2020: The End is Nigh

Hard to believe 2020 is almost over. This has been both the longest and fastest year of my life. Time has lost all meaning.

Its been incredibly isolating. We've really only seen the same 4 people since March, and I don't know when that's going to change. 

I'm so very restless —this is the longest I've gone in years without an objective, some climbing trip or exotic vacation. I've been distracting myself with online workout programs and increasing involvement with online diabetes communities. I've managed to establish something resembling a routine, with morning climbs twice a week and daily HIIT and strength training with a smattering of runs. But at the end of the day, I feel adrift. I lack the emotional energy to feel anything other than disgust with the selfishness of people who refuse to follow social distancing guidelines or wear masks. I am upset by the incendiary, hateful rhetoric coming from news media and politicians, but beyond sending emails to my elected officials, I just don't have it in me to act. 

We've been making it work. The internet is a wonderful thing, and Ev and I were able to video chat with our families on Christmas. We've celebrated the holidays with our small bubble, using it as an excuse to cook overly-large meals, make fancy desserts, and pretend that things are normal. We've gone out into the mountains to ski and bask in the glory that Alaska has to offer. 

On the plus side, I have more ab definition than I've had in years. I went through three exercise mats before getting one that withstands my new exercise regime (turns out, you do, in fact, get what you pay for with exercise mats). I've done a lot of baking. I've become even more of an anti-social homebody than I already was. Things aren't all bad.

But I miss normal.

I miss regular interaction with people at the office and going out to dinner at restaurants. 

I miss not having anxiety every time I go to the store.

I miss shooting the shit with people at the climbing gym and exchanging beta on a route.

I miss pre-pandemic life.

On the whole, I think people are trying to do what's right and listen to the science. The majority of Alaskans believe masks work and are wearing them. People are trying to to keep their distance, even if they slip up sometimes because we've spent lifetimes not worrying about being within 6 feet of someone. Nobody is perfect, but at least most of us are trying. 

So as 2020 draws to a close, I'm not going to write some optimistic, positive drivel about how things are going to be great. The goal this year has been to maintain and survive; the very fact that we've made it this far without a psychotic break is pretty awesome. 

But 2021 will not be magically better. We still have a pandemic to deal with, a dysfunctional government, social injustice, and economic uncertainty for millions of Americans. These problems were highlighted in the past year, in many cases as a result of the pandemic creating time for people to be more aware of the world around them and vocal about injustice and corruption. The mental fatigue from prolonged isolation and the inconsistently-managed global health crisis have highlighted long-standing failings in the American healthcare system. These issues were not new in 2020. 

In the next year, let's continue to be outraged. Speak out if and when you have the mental energy to do so. Be kind to others, because it costs you nothing and may mean the world to them. We are all on edge. Take care of yourself. Remember that it's okay to not be okay. Give yourself the same benefit of the doubt that you give others. 

The past year has been hard, but we persevered. 

I'm not setting a lofty New Years Resolution. My goal is to maintain, to keep doing what I'm doing and try to lead by example to the extent that I'm able. 

2020 has been hard.

2021 just needs to be better.

Growing Up and Raising Diabetic Children - A Retrospective

Being a parent is hard. I mean, duh, right? Shaping and guiding another person into semi-functional adulthood is a lot of responsibility. Now add in a chronic condition that requires multiple daily injections, carb counting, and keeping a schedule.

Sound extra tough?

Welcome to the childhood of a diabetic. Yet somehow, my parents (and many others) managed to pull it off, and my sisters and I are (mostly) functional and well-adjusted human beings. Looking back at that, however, I can only imagine the hell we put our parents through. So obviously, I decided to blog about it.

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It should surprise nobody that I was a stubborn, difficult child. My mom likes to say that I was born going "you can't make me," and honestly, I don't think I ever grew out of it.

Here's the thing: I have no memories of life before diabetes. I was diagnosed when I was 4, and growing up we carb counted everything. Juice came in 15g of carbs boxes and was only used to treat lows. Soda came in diet and was something we got when our blood sugars were high and we needed to flush ketones (apparently getting small children to drink lots of water wasn't a battle worth fighting). We ate 15 or 30g snacks at the same time every day. 

I remember refusing to take my injections when I was fairly young (somewhere between 4 and 8) and my parents had to chase me around the house and sit on me in order to administer them. Eventually, I grew out of it and became fiercely and belligerently self-sufficient, to the extent that I refused to let doctors or nurses prick my finger to check my blood, insisting instead on doing it myself. 

We had "diabetes drawers" in the school nurse's office where we kept our glucose meter and diabetes supplies, and would go down a couple times a day to check our blood. My folks had to strongly advocate for school nurses throughout our school years, to the extent that one nurse actually delayed retirement until my sister and I were through school. In middle school, we carried our supplies in a trapper keeper, and by the time high school hit, we just stuffed it in our lockers. But from day one, it was ingrained in us that if you feel weird or off, you check your blood. If you need to walk out of class to treat a low, then that's what you do and damn the consequences. 

In short, my parents managed to make managing diabetes a normal part of our lives, to the extent that I never second-guessed myself if I needed or wanted to go treat it.

I know now that my folks did a lot of priming the people we interacted with. All of our teachers and sports instructors somehow knew that we had diabetes and made a point of telling us that if we needed to do something for it, to just go do it. My karate instructor and high school rifle coach, in particular, made a point to empower me to self-manage my diabetes and not feel like I needed to ask for permission. To this day, that sense of responsibility, self-worth and entitlement to self-manage this disease has stayed with me. 

My parents taught us to use education as a tool when people tried to make us feel bad or different. I can't ever remember being ashamed of my diabetes, or feeling like I needed to hide or excuse it. I would (and still do) take injections in public, wear my insulin pump clipped to the outside of my jeans, and display my CGM shamelessly. After all, if I need stuff to stay alive, why on earth should I make excuses for it?

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I recognise that my experiences as a diabetic child were unusual as a result of Dad being a doctor. After my sister and I were diagnosed, he began to specialise in diabetes, which opened up a lot of doors and dramatically changed the course of my childhood. So I started asking other Type 1 Diabetics (T1D's) about their experiences growing up. Some people experienced multi-year burn out, were not afforded the accommodations needed to properly manage this disease in school (yes, that's illegal, and no, it doesn't always matter), and struggled with depression and feelings of isolation. Our experiences varied, but common threads remained.

Kenneth was diagnosed soon after his 13th birthday, a few days after the death of his biological father. Obviously, this was overwhelming, but even then he could tell that his mother and step-father were more scared than he was. His mother, like mine, felt incredibly guilty after the diagnosis, feeling that it was somehow her fault. That was difficult to get past because even though he knew her feelings were based on the incorrect idea that she could have prevented his T1D, it still felt like he was the cause of her guilt. Even if we know intellectually that nothing we or anyone around us did caused this disease, it's hard to not feel guilty all the same.

