A New Low

There have been two evening concert band rehearsals this winter, from 6:30-9 p.m. These are intense monthly rehearsals during which the kids are playing challenging music non-stop.

The nights after both of these rehearsals have been multiple juice box affairs.

After 14 years of T1D, we have learned when to expect most lows.

Running, dancing, swimming, and miscalculating the number of carbs in a meal are the causes everyone knowledgeable about diabetes would expect. 

Slow but steady walking, staying up late even if it involves no physical activity, and being sick with a cold all also trigger lows for my kid.

Could playing a wind instrument for an extended period also lead to dropping blood sugar?

The first post- concert band rehearsal low seemed to come completely out of the blue. She hadn't been having any overnight lows at the time, and the rest of the day hadn't involved any unusual food or activity. The only variable I could come up with was the rehearsal. Could the physical exertion of playing her clarinet for that long combined with the mental energy to concentrate on and learn new and difficult music be what led to a 50-something blood sugar so slow to budge? Maybe, I guessed, but since one instance doesn't make a pattern, we chalked up to a mystery low and set the episode aside.

Until it happened again this week. Both times she was at a nice 90-ish number when she came home and had a snack. Then around 1 a.m., she tanked.

Despite using a variety of search terms, my research turned up only one mention of this phenomenon. It's master's thesis from 2006 by Derrick Alan Crow called 'The Effect of Instrumental Rehearsal on Blood Glucose Levels of Five Low Brass Players.'  The link will take you to a several-page preview of the study, which was all I was able to access. His participants, as far as I can tell, did not have diabetes. The blood sugar checks were before, during and immediately after rehearsals, not hours later. But his preliminary background research was interesting and, based on it, he posed some logical hypotheses. His results, while inconclusive mostly due to the small sample, did note some trends of lowering blood sugars during long rehearsals. His theory was that between the mental, aerobic (from breathing), and muscular energy expended by a wind instrument player during a lengthy rehearsal, blood sugar levels drop.

I'd love to see this study repeated in instrumentalists with diabetes. I'd love to see the research include investigating a delayed drop of the sort people with diabetes see with some other kinds of exercise. Clearly, I need to befriend a musical scholar. Or convince my kid to become one.

Meanwhile, we'll plan on covering fewer carbs on concert band nights, and/or setting a temporary basal rate. Or maybe next time this won't happen at all.

Marching Band

Our meeting a couple of weeks ago with the new school nurse also included the band director. Marching band is a serious endeavor in our district. There have been weekly 3 hour rehearsals since June. Band camp week in August consists of twelve hour days at the high school. Our fall weekends are spoken for.  There will be weeks when my daughter spends more time with the band and its staff than she does with us, her beloved (and diabetes-familiar) family.

She's the first kid with diabetes to be in the band, so this is new territory. Both the director and assistant director agreed to be glucagon trained, which is great.  More important to me, though, was to teach and then strategize so that they will never have to use that training.  So we talked about diabetes.  We talked about how steady exercise (like walking and presumably marching) can lead to low blood sugar. We talked about the importance of treating a low blood sugar as soon as it's noticed.  We talked about the importance of checking blood sugar obsessively on days of important events (like band competitions) so that my daughter can use every tool at hand to aim for a in-range number at show-time.  We talked about the importance of keeping diabetes supplies accessible at all times.

The last time we had to explain and discuss diabetes in this kind of detail was at our initial 504 plan meeting at the middle school . The goal of both meetings was, of course, to get the staff to agree to allow my daughter to do what she needed to do to take care of her diabetes.  The tactic we used both time was conversation and education.  More effective than making a list of demands, I think, is to talk about life with diabetes: what a low blood sugar feels like, how it's treated, how we use the tools we have at hand to prevent diabetes emergencies, how good my kid is at taking care of her diabetes with a minimum of disruption, and how much bigger a disruption it would be if an oncoming low turned into a medical emergency.  This information, presented with a healthy dose of 'we've been doing this forever, and we know what we're doing,' seems to slowly but effectively shuffle people's preconceptions about how things should be done and lead to building consensus on a mutually agreeable plan.

The conversation with the band director led to a game plan, to be fine-tuned as events start to unfold.  She will have her meter kit on the sidelines of all rehearsals.  While the director is strict about nobody leaving the lines for any reason during practice, my daughter has permission to slip away to check if the Dexcom alarms or she's feeling low. The band director will carry glucagon and a spare meter in the first aid bag which accompanies him onto the field. At performances she will check her blood sugar during the time just before they enter the field and then hand her kit to the director or a parent volunteer as they line up. The uniform jacket has a pocket in which she can keep a roll of glucose tabs to use in an on-field emergency. The lines of communication remain open and if we have any concerns, we'll bring them up. Ditto for the band director. We left feeling comfortable with the plan.

Next up, how wear the pump and dexcom with the uniform, how to survive a week of band camp in the August sun and how to balance the busy fall band season with the first semester of freshman year of high school...