Exercise Training and Insulin

Jim Dumas said:

Just to say that I've settled into a summer bicycling
routine in the hot Florida sun. I exercise in the morning
for an hour then dose ultralente after I've cooled down. I
have NPH waning from a bedtime dose during the training
period. This usually keeps BG flat during training. But
I've measured low BG after the training period when I took
more bedtime NPH to move triglycerides into fat cells
after a high fat dinner. So I have to be careful with the
NPH bumper if I plan to exercise the next day.

The rationale for dosing ultralente after the training is
to prevent rapid absorption at the injection site during
training. It's important to note that all insulin is
absorbed faster during an endurance workout. This is
caused by increased temperature and blood flow at the
injection site during training. These effects will be
minimized when exercising before breakfast.

I also bump an insulin sensitivity multiplier by 1/3 for
24 hours post exercise period. This lowers insulin
requirements for the current day.

I have a heart rate monitor on the road racer as well. The
target range I've set is 130-160 Beats per minute (50 yo
male so max is 220-50=170 BPM). A bar graph shows me where
I'm at in real-time so I can optimize the training
effects. I plan to eventually calculate calories burned
per hour and use this to estimate the drop in insulin
requirements for the next 24 hours.

In any case, I'd be interested to know if anybody has used
the level of stress in a workout to modify insulin dosing
requirements. I'm currently thinking of using miles
travelled, time duration, elevation climbed (sum of upward
movement in feet) and average BPM. All this info is in the
bicycle computer and is downloaded to the PC (Specialized
PeaBrain computer on the bike). As an example, let's say I
use distance travelled and average heart rate to estimate
increased insulin sensitivity. This would give:

S is proportional to D*(H - 72 BPM)

where S is insulin sensitivity, D is distance and H is
average heart rate.

So I think I could use the total distance times the
average heart rate as a proxy for the stress level of the
workout. Then set up some curve fit for this data. As I
get stronger, my heart rate will lower and my insulin
sensitivity will lower as well. If the workout is light,
the heart rate will be low and insulin sensitivity will be
low as well. If my average heart rate falls below a
baseline of 72 BPM, then the workout is trivial and there
is no increase in insulin sensitivity. This baseline will
lower with training as well.

Any ideas or suggestions?

I think yer trying to measure insulin/glucose utilization to
a level of accuracy that is impossible with the human body
and the Florida weather.

But it's an interesting exercise.

I hope it works for you. I've found that in my case insulin
sensitivity is affected by exercise at a variety of time
scales (hours, days, weeks) and is noticeably nonlinear.
Sensitivity increases that express as required basal rate
changes seem to occur as threshold or step function events
rather than smooth proportional changes. This was one of the
major reasons I went to the pump with which basal
alterations are fully functional in order 4 hours rather
than order 24 or 48. My exercise is variable and given the
various lag times I alter dosages fairly often.

There is a converter from % heart rate to % VO2 max at
brianmac.demon.co.ukmaxhr.htmOpen ↗

I would imagine everyone doing any kind of serious exercise
factors the intensity level and length into their short term
bg management strategy be it insulin modification, carb
increase, or a combination.

In addition to any increase in insulin absorption with
exercise, non insulin mediated glucose transport pathways
are opened up with exercise. These and total insulin storage
within the cell are affected by fitness levels and throw
another non linear effect into the equation.

Charly Coughran ccoughran@UCSD-DELETE-TO-RESPOND-EDU

Jim Dumas <[email protected]!mindspring.com> wrote in
:"]news:[email hidden]:

Quoted message said:

Just to say that I've settled into a summer bicycling
routine in the hot Florida sun. I exercise in the morning
for an hour then dose ultralente after I've cooled down. I
have NPH waning from a bedtime dose during the training
period. This usually keeps BG flat during training. But
I've measured low BG after the training period when I took
more bedtime NPH to move triglycerides into fat cells
after a high fat dinner. So I have to be careful with the
NPH bumper if I plan to exercise the next day.

The rationale for dosing ultralente after the training is
to prevent rapid absorption at the injection site during
training. It's important to note that all insulin is
absorbed faster during an endurance workout. This is
caused by increased temperature and blood flow at the
injection site during training. These effects will be
minimized when exercising before breakfast.

I also bump an insulin sensitivity multiplier by 1/3 for
24 hours post exercise period. This lowers insulin
requirements for the current day.

I have a heart rate monitor on the road racer as well. The
target range I've set is 130-160 Beats per minute (50 yo
male so max is 220-50=170 BPM). A bar graph shows me where
I'm at in real-time so I can optimize the training
effects. I plan to eventually calculate calories burned
per hour and use this to estimate the drop in insulin
requirements for the next 24 hours.

In any case, I'd be interested to know if anybody has used
the level of stress in a workout to modify insulin dosing
requirements. I'm currently thinking of using miles
travelled, time duration, elevation climbed (sum of upward
movement in feet) and average BPM. All this info is in the
bicycle computer and is downloaded to the PC (Specialized
PeaBrain computer on the bike). As an example, let's say I
use distance travelled and average heart rate to estimate
increased insulin sensitivity. This would give:

S is proportional to D*(H - 72 BPM)

where S is insulin sensitivity, D is distance and H is
average heart rate.