Where my parents were very involved and encouraged self-management, Kenneth's parents fell on the other end of the spectrum, and were mostly hands-off with his diabetes care. Besides some specific occasions like middle of the night tests, he did all of his own injections and testing. In his situation, diagnosed later in childhood, he feels that this hands-off approach was mostly the right one. However, it's still important to remember that the struggle to feel normal can lead to unhealthy behaviour.

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And things can get traumatic. 

I had hypos because I would refuse to eat after taking my insulin, which ultimately resulted in my parents only giving short-acting insulin after meals.

I flat out refused to use needles, so Mom found a god-awful contraption known as the Medi-Jector which used air to inject. I'm 100% sure it hurt more than a needle, but try telling that to a 6 year old.

I had multiple diabetic seizures caused by hypoglycaemia (extremely low blood sugars) and requiring glucagon injections to treat. In case you didn't know, glucagon can result in voracious vomiting and is pretty much a last resort. (I should note that over the years, I've self-administered glucagon on several occasions. You can take a half-dose of the injectable. It also now comes in a nasal delivery system, which is an all-or-nothing thing, but waaaay easier to administer. For starters, you don't have to do any mixing and messing around with needles in a high-stress situation.)

I refused to log my insulin, carbs, and blood sugar levels (still do, actually).

My mother vividly remembers when my little sister got diagnosed, almost a year to the day after I did. Apparently, when I found out, young diabetic me went, "I'm glad Paige is diabetic. Now I'm not alone."

As we got older, Kenneth and I would sneak food and candy, and then take an extra injection to hide it. We would hide our blood sugars to prevent people from hovering and watching our every move. When I got a pump, life got much easier because I didn't have to try to sneakily take a shot. I went to great lengths to remove anyone else from my diabetes management equation - in my mind, nobody else should be telling me what to do or how to do it.

Yet somehow, I never experienced diabetic burn-out. Going onto an insulin pump when I was 11 provided a degree of freedom that up to that point I'd lacked. I don't remember having crazy issues during puberty or in my teens with my blood sugar levels (but I was definitely an awful teenager to deal with). I navigated my first sexual encounter dodging pump tubing (if you can't laugh about the tubing, you don't deserve me, dammit). I got drunk for the first time knowing absolutely nothing about what alcohol does to your blood sugars, but somehow didn't die or have any hypos. I pulled all-nighters at LAN parties, drinking regular Mountain Dew and Pepsi (I refused to drink diet soda in high school as an act of diabetic rebellion. Yes, I really was that self-aware), I snuck out of the house to do stupid shit (I suspect my parents know, but refuse to ask), and, ultimately, I became an actual adult with a life of my own. 

In my household, and thus my universe, diabetes was just one more thing to account for. It was never an excuse to fail, or be cut extra slack, or get special treatment (although in hindsight, I got lots of special accommodations in order to self-manage my diabetes. It just didn't feel like anything special because I didn't get to exploit it). 

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Here's the thing: I was lucky. 

My parents bent over backwards to make sure that we a) didn't die, and b) were able to thrive. Arguments and disagreements about food and treatments were done in such a way that the kids weren't even aware of them - a fact that I'm sure helped us feel like our diabetes wasn't that big a deal. But as I began to talk to my parents about how they dealt with two young, diabetic children, they had some different recollections.

Despite my utter lack of memory involving juice in the house, apparently there was a bit of a show-down between my folks regarding my Dad's morning glass of orange juice. Mom insisted that they needed to lead by example, and if the kids couldn't drink juice just because, neither could they. To this day, juice is a low-treatment in my mind, rather than a tasty beverage for at-will consumption. And apparently, my father no longer even likes orange juice.

Growing up, we weren't allowed to be cranky until we checked our blood sugar. If we were low, we fixed it. But we didn't have the right to be cranky until we know. Recognising the effect diabetes can have on mood and including that the equation when dealing with kids is wild to think about, but in my house, it was normal. Even today, when we're visiting and someone is tired or cranky, the first question is "what's your blood sugar?"

My parents vividly remember the days of having to chase me around the house to give me my insulin injections. I thought it was traumatising for me, but my mother clearly has PTSD from it. 

So I asked my them what they wished they knew, and what advice they would offer other parents of diabetic children.

Advice from Parents of Diabetic Children

Diabetes doesn't care if you treat it or believe in it. It doesn't allow concession - you can't not deal with it; you have to find a way. 

Without question, having a child get diagnosed is the end of life as you know it. But the new life doesn't have to be any less rich or fulfilling, although it requires a big change in the parent-child relationship. Parenting is about boundaries and expectations, and diabetes adds additional ones. As a doctor, my dad knew about diabetes in theory, but learning to live with it was hard. 

Additionally, parents have an obligation to make sure their kid knows that diabetes isn't their fault. Regardless of age, it's not okay to make diabetes the kid's problem, because they need a support system. They have to understand that taking shots hurts, that finger pokes are unpleasant, and that you don't get to do whatever you want. They can't abdicate responsibility of management to the kid; you don't get to say "well, sorry you have this disease. It sucks." and move on. The job of a parent is to help and teach your child to self-manage and be effective.

Empower your diabetic child as much as you can. Give them control, teach them to self-manage, and then (the hard part), let them do so. My parents agree that the hardest part is taking a step back and letting your kid take the wheel. 

Encourage autonomy. Adults are responsible for their behaviour, and you want the kids to grow up and choose to make good choices, to be healthy and responsible. But be there through the different stages of their childhood and adolescence - the needs of kids change as they grow.

Bribery is great. Find out what motivates your kids and use it. My dad used to pay me $0.25 per day if I kept my blood sugars below 200 mg/dL (keeping in mind that this was before continuous glucose monitoring was a thing, so it was much easier to "stay below 200" for a day because post-meal spikes didn't get captured). 

Having diabetes in the house is a little like having someone with a restrictive diet - the easiest thing to do is remove temptation and have everyone eat the same things. To quote my mom, "why make it harder on people with dietary restrictions?" Control what you can where food is concerned - my parents never forbid anything (except frosting and regular sodas), but by god did we count carbs and try to eat protein with every meal. At Halloween, we would all go trick-or-treating and then sit in the living room and sort our candy. Mom would pull out a "gift box" that was stocked with random, non-food goodies, and we would bargain and horse-trade. At the end of the night, the kids would have a couple pieces of candy left, and Mom would have all the sugar she wanted for a month or two. Mom remembers feeling like they were swimming upstream when trying to establish a non-food-based reward system - you never realise how many traditional rewards are centred around food. 

