middle of the night. 
Ask yourself the following questions: Whats your current blood sugar? how much insulin did you take tonight? How much insulin is still active? How physically active were you tonight? If you consumed alcohol, how much?  If you wear a CGM, which direction is your glucose trading?

The main idea is to limit the decisions you need to make about diabetes while socializing. Better decisions will be made when they have your full attention. 


Do you have a game plan with proven results for social gatherings? Please share below to contribute to the discussion.  

Friday, August 12, 2016

My Triathlon

I was a guest blogger for Integrated Diabetes. In my article I talk about the Do's and Don'ts (both from experience) on long distances racing with diabetes. To access the article click on the CGM report!

Sunday, January 12, 2014

Risk Factors of Repeated Hyperglycemia: Cardiovascular Complications


Typically physical activity is associated with hypOglycemia (low blood sugars) in a population with diabetes, but hypERglycemia (high blood sugars) should be an equal concern to an athlete with diabetes. For example, an athlete that hopes to be competitive in their sport, in-target blood sugars are vital to allow for adequate recovery after any training period. All that hard work is put to waste without giving your body the proper conditions to adapt and recover.  For both the competitive athlete and the weekend warrior, there are health concerns beyond athletic performance associated with hyperglycemic blood sugars.  Although athletic activity is a good tool in avoiding complications to diabetes, it will not shield you from them.  Good blood sugar control is the first and foremost concern.  Today’s blog is very education heavy about the cardiovascular of complications associated with hyperglycemia.  

HYPERGLYCEMIA is defined as a blood sugar above 200 mg/dL. This could be caused by a hormonal surge (stress response, high intensity activity, or dawn phenomenon), not enough insulin, insulin not given in a timely manner before a meal, the body's inability to properly use insulin. or illness.  What does it feel like? 
*these signs may be blunted if you are currently under poor control.
Hyperglycemia causes serious long-term problems, starting at a microvascular level. This complications present themselves through nerve damage, blindness, kidney disease and other problems.

Hyperglycemia also accelerates the development of atherosclerosis, which narrows the arteries and increases the risk of a heart attack or stroke.
According to the ADA, heart disease is the leading cause of diabetes-related deaths. People with diabetes are three to five times more likely to die of heart disease than those without diabetes. Two-thirds of people with diabetes surveyed failed to link their increased risk of cardiovascular disease to their diabetes!

The Epidemiology of Diabetes Intervention and Complications Study found that those patients who had received intensive treatment in the DCCT were 42% less likely to experience any cardiovascular disease event, and 57% less likely to experience nonfatal myocardial infarction, stroke, or death for cardiovascular disease.


The Scientific Side:

High blood sugars lead to high blood pressure. With all that extra sugar in the blood, it starts to get sticky like molasses. The heart will have to work much harder to push the molasses-like blood through blood vessels. Imagine how hard it would be to push molasses through a straw! This creates a higher blood pressure making the heart fatigue, and eventually enlarge, leading to further dysfunction.
High blood sugars increase LDLs- bad cholesterol. When blood sugar is high LDL cholesterol and the receptors in the liver that are responsible for removing LDL cholesterol become coated with sugar (glycosylated).  This inhibits the body from removing LDLs.  Even a well maintained diet, low in saturated fat will not help lower cholesterol unless blood glucose levels are consistently within target range.

What to do:

So hopefully you are aware of why it is important to avoid hyperglycemia. The question is how? Below are a few vital steps. Keep coming back to this blog for tips on how to achieve good blood sugar control.


  • ·      Bolus for meals 5-10 minutes before eating
  • ·      Avoid rebound highs from hypoglycemia: 15/15 rule (will explain next week)
  • ·      Check blood sugars frequently and ask physician if continuous glucose monitoring will benefit you

Wednesday, September 18, 2013

Prescription: Healthy Fruits and Veggies

Upon hearing this story on NPR this morning, I could not resist to post and share it everywhere possible.  Regular intake of WHOLE fruits and vegetables (not juice) will make diabetes control easier to achieve. But more on that later, read and listen to this story.

Monday, September 9, 2013

Hiking with Diabetes

September is here and fall weather is upon us.  Here in Washington DC, that means the humidity has lifted!  (I hope.) Fall is a great time for walks and weekend hikes. They are enjoyable, relaxing and healthy, but especially for the most seasoned athlete with diabetes, hiking can be a sneaky culprit to blood sugar control.  Its time to put the ego aside and accept even the most leisurely hike will in-fact effect your blood sugar management.  Some of you egomaniac ironman triathletes might be rolling your eyes—I used to be one of you.  Then I got sick of my dad—type 1 patient, 50 years old, sits behind a desk all day (“twirling in his chair” my brothers joke)—waiting on me, the young buck, the “athlete” in the family, recovering from a low blood sugar in the middle of a leisurely family hike.