So I think I could use the total distance times the
average heart rate as a proxy for the stress level of the
workout. Then set up some curve fit for this data. As I
get stronger, my heart rate will lower and my insulin
sensitivity will lower as well. If the workout is light,
the heart rate will be low and insulin sensitivity will be
low as well. If my average heart rate falls below a
baseline of 72 BPM, then the workout is trivial and there
is no increase in insulin sensitivity. This baseline will
lower with training as well.

Any ideas or suggestions?

yeah. get an insulin pump.

dave

Jim Dumas wrote: snip

Quoted message said:

Any ideas or suggestions?

"Jim Dumas" <[email protected]!mindspring.com> wrote in message
"]news:[email hidden]...

Quoted message said:

Just to say that I've settled into a summer bicycling
routine in the hot Florida sun. I exercise in the morning
for an hour then dose ultralente after I've cooled down. I
have NPH waning from a bedtime dose during the training
period. This usually keeps BG flat during training. But
I've measured low BG after the training period when I took
more bedtime NPH to move triglycerides into fat cells
after a high fat dinner. So I have to

be

Quoted message said:

careful with the NPH bumper if I plan to exercise the
next day.

The rationale for dosing ultralente after the training is
to prevent rapid absorption at the injection site during
training. It's important to note that all insulin is
absorbed faster during an endurance workout. This is
caused by increased temperature and blood flow at the
injection site

during

Quoted message said:

training. These effects will be minimized when exercising
before breakfast.

I also bump an insulin sensitivity multiplier by 1/3 for
24 hours post exercise period. This lowers insulin
requirements for the current day.

I have a heart rate monitor on the road racer as well. The
target range I've set is 130-160 Beats per minute (50 yo
male so max is 220-50=170

BPM).

Quoted message said:

A bar graph shows me where I'm at in real-time so I can
optimize the training effects. I plan to eventually
calculate calories burned per hour and use this to
estimate the drop in insulin requirements for the next
24 hours.

In any case, I'd be interested to know if anybody has used
the level of stress in a workout to modify insulin dosing
requirements. I'm currently thinking of using miles
travelled, time duration, elevation climbed (sum

of

Quoted message said:

upward movement in feet) and average BPM. All this info is
in the bicycle computer and is downloaded to the PC
(Specialized PeaBrain computer on the bike). As an
example, let's say I use distance travelled and average

heart

Quoted message said:

rate to estimate increased insulin sensitivity. This
would give:

S is proportional to D*(H - 72 BPM)

where S is insulin sensitivity, D is distance and H is
average heart rate.

So I think I could use the total distance times the
average heart rate as

a

Quoted message said:

proxy for the stress level of the workout. Then set up
some curve fit for this data. As I get stronger, my heart
rate will lower and my insulin sensitivity will lower as
well. If the workout is light, the heart rate will be low
and insulin sensitivity will be low as well. If my
average heart rate falls below a baseline of 72 BPM, then
the workout is trivial and there is no increase in
insulin sensitivity. This baseline will lower with
training as well.

Any ideas or suggestions?

Just the one Jim. Get real man!!!! Do your bike riding and
ENJOY it rather than turn it into an exercise in maths,
logic, extrapolation and guesswork.

(Sorry Jim, but sometimes you REALLY overcomplicate thing to
the extreme.)

Beav

Interesting. I think one problem you will continually
encounter is your digestive system. That's a variable that
is impossible to control despite your best efforts.
Absortion continues to occurr down through your
intestines, such that a meal you ate yesterday may still
be obsorbing and releasing glucose into your body. Also,
your activity level on a particular occasion may be
similar but never the same. Metabolism isn't that
predicatable and is influenced by many things such as
temperature and stress level. Don't forget as well the
activity of the liver in releasing glucose.

I have tried all the insulins, and recommend that for best
overall result, use Lantus or a pump.

The absorbtion rates of long-acting insulins such as NPH,
Lente, etc., are also variable and dependent on many factors
such as the injection site, scar tissue, amount of fat in
the injection location, body temperature, and activitity
level. This unpredicability has led to the popularity of
pumps and Lantus insulin, which has a more predictable
release curve.

In short, you're trying to solve a problem with too many
variables which change due to factors you cann never control
with the accuracy you're striving for. The math and
equatations are interesting but ultimately probably a waste
of time, given the inherent uncontrollable variables. You're
efforts at control are nonetheless admirable.

"Jim Dumas" <[email protected]!mindspring.com> wrote in
message
"]news:[email hidden]...

Quoted message said:

Just to say that I've settled into a summer bicycling
routine in the hot Florida sun. I exercise in the morning
for an hour then dose ultralente after I've cooled down. I
have NPH waning from a bedtime dose during the training
period. This usually keeps BG flat during training. But
I've measured low BG after the training period when I took
more bedtime NPH to move triglycerides into fat cells
after a high fat dinner. So I have to

be

Quoted message said:

careful with the NPH bumper if I plan to exercise the
next day.