And at the end of the day, recognise that sometimes the goal is to do the minimum needed to stay out of the hospital. And that's okay.

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Diabetes management today is wildly different than it was in the late 90s and early-2000s. Where our parents had to rely on finger sticks and log books, today they have CGM's to monitor blood sugar levels, and apps like MySugr to track carbs and dosing. The days of hiding a hypo are gone. 

As diabetics who managed to survive childhood, Kenneth and I have some advice to parents and diabetic kids alike:

Kids are tough. There's nothing wrong with checking in to make sure a low or high is being treated. If they're using a CGM and sharing those numbers over the internet, that can be easy, but it's important to understand that too much of a focus on the moment-to-moment aspects of diabetes can cause much more harm than any non-emergency diabetes situation ever could. Kids just want to be "normal", but we don't understand at that age that "normal" isn't really an attainable thing for anyone. 

To our parents, for everyone's sanity, don't obsess about high glucoses and what's "best," like perfect carb counting and post-meal monitoring. Instead, emphasise "good enough" habits that allow for a child to responsibly be irresponsible - it's better to lowball the carb count for some unknown food than to eat it and not bolus at all. Almost everything you're told to do by doctors is informed by their clinical understanding of what's best, not a personal understanding of what it feels like to live with diabetes. And almost everything can be done less than perfectly, if that's what it takes to stay engaged with self-care in the long term.

At the end of the day, don't let perfect be the enemy of good. You have to deal with this disease day in and day out, and even the best parent or doctor can't understand exactly what that's like or the number of minute decisions that get made every day. So do what you need to do for your mental health. If that means you let your control lapse for a week or a month because you're burned out, so be it. As long as you do the bare minimum (basal/long-acting insulin and bolusing for food), it's going to be okay.

Talking to Your Diabetic Spouse: a lesson in self-preservation and validation

Diabetes is dumb. We constantly have to manage it, even if it's background noise to the rest of our life. Carb counting, insulin dosing, predicting how our BGL will respond when you do X, Y or Z... the list goes on. And it can be incredibly overwhelming, to both the diabetic and those who get involved with us. Our BGL affects our moods and often mirrors the behaviour of a slightly belligerent drunk. But beyond the highs and lows, there's the mental fatigue that goes along with this disease. We'll get to that later.

The truth of the matter is there are very few situations where you can say something about diabetes management to a diabetic without getting your head ripped off. We love you, we know you're trying to help and have our best interests at heart. But when we're low/high, we are not always rational. 

With the help of that one dude brave enough to marry me, as well as random diabetics from the internet and real life, allow me to share some pointers on how to talk to the diabetic in your life. 

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"Sometimes shit needs to be said, and you just have to be willing to be a punching/stabbing bag and wait a couple days for an apology that might never come." - my husband

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The Lows

Low diabetics are cranky, often unreasonable assholes. The only "acceptable" thing to say to a hypo diabetic (according to us) is nothing. Fine, you can push food on us, pester us until the low has been treated, but after that... stfu. Just realise that nothing you say will be taken in the manner it was intended. 

Acceptable things to say (but you'll still get yelled at):

"You should eat some sugar." 

"Have you treated yourself?" 

(silence)

The Highs

When our sugars are high, we often feel like garbage (headaches, nauseous, etc). It can take time to feel normal after our sugars start to drop, and honestly, it's a horrible feeling when you've been high for a prolonged period of time. We feel icky, lethargic, and sick. 

Acceptable things to say: 

"Have you taken a correction?" (risky, this is pro-level diabetic spouse)

"Do you want me to go away?"

"Here's some water."

Other general stuff that should be said and may or may not result in getting yelled at, as evidenced by that one dude who puts up with my nonsense:

"I'm sorry you feel like crap. Let me know if you need anything." - my husband

"You haven't moved and I heard your CGM alarm... are you okay?" - also my husband

"Did you bring low food for our run?" - still my husband

"I'm going to go into the other room." - my husband when I'm low/high and being psycho. He's pretty smart.

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The Mental

I get a bit worked up about the lack of emphasis on the psychological side-effects of diabetes during diagnosis and routine visits. It's not uncommon for diabetics to experience some level of depression, and the pressure to keep your BGLs within a tight range and have a good a1c (basically a representation of your average BGL over 3 months) can result in burnout. It doesn't help that control is a moving target, and how your body responds to carbs and insulin changes as you age, have lifestyle changes, move to a different climate, get stressed... the list is never-ending. Hell, seasonal allergies affect my insulin resistance, and if that isn't the dumbest thing ever I don't know what is.

My point is, you can figure out what works and be good for years, and then suddenly and for no apparent reason it stops working. I've encountered this recently with coffee - I've never taken insulin for it (and I drink a lot of coffee), but over the last month or so my sugars have skyrocketed when I drink it, even if I'm still fasting. So, after 15 plus years of caffeine never being an issue, I now have to bolus for my coffee. And boy, does that feel wrong. 

When we're feeling overwhelmed and like nothing we do is working, it's all too easy to spiral into a vicious loop of self-loathing and fatigue. I've heard many diabetics express the desire to just say "fuck it" and not bother with trying to control their diabetes because it feels unattainable and pointless. There's even a name for this malcontent - diabetic distress, with symptoms including fatigue, depression, anxiety, and stress. 

This disease sucks. There's pressure to have numbers that may or may not be reasonable depending on the individual's lifestyle and where they're at. The focus on meeting a target number may work for some, but can also result in people obsessing and not living their lives because they're afraid of being out of range. I hear too many diabetics talk about how their medical provider emphasises their a1c and ignores their concerns about exercise or stress or insulin ratios. Numbers only tell part of the story, and it's exhausting trying to keep tight control when it feels like your world is burning down around you. 

And when you feel powerless to control your body and your disease, it's incredibly hard to care.

To my fellow diabetics who are struggling, please, please take this to heart:

It gets better. Maybe not today. Maybe not tomorrow. But it will get better. You don't have to have perfect blood sugars; our bodies kicked perfect to the curb and anyway, perfect is the enemy of good. It's okay to be high or low sometimes. It's okay to treat yourself to a donut or piece of cake or candy or whatever food or drink you're supposed to stay away from because this disease really messes with your diet and how we view food. It's okay to have off days. It's okay to feel overwhelmed. It's okay to talk to someone about your struggles, be it a shrink or a fellow diabetic or your loved ones. You are not alone.