A hike probably includes more hills than you realize and use the large muscle groups directly affecting your blood sugar. How? I thought you would never ask!

Today’s science lesson:
When you were diagnosed with diabetes, your doctor or educator taught you that insulin, the “key,” binds with a “lock” (the tyrosine kinase receptor) on the membrane of a cell unlocking he “door” (GLUT4) that allows glucose to enter the cell.  When muscles cells are in use, their affinity for accepting glucose drastically increases. That means less insulin or more glucose is needed to sustain a level blood sugar level. 



What to do:
If this is a spontaneous hike or you are on medication or long acting insulin, bring extra glucose with you.  I typically bring 3 packets of fruit snacks each containing 20g of carb with me.  If I have recently eaten and have active short acting insulin on board, I eat 15 grams of fast acting carb 10 minutes into the walk. This helps me avoid a low blood sugar.
If this hike is planned hike and you have an insulin pump, decrease your basal rate 45 minutes before the hike.  The basal rate should be decreased between 10-20% for a leisurely hike, and more than 50% for a strenuous hike such as a backpacking trip through the mountains.  These values are guidelines, not absolutes.  Every one’s body is different, and your own body is divergent of past performance.  It is important to check your blood sugar whenever there is doubt to where your levels are heading.

There is some great information regarding advanced level hiking and backpacking on the web.  The links below have been helpful for my adventures.






Sunday, September 1, 2013

Avoiding Low Overnight Blood Sugars

What do you fear most about your diabetes? What literally keeps me up at night is the possibility of having a low blood sugar while asleep.  One night in high school, after an intense week of football, I woke up to a low blood sugar.  It was a long, hard fought week; I was resting after a close game against our rival program.  I was exhausted.  I must have been low for a while because upon awakening , I was very shaky.  I began to treat it as usual with  glass of orange juice, wait 15 minutes, and assess.  My blood sugar began to rise, but I was still shaky.    In the blink of an eye, I was in a hypoglycemic seizure.  Luckily my parents were awake and present to treat me with injectable glucagon, eventually raising my blood sugar level and ending my seizure.

What had happened that night? My blood sugar had clearly begun to rise, responding to my orange juice intervention, but then it quickly dropped again.

Today’s science lesson:  Your muscle cells store its own glucose for fuel. When you work out for an extended period of time without supplying them with constant fuel, the glucose stores are depleted.  Exercising on a consistent basis, your liver’s glucose reserves begin to run low as well.  After a long hard week of football, my reserves were depleted.  No matter the activity: hiking, swimming, football, etc,  between 2-48 hours after a workout, your muscles will try to replenish its glycogen stores, soaking up all the glucose they need from your circulating  blood . 

That’s crazy! How are you supposed to anticipate that?!

In an individual that produces their own insulin, their pancreas will temporarily shut down insulin production, allowing the liver to release it’s glycogen stores and keep your blood glucose levels at a level in which your brain can happily function at (no seizures).  A person with insulin dependent diabetes does not have the luxury of knowing when the replenishment will occur.

Another factor to consider depends on your normal activity level.  If you recently became more active, you are more prone to having such events even after only one day of physical activity.

What can you do as an athlete with diabetes to avoid this?
The unfortunate  truth is that there is no way to know when your muscles are going to decide to replenish its glycogen stores.   You can, however, develop a safety strategy. I have implemented the 20/20 rule:  20 grams of carbohydrate for every 20 minutes of exercise.  This will keep the glycogen in our muscle cells, a decrease the risk of the replenishing event that can get you in trouble as a person with type 1 diabetes.  A recovery meal consisting of the correct ratio of carbohydrates, protein and fat within 20 minutes of ending your exercise will help raise your glycogen levels in your muscle cells.  I also encourage you to check your sugar levels often when starting a new fitness regiment. This will help you learn how your body reacts to fitness, heightening your potential of performance.


No matter how careful we are the body can sometimes be unpredictable.  There are more lessons to present on avoiding such a situation and the safety steps you should always have in place for yourself/your child/spouse/roommate.

Please share stories of diabetes issues you have had and if you have found solutions in comments!