To the brave souls who love us, please don't trivialise what we deal with every day. Don't brush aside the complaint about how our sugars are all over the place and it's frustrating as hell. The flippant "you'll get over it" is a painful thing to be on the receiving end of. If we trust you enough to vent about our disease, please realise how hard that can be and be supportive. Validate our feelings, because we often shove them down and ignore them, let them fester until we start sliding into frustration and anger and depression. 

Acceptable things to say:

"I'm sorry you're struggling. Let me know if there's anything I can do."

"It's okay if you're not perfect. You deserve to live your life."

"I have faith that you'll figure this out."

"I love you anyway." 

If you want a bit more reading about the psychological component of diabetes, here are some good articles:

blog about judgement and stigmas surrounding diabetics 

CDC discussion on diabetes and mental health

Mental Health America discussion on Diabetic Distress (this one is really good and I highly recommend it)

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Finally, I have collected some gems from people who think they know stuff about diabetes. It's hilarious after the fact and occasionally aggravating during. I hope you enjoy this taste of idiocy and unintentional humour. 

Unsolicited (and idiotic) advice told to real life diabetics:

"Eat a lot of broccoli and your diabetes will go away." - idiot talking to a type 1 diabetic

"You're diabetic, you can't eat sugar." - idiot talking to a diabetic treating a hypo

"If you live a healthier life, you wouldn't have diabetes." - jackass who apparently wants to get punched

"You can't be diabetic." - armchair expert

"Take a tablespoon of apple cider vinegar and honey every morning. That will cure you." - Type 2 diabetic teacher to a Type 1 student

"God can cure your diabetes." - science denier

"I heard cinnamon can cure diabetes." - internet dummies

"Stop taking insulin, it makes you sick." - someone who doesn't understand how the human body works

Black Lives Matter and De-Escalation

I generally try to keep this blog politically neutral. In practice, I'm pretty middle-of-the-road: fiscally more conservative, socially liberal. I firmly believe that everyone is entitled to their opinion and the overwhelming majority of the time, people with views opposing yours are not evil or ill-intentioned. Despite my admittedly abrasive-at-times personality, I've had many deep conversations with people who disagree with me about the "no no issues" (politics, abortion, gun rights, welfare programs, etc.). I like to understand where people are coming from, because it's rarely irrational. My mind can be changed. My opinions are not set in stone.

That said.

I cannot put into words how horrified and angry I am with the circumstances that created and the government response to the Black Lives Matter movement and protests over the killing of George Floyd. 

I refuse to believe that all police disagree with the BLM protests. I refuse to believe that the majority of police want to harm protesters. I refuse to believe that targeting protestors and journalists adheres to the interpretation of "protect and serve" by most police. It's much more likely that everyone is scared. Fear is a powerful thing. Someone gets nervous and overreacts, bumps the trigger, trips and pushes someone. It takes next to nothing for crowd mentality to take over and the situation to escalate. A small spark that sets off an inferno.

That said.

I'm sick of hearing people make apologies for the terrible behavior and reprehensible choices by those who are supposed to make us feel safe. I'm not going to argue that all police behave that way, because you and I both know that they don't. But as a country, there is a failure to provide law enforcement officers with tools to respond in a non-violent or non-aggressive manner. Sure, de-escalation tactics are taught at police academies, but in general, the majority of recruits only get around 8 hours of de-escalation training, compared to over 100 hours of firearms and tactical training. Most states don't require de-escalation training, or if they do, it's woefully inadequate (the average appears to be around 1 hour a year).

When police and other law enforcement officers react aggressively when they feel threatened or pressured, they are doing exactly what they've been trained to do.

This is, by definition, a systemic problem.

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An aside:

Malcom Gladwell's book "Talking to Strangers" is a riveting and disturbing look at why situations escalate. He neither accuses or apologises for the police involved in the altercations that lead to the death of unarmed people of color. Instead, he looks at the establishment and training that lead them to believe that aggressive responses are the solution. It's a great read, if a bit uncomfortable, and I highly recommend it.

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I am not trying to say that there are not malignant racists embedded in our justice system who use their position of authority to oppress minorities. I am not trying to excuse the law enforcement officers who find themselves in volatile, quickly evolving situations and chose to escalate or respond with disproportionate force. 

The trend of using disproportionate force on minorities because of a perceived threat is inexcusable and unacceptable.

Interesting (terrifying?) tidbit: There has been research (using numbers from 2014 and 2015) that indicates that police as a whole (not white police) are disproportionately likely to kill people of color. The issue is not one of white cop versus person of color, but rather cop versus person of color. The numbers are grim: approximately 12% of the US population is black, but they account for 28% of people killed by police. Latinos are also killed at a rate higher than would be expected using population demographics alone, and, unsurprisingly, whites are less likely to be killed by police. Even accounting for racial disparities of crime, blacks are more likely to experience use of force by police, on the order of 3.6 times more likely than whites. 

The argument that police patrol areas because they are low-income and thus hotbeds of crime, therefore systemic racism isn't actually what's going on, is bullshit. Ghettos and low-income neighborhoods are a relic of segregation and racist policies that prevented blacks from living in "desirable" areas and holding many jobs. This creates an at-risk group that in turn gets trapped by socio-economic circumstances that make breaking out difficult, if not all but impossible. 

Yeah. Shit's gotta change. 

Our armed forces manage to exercise restraint and control in combat zones and not kill the people they detain. They are expected to act as the world's police (which is a rant for another time) and pull it off time after time. They adhere to the rules of engagement (I am aware that the rules of engagement are extremely limiting and do not apply to domestic law enforcement. My point is, it's perfectly possible to be subjected to high-pressure and dangerous situations and not kill anyone as a knee-jerk reaction).

Why do our police not do the same? Why are we not giving our law enforcement officers the training and tools and empowering them to protect themselves by backing down? 

We spend our childhoods being taught that violence isn't the answer. And then we enter the real world, where entire portions of our population live in fear when they see someone who's job is supposed to be to make them feel safer. Countless people who are taught a script at a young age, actions to take to reduce their chances of being arrested and minimize the chance of escalation by police. 

That. Is. Bullshit.

There is something wrong with our law enforcement when the gut reaction of the citizens is fear.

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In many countries, police are viewed as an asset, a friendly face, someone who you can ask for and is there to help. Ev and I witnessed this firsthand living in the Netherlands, where the police are trained in (and very good at) de-escalation. Many of them don't even carry firearms.

My point is, I know things can be better.

The Black Lives Matter movement has so many reasons to exist, to be outraged, to demand change and reform. To try to downplay that is to trivialise the experiences of hundreds of thousands of Americans. 

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The protests have escalated, but I can't say I'm as appalled as I might be at the looting and rioting. The police response has been... less than ideal. For God's sake, some of them (bad apples, I can only hope) are targeting journalists. This is, in every possible sense, unacceptable.

Freedom of the press, as well as the freedom to assemble and protest, are enshrined in the US Constitution. Very, very explicitly (unusual in that document, to be honest). Assaulting peaceful protesters is unconstitutional. Trying to stifle or intimidate the press is unconstitutional (recall my rant about freedom of the press). 

I guess what I'm trying to say is, black lives matter. All lives matter, but it is wilfully ignorant to try to brush off the Black Lives Matter movement as an overreaction or baseless. This country needs institutional change and leadership from the top, not a petulant child incapable of empathy or compromise. Black Lives Matter is the result of systemic and well-documented injustice and disparity. They are not alarmists. They are not irrational. They are not exaggerating.

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So please, please make sure you're registered to vote. Most states will let you request an absentee ballot, which means you can vote early (which you should do, because there will likely be unprecedented absentee voting this election cycle a la Covid). Change is possible, and we should push for it from as many angles as possible: Protest. Vote. Write and call your representatives. Speak out when you see discrimination or racism. Be a positive influence in the world. 

Because right now, with the unrest and uncertainty and volatility, the one thing we can't afford to be is silent.

Virtual Races and Diabetes: Have I Mentioned that T1D is a Pain?

Way back in April, in a moment of... something... I succumbed to peer pressure (shocking, I know, and very out of character) and signed up for a virtual race with a couple friends. The Social Distance Run promised to be goofy enough to appeal to my tongue-in-cheek sensibilities and historic loathing of organised events. With the lure of dad jokes, a cool shirt, a medal, and the slightly terrifying prospect of an actual training plan, I agreed to run a half marathon.

At first glance of the training plan, I went "oh god, training plans. Barf." But since I'm not a quitter (most of the time), I sucked it up and mostly followed it. Two shorter runs, an intervals day (hills or track, but I hate tracks so only did hills), and a long run on the weekend. There was a strength and stability day in there, too, but after doing it twice and limping around like a cripple for a few days after, I decided to stick to the running and leave the "getting stronger" thing for other people.

Gotta say, I've fallen back in love with running. Daniel (of aforementioned peer pressure) did most of the long runs with me (at a socially appropriate distance, of course), which made for an awesome weekend tradition that I'm hoping to keep up after race day.

 

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I've been running for 10 years ish and was so goddamn sure that I had a handle on the diabetes and endurance running. I've talked in the past about my learning curve when I started running and how I'd managed to get things figured out. Welp, it turns out that when you haven't been doing long runs or high milage for a few years and are also, ya know, ageing, your body behaves differently. My diabetes didn't get the memo about behaving the way it did 6 years ago.

This virtual race thing coincided with my relatively new use of Tandem's Control IQ system. Initially, I was super pleased with Activity Mode. It impressed on shorter runs (2-3 miles) and hikes, and as long as I had minimal insulin on board and ate 15g of carbs before starting, it seemed promising and sustainable. When I wrote my review of Control IQ, I raved about it, noting that it was great for physical labor, hiking, and the runs I was doing at the time. 

Welp, fast forward two months and 150 miles and I need to amend my original review. It turns out, my 30-year-old body doesn't like to process sugars or carbs while exercising. Also, I get ultra-sensitive to insulin while running / doing aerobic exercise. Looking back, I always addressed this by carbo-loading and setting temporary basel rates, going into long runs with a high blood sugar, and no insulin corrections. Unfortunately, the Control IQ algorithm doesn't allow you to do this effectively, what with the auto-corrections to keep you in the target range and the inability to set temporary basal rates. 

As I followed my training plan (complete with the promised dad jokes) and upped my milage to 20-ish miles a week, I found myself constantly fighting hypos. I started messing around with my diet in an attempt to stave off the inevitable crash during long runs, joined a couple Facebook and reddit type 1 diabetic running groups, and trying different supplements and gels on the recommendations of other T1D runners. I even tried making my own gummies using UCAN powder (surprisingly easy), which seem to be pretty effective at postponing the BGL crash if I take them 45 minutes before a long run. Supplement with regular gummies and Huma gels, and I think I have the diet thing mostly sorted out. After much struggling and many hypos, I also stopped trying to make Control IQ work for runs farther than 3 miles and started turning it off so I could set a temporary basal rate. I'm definitely on a stats kick right now, tracking my BGL and carb intake throughout my runs.

A major problem for me is that, for some unknown reason (probably because it likes being contrary), my body does not seem to absorb sugars when I'm exercising. What this means in practice is that I start a run, begin trending low, treat with some fast-acting sugar, and nothing happens. I can take on 60g of sugar during a run and still maintain a gradual (or fast) downward trend until an hour or so after the run is over, at which point it all seems to absorb at once and I skyrocket back into normal range (sometimes I get high, but as long as I don't keep treating the low, I don't seem to rebound in an extreme fashion). Basically, my best outcome for a long run is to slow the decline enough that I'm finished before it gets dangerously low.

Have I mentioned how annoyed I am that my old method of "carb up, wait 30 min, then run" no longer works?

Further complicating matters is the fact that I've been having some pretty gnarly reactions to the Dexcom adhesive, making my CGM use a bit sporadic. I've been on the phone with Dexcom about this repeatedly, and they insist that nothing has changed in their adhesive or manufacturing. I call BS. The T1D running forums are full of people complaining about abruptly developing allergic reactions to the Dex adhesive and seeking ways to mitigate it. So far, I've tried Flonase and IV Prep to create a barrier (to no avail). This week I tried some Skin Tac barrier, but it's definitely not going to last the full 10 days; at this point, I'm hoping it stays on through my half marathon before the reaction bubbling under the adhesive rejects the CGM completely. The next attempt will be an actual adhesive barrier like Tegaderm, which I've been trying not to do because I have a history of reacting to similar products. I have photos of the reaction progression. They're not pretty. If you want to see them, I can show you, but let's spare unsuspecting eyes the trauma.

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Tomorrow is race day. I have a plan. The plan involves lots of complex carbs in the morning, a bunch of slow-release carbs during the run, and a beer at the end. Ev and I are aiming to meet Daniel around his halfway point (crazy guy's doing a marathon) and finish the run together at a brewery.

Let's be honest.... I'm really just in it for the beer.

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Update:

Half marathon on the books. And apparently, I finally got the diabetes part right (shocking, I know). Also, selfies while running (and dying) are super flattering.

The Quarantine Diaries

Day 45

0530 My internal clock is telling me I should get up. You’re late for the climbing gym. You want to skip traffic. You have a ton of work to do and it’s easier to get it done before everyone else shows up at the office. I shut that shit down, steal the blanket back from my husband, and fall back asleep.

0655 The first alarm goes. I just fell all the way back asleep. Hard pass.

0710 The second alarm goes off. This time I roll out of bed and limp my way to the kitchen. This is why I prep coffee the night before. Hit the “go” button and then the bathroom. Cold face wash gets my eyes open, and working the ankles gets them actually mobilizing for the day.

0715 Coffee time. Also a yogurt. But mostly coffee. A decade of exposure to my cheerful morning ways keeps the husband from talking to me and it’s fantastic. 10/10 would recommend.

0745 Actually awake and approaching functional. I consider putting on real pants, and opt for yoga pants (again). Jeans are a relic of the past, but I try not to wear actual pajama pants during the day. Relocate from the kitchen island to the dining room table, aka my work station. If I think about it at all, I get annoyed that I’ve given up my dining room table to work from home. We’ve been eating in the kitchen, standing up, and on the floor or couch the last two months. 3/10 would not recommend.

0750 Log in, check emails and missed Teams messages. Grumble about how stupid this is. Start working on whatever nonsense I had going the day before.

0830 The daily department check-in meeting is such an adventure. We’re all keeping busy, and while this call always starts on-topic, we wind up discussing home buying, yard work, and how reports from people who have “recovered” from Covid are incredibly terrifying. I compare Covid to polio insofar as just because you survive doesn’t mean it doesn’t fuck up your life long-term. Surprisingly, nobody disagrees with me. We all agree that discussing it in terms of mortality and recovery rates alone doesn’t capture the actual magnitude of the pandemic. We’ve been in this meeting for 45 minutes and off topic for 20. We should probably go do the things we actually get paid for.

1000 The husband wanders out of his “office” (aka the gear room, home of the climbing gear, camping equipment, and general happiness. I think he got the better office space in our arrangement. I wonder if I can convince him to trade work stations?). We go on a walk to the coffee stand down the street. It’s a nice excuse to stand up and move around for 5 minutes. Also coffee. I should really build a shrine to it.

1010 Triple shot americano in hand, it’s back to work. Time to zone in and do… oh god, why is the model acting like this? These numbers don’t make sense… the math isn’t that complicated… maybe I’ll do a hand calc just to compare. Wait, I’ve already done hand calcs. Okay, I guess I’ll update it to the specific modeling method. I swear I’ve been stuck in this loop for a week.

The model I’m working on looks like a penis. Has anyone else noticed this? How has nobody commented on how bloody phallic this geometry is. *snicker*

I think I know why the program is outputting different values. But I want someone to confirm. Tech support is lost and just sent me to an actual programmer. He’s lovely and looking in the back-end at equations and dependencies for me. I’m pretty sure I found a fairly important limitation (from a user-perspective) when constructing models, but I really want it confirmed. Have I mentioned I want confirmation of my hunch?

1300 How is it already afternoon? I should grab some food. Looks like leftovers. I’m down with that. Oh! Cookies! I like cookies.

1305 Back to the models. Maybe I’ll stop trying to figure out what’s going on and just use a simplified method. Less exact, more conservative, but at least I understand why it’s calculating things the way it is.

1400 The phone rings. Who even uses phones anymore? Isn’t that why we have Teams and email? There’s a metaphorical dumpster fire and they need me to design a retaining wall. “Do you have a couple hours to get on this?” Not really, but I suppose there isn’t anyone else, sooooooo…. “They need it designed by Wednesday. Have to get it submitted for permitting.” Alrighty then. I am a retaining wall ninja. I shall design this retaining wall using my extra-special Mathcad sheet. I went through it and updated it to highlight the user inputs, manual table updates, and check values a couple weeks ago. This will be a good test to see if I missed anything.

Ooooooh! How do other states have such well laid out design guides and standard drawings? This is making my life so much easier! I should get a Washington license and only work on jobs down there.

1600 It’s quitting time. Working through lunch is great. I love not working. I should probably finish this retaining wall design though…. It’s almost done. 5 more minutes.

1630 Time is a construct and I’m bad at managing it. Quitting time for real. Switch from the dining room office back to the kitchen island, open up the laptop, and dink around on the internet for a bit. Mmmmm internet. For some reason, I’m cranky. No reason to be, but I feel my mood deteriorating. I blame work and being stuck in the house.

1700 The husband is done with work. We discuss going for a run, but he needs half an hour to “decompress.” Fine. I can wait. The couch is calling.

1730 Run time. In a fit of stir-crazy, I signed up for a virtual race with a couple friends. It comes with a training plan. Being slightly compulsive, I’ve been trying to stick to it. I hate training plans, but I guess it keeps me motivated. I am now fully on edge and rapidly approaching stabby. According to the plan, it’s a 3 to 5 mile day. Fuck that noise, I want to sit on the couch and not wear pants and wallow in my crankiness.

Mile 1: This is stupid. I hate my job. I want to stab everyone.

Mile 2: I guess things are actually okay. I like being outside.

Mile 3: I suppose I also like my husband. I’m actually in pretty good shape these days… all this running around the neighborhood is good for my mileage.

Mile 4: Goddammit stupid diabetes. Blood sugar is tanking. The day is beautiful and I’m happy again, but also fuck everything cuz I’m low. I seriously need to reconsider my diet.

1900 Finally got the blood sugar level trending up. No idea what we’re doing for dinner. I hope that if I ignore it, the husband or sister will cook. We play a sad game of cooking chicken in this house. I often win.

2000 Consider showering but decide it’s too late and I don’t want to sleep on wet hair. This is a garbage excuse, since nobody sees me in this time of Covid. We turn on White Collar and zone out to the TV instead. Amazon Prime has surprisingly limited commercials. Also, Rachael Ray’s dog food commercial is making me homicidal. Nobody should be that perky. It plays every time there’s a break. Kill me now.

2200 Despite heckling from the couch, I call it a night and relocate to the bed. Not like I’m going to sleep or anything… I start off reading a couple chapters of “Sapiens” and then switch to a free trashy romance novel. Variety is the spice of life. Also, thinking keeps me up at night. I refer to romance novels as a “pallet cleanser”.  

2330 Unfortunately, the pallet cleanser is easy reading and I go through half the book before I feel tired. Did I read this much trash before social distancing? I should really go to sleep…

Extra Fancy Toys: Tandem t:slim X2 with Control IQ and Dexcom G6

After much excitement (and anticipation), Tandem rolled out their fancy new hybrid closed-loop insulin pump - CGM system, aka Control-IQ. Obviously, I was super excited to try it out and wasted no time in getting my hands on it. 

I figured I'd give it a month or two to put it through its paces before writing a review. It's worth noting that aside from some minor interface changes (which improved the intuitiveness of the system), my original review of the t:slim x2 still applies.

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Closed Loop Systems

I'd like to take a moment to point out that Tandem works with Dexcom, who has been working with other insulin pumps (notably Omnipod) to make closed-loop systems available on a multitude of systems. This is a huge step for making diabetes management systems more widely available for people with pumps still under warranty or who don't want to switch systems. The big push for an FDA-approved loop system that allows diabetics to create a closed-loop system on a variety of insulin pumps and CGMs is being spearheaded by Tidepool, who is working with a multitude of manufacturers, including Dexcom, Omnipod, and a couple unnamed pump manufacturers (who I'm sure includes Tandem) to create an iOS-available closed-loop app. A short but worthwhile discussion on this and potential ramifications can be found here.

Also, in case you missed it, the Control IQ software is interoperable, meaning it's compatible with hardware from other manufacturers. Additionally, the Control IQ algorithm was approved by the FDA, rather than a stand-alone device like the Medtronic 670G. 

Control IQ vs. Medtronic 670G

Unsurprisingly, there are already well-written and fairly comprehensive comparisons between the two closed-loop systems on the market. Personally, I like this one (it's a little outdated, but the comparison between Control IQ and the 670G is on point). Another good, detailed comparison between the two systems can be found here.

The Control IQ system works by automatically adjusting your basal rate (aka background insulin) up or down to keep your BGL within a fixed target range. The algorithm uses the rate of rise or fall and amount of active insulin to determine when and how much to adjust the basal rate. Where Control IQ differs from Medtronic's 670G hybrid closed-loop system is that Control IQ delivers automatic-corrections if your BGL is predicted to rise above 180 mg/dL to increase your time in-range (for the record, the next generation Medtronic system will also deliver automatic corrections). This helps reduce highs if you forget to bolus for food. It also has two activity modes that adjust the target BGL range and auto-corrections: sleep mode and exercise mode. I'll get into those in more detail in a bit, cuz I'm super impressed with exercise mode.

The other significant (and I would argue more important) difference between the 670G and Control IQ is that the Dexcom G6 does not require any external calibrations, whereas the Guardian CGM requires calibration twice a day. As always, I'm a huge fan of having as few things to enter as possible to help reduce data entry error.

In case you were wondering, Control IQ is considered more aggressive than the 670G and has a higher time-in-range for users. 

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Getting Started

Feel the excitement!

One of the big selling points of Tandem is that software updates can be downloaded directly to the pump, rather than requiring a hardware trade-out. If you recall, I knew Control IQ was in the works when I switched to the t:slim last year, and the easy upgrade was a huge selling point. Tandem cut a deal with the FDA that allows t:slim users to do online training on Control IQ (rather than the traditional in-person training) to unlock a code in order to download the upgrade.

The online training is a couple hours of mostly intuitive stuff, and a detailed breakdown of how the Control IQ algorithm works. Pretty painless overall. Like my transition to the t:slim from my Medtronic pump, the system is intuitive and user-friendly. I continue to be impressed with the interface and durability of the t:slim, as well as the effectiveness of Tandem's customer support team.

By the way, you should definitely WATCH THE TRAINING VIDEOS! My sister, apparently, did not (I guess when you switch to Tandem they don't have a mechanism to force you to do the training videos before using the pump), and as we were discussing how she liked the system, many of the things she brought up were addressed in the videos. So apparently, the videos are good. Watch 'em. Tandem also offers in-person training, which I hear is also good. But, being an anti-social engineer-type, I'm all about not talking to a human if at all possible.

As you may have gathered from the previous paragraph, I recently convinced my sister to switch to the t:slim from her Medtronic pump and closed-loop system. She's been on it for two weeks-ish. When asked, she had the following comments:

- The Dexcom app is amazing (I agree)

- She likes the size of the pump (again, I agree. The t:slim is tiny and amazing)

- She doesn't like that it has to be recharged and has concerns about battery life and not being able to just replace a AA or AAA battery (I had similar concerns when I switched over, but overall have been pretty impressed and not had any issues keeping the pump charged, even in the field or while off the grid)

- The setup was easy and user-friendly

- She dislikes that you can't change the active insulin duration (see my conclusions for a bit of discussion on this)

- The belt clip/pump case is dumb. Yet again, I agree with her. It's worth noting that after my original review, I stopped using the case all together and now just shove the pump into pockets and sports bras. It's small and light enough that this works just fine.

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A random aside
As a Tandem user, issues with the Dexcom CGM are now supposed to be handled through Tandem. If you call Dexcom with an issue, they'll run you through their system and then transfer you to Tandem, who will troubleshoot/replace the CGM for you. It's a bit different and I'm not sure why it's being handled that way now, but it seems to be fine. Although if you don't call Tandem directly, you spend a bunch more time working your way through the phone tree. Personally, I think this is stupid.

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Activity Mode (and why I love it)

Shocking disclosure: I'm not exactly the target demographic for a closed-loop CGM. My basal rates are good enough that I spend around 80% of time with my BGL in-range, and the spikes I do get are generally post-meal and exercise related. That said, the bane of every active diabetic's life is the struggle to control during- and post-exercise lows. Many of us pre-load carbs so that we go into exercise with an upward trend and use temporary basal rates to reduce during-exercise drops. It's not ideal, and research suggests that one of the reasons Type 1 diabetics struggle to lose weight is that we have to eat carbs (and thus calories) to prevent hypos during exercise, thus offsetting potential gains. Obviously, anything that allows me to use fewer carbs and exercise longer is a win in my book.

So. Activity mode. It comes in two flavours: sleep mode and exercise mode.

Sleep Mode
Sleep mode is intended to reduce nighttime hypos by turning off the auto-corrections and narrowing the target BGL range. You can set it so that sleep mode engages automatically at a certain time for different days of the week, which means there's one less thing to remember to do. I've found that sleep mode helps keep my BGL level while I sleep and I wake up around 110 mg/dL, which is pretty great. It also seems to help keep things more stable while I sleep if I've had a couple drinks (I have a long history of getting low during the night if I've been drinking). In short, sleep mode is 100% worth the cost of admission and it may be worth switching to Control IQ for sleep mode alone.

Exercise Mode
I admit to being skeptical about exercise mode when I went through the Control IQ training. Of all the features, I expected exercise mode to be lacking and didn't have high (read: any) expectations of it being effective. In fact, I had to talk myself into giving it a chance because there was no way in hell it was going to work. Boy, was I (happily) wrong.

Like sleep mode, exercise mode tightens up the target range when activated. That said, I highly recommend leaving it on for a bit after you finish exercising to help mitigate the post-exercise crash. Thus far, I've had great success with eating 15 grams of carbs before starting a run and leaving exercise mode on for 30 minutes after I finish. Once again, between the target range while in exercise mode and the auto-adjustments of the Control IQ algorithm, I highly recommend the pump for activity mode alone. It's worth keeping in mind that going into exercise with minimal insulin on board (IOB) helps keep your BGL level.

Exercise mode has noticeably reduced my hypos during exercise (circled in yellow). Yes, I'm totally showing off. But also, I really do love it.

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Conclusions

Things I love:

- Exercise mode is the bomb. F'reals. I love it and 100% recommend utilising it. As an active diabetic, I've been engaging it during cardio, like running or hiking, and strenuous activities (hauling pallets of sand comes to mind), but not while climbing, which doesn't seem to affect my BGL much.

- Sleep mode is also the bomb. My husband reports feeling less anxious about nighttime hypos since I switched over, too.

- The CGM reading is automatically filled in when you open the bolus screen (using Basel IQ you had to enter it manually).

- I have had a noticeable reduction in swings (both up and down) using Control IQ.

- I have an increased time in range and am loving it. That said, it's worth noting that it seems to take a few days (or more) for the algorithm to fine-tune itself for each personal profile (aka basal rates and ratios), so if you switch profiles, you'll see some variation in your BGL's before Control IQ starts being super effective. The only reason I noticed this is because I work night shift in the field and switched onto my "night shift" profile (which is literally my normal profile offset 12 hours).

- The size. I continue to love how small the t:slim x2 is (if you recall, it was one of the reasons I switched systems). I don't use a case and just shove it in pants pockets or a sports bra, which works shockingly well.

Things I don't love:

- Control IQ doesn't take into account the carbs on board in the bolus calcs. What this means in practice is if your BGL is below target and you treat with carbs, the pump recommends a reduced bolus. If you eat something else after treating the low, Control IQ will continue to recommend a reduced bolus, even though that is functionally double-correcting. The workaround is, obviously, to override the recommended bolus if you eat after treating a hypo. It would be nice if the Control IQ algorithm actually accounted for carbs on board as well as IOB (I should note that the Loop systems, aka hacks, do account for carbs on board).

- I've been having ongoing issues with losing connectivity with my Dexcom. It's weird (and annoying), since this issue only started when I started using Control IQ (wasn't an issue with Basal IQ). A quick internet search shows that I'm not the only person having connectivity issues with the Dex using Control IQ. In addition, I keep having issues with my CGM requiring manual calibrations upon startup, even though I have the code. I've talked with both Dexcom and Tandem about this, and once we get past the "it only asks for calibrations if it needs them" speech and I get them to understand that the CGM is requiring calibrations every 24 hours (barf), they've been... well, sorta helpful. It's annoying as shit and makes me kinda cranky with Dex. If we're being honest, the batch of sensors I've been having issues with may (read: definitely) have had some exposure to extreme cold that I'm starting to suspect messed with both the adhesive and the internal workings.

- You can't change the active insulin duration. When you're using Control IQ, it's set to 5 hours. For many of us, this is too long. I had to counter-act this by changing my food to insulin ratio and my correction ratio, resulting in a net increase in insulin usage. After talking with my sister, she had the same comment and also adjusted her ratios to compensate.

- Occasionally the screen turns off while you're mid-bolus. This doesn't interrupt the bolus, but you do have to unlock the screen again. After talking to a couple other t:slim users, this seems to be something we've all experienced. It's not particularly disruptive, but it is kinda annoying and enough to warrant a minor bitch-fest during the discussion.

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Final Thoughts

I continue to love Tandem and their customer support team, and Control IQ is just another reason to be happy. I've found it works well (and as advertised) and is user-friendly with an improved interface. While there are a couple features that I wish were different (notably the insulin duration), there are work-arounds (changing food and correction ratios), but they result in an overall increased insulin usage.

The one feature of Control IQ that I was sure would be garbage turns out to be my absolute favourite. Activity mode is a powerful tool that should be utilised by all users. Sleep mode is an excellent way to help prevent nighttime hypos, and exercise mode actually works exercise mode has a place (see update below for revised conclusions). Honestly, it's almost worth switching to Control IQ for no other reason than to utilise activity mode.

Unfortunately, the Dexcom is the weak link in the system. I'm not sure where the issue originates, but I suspect it's something with the pump, since connectivity issues don't seem to extend to the phone app. I've been having some non-pump related issues with the Dex as well, which hopefully will get resolved. That said, the issues with the Dex are not significant enough to keep me from recommending Control IQ.

tl;dr
Control IQ is awesome and you should use it.

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Update (5/30/20)

I've revised my opinions on the effectiveness of Activity Mode as far as endurance activities (long, hard hikes and runs). Two months and 150 miles in, and I am less enamoured with it. It turns out, my 30-year-old body doesn't like to process sugars or carbs while exercising. Also, I get ultra-sensitive to insulin while running / doing aerobic exercise. Looking back, I've addressed this by carbo-loading and setting temp basel rates, going into long runs with a high blood sugar and no insulin corrections. Unfortunately, the Control IQ algorithm doesn't allow you to do this effectively, what with the auto-corrections to keep you in the target range and the inability to set temporary basal rates.

As I've upped my milage to 20-ish miles a week, I found myself constantly fighting hypos. I started messing around with my diet in an attempt to stave off the inevitable crash during long runs, joined a couple Facebook and reddit type 1 diabetic running groups, and trying different supplements and gels on the recommendations of other T1D runners. After much struggling and many hypos, I also stopped trying to make Control IQ work for runs farther than 3 miles and started turning it off so I could set a temporary basal rate.

So basically, Activity Mode works well until I'm doing prolonged aerobic activities, at which point I have better luck going manual (you do not get the auto-suspend when your CGM is trending low this way, fyi).

Regarding the Dexcom

I don't care what the official line is from Dexcom, something in their adhesive has changed that I (and many other T1D's on the internet) am super allergic to it. I'm officially doing the "sandwich" method, consisting of Flonase, tegaderm, insert sensor on top of tegaderm, then put a grifgrip patch on top. It's a lot of tape, but at least I don't get nasty, puss-y bubbles and rashes this way. Also, inserting the cgm through a barrier is not recommended (by Dex).

The customer service folks I've talked to at Dex (who are awesome, btw) have mentioned they've been receiving a really high volume of calls regarding reactions to the adhesive. Despite the fact that they insist nothing in their adhesive or manufacturing has changed, the evidence does not support that claim. It only takes a quick perusal of T1D forums to discover a surge in complaints about adhesive reactions starting around January.