The rationale for dosing ultralente after the training is
to prevent rapid absorption at the injection site during
training. It's important to note that all insulin is
absorbed faster during an endurance workout. This is
caused by increased temperature and blood flow at the
injection site

during

Quoted message said:

training. These effects will be minimized when exercising
before breakfast.

I also bump an insulin sensitivity multiplier by 1/3 for
24 hours post exercise period. This lowers insulin
requirements for the current day.

I have a heart rate monitor on the road racer as well. The
target range I've set is 130-160 Beats per minute (50 yo
male so max is 220-50=170

BPM).

Quoted message said:

A bar graph shows me where I'm at in real-time so I can
optimize the training effects. I plan to eventually
calculate calories burned per hour and use this to
estimate the drop in insulin requirements for the next
24 hours.

In any case, I'd be interested to know if anybody has used
the level of stress in a workout to modify insulin dosing
requirements. I'm currently thinking of using miles
travelled, time duration, elevation climbed (sum

of

Quoted message said:

upward movement in feet) and average BPM. All this info is
in the bicycle computer and is downloaded to the PC
(Specialized PeaBrain computer on the bike). As an
example, let's say I use distance travelled and average

heart

Quoted message said:

rate to estimate increased insulin sensitivity. This
would give:

S is proportional to D*(H - 72 BPM)

where S is insulin sensitivity, D is distance and H is
average heart rate.

So I think I could use the total distance times the
average heart rate as

a

Quoted message said:

proxy for the stress level of the workout. Then set up
some curve fit for this data. As I get stronger, my heart
rate will lower and my insulin sensitivity will lower as
well. If the workout is light, the heart rate will be low
and insulin sensitivity will be low as well. If my
average heart rate falls below a baseline of 72 BPM, then
the workout is trivial and there is no increase in
insulin sensitivity. This baseline will lower with
training as well.

Any ideas or suggestions?
--
Jim Dumas T1 4/86, background retinopathy, rarely
hypoglycemic: <1/mo. lispro+R+U+NPH daily, moderate
exercise, typically <6% HbA1c

mike gray said:

I think yer trying to measure insulin/glucose utilization
to a level of accuracy that is impossible with the human
body and the Florida weather.

Hi Mike,

You use insulin. So how do you handle this variable workout
issue now?

I hope you have some method,
--
Jim Dumas T1 4/86, background retinopathy, rarely
hypoglycemic: <1/mo. lispro+R+U+NPH daily, moderate
exercise, typically <6% HbA1c

It took approximately 10 minutes for somebody to point out
that I wrote "insulin" where I clearly meant "glucose". It
is corrected below. Charly

Charly Coughran <[email hidden]> wrote
in :"]news:[email hidden]:

Quoted message said:

I hope it works for you. I've found that in my case
insulin sensitivity is affected by exercise at a variety
of time scales (hours, days, weeks) and is noticeably
nonlinear. Sensitivity increases that express as
required basal rate changes seem to occur as threshold
or step function events rather than smooth proportional
changes. This was one of the major reasons I went to the
pump with which basal alterations are fully functional
in order 4 hours rather than order 24 or 48. My exercise
is variable and given the various lag times I alter
dosages fairly often.

There is a converter from % heart rate to % VO2 max at
brianmac.demon.co.ukmaxhr.htmOpen ↗

I would imagine everyone doing any kind of serious
exercise factors the intensity level and length into their
short term bg management strategy be it insulin
modification, carb increase, or a combination.

In addition to any increase in insulin absorption with
exercise, non insulin mediated glucose transport pathways
are opened up with exercise. These and total glucose
storage within the cell are affected by fitness level and
throw another non linear effect into the equation.

Charly Coughran ccoughran@UCSD-DELETE-TO-RESPOND-EDU

Jim Dumas <[email protected]!mindspring.com> wrote in
:"]news:[email hidden]:

Quoted message said:

Just to say that I've settled into a summer bicycling
routine in the hot Florida sun. I exercise in the morning
for an hour then dose ultralente after I've cooled down.
I have NPH waning from a bedtime dose during the training
period. This usually keeps BG flat during training. But
I've measured low BG after the training period when I
took more bedtime NPH to move triglycerides into fat
cells after a high fat dinner. So I have to be careful
with the NPH bumper if I plan to exercise the next day.

The rationale for dosing ultralente after the training is
to prevent rapid absorption at the injection site during
training. It's important to note that all insulin is
absorbed faster during an endurance workout. This is
caused by increased temperature and blood flow at the
injection site during training. These effects will be
minimized when exercising before breakfast.

I also bump an insulin sensitivity multiplier by 1/3 for
24 hours post exercise period. This lowers insulin
requirements for the current day.

I have a heart rate monitor on the road racer as well.
The target range I've set is 130-160 Beats per minute (50
yo male so max is 220-50=170 BPM). A bar graph shows me
where I'm at in real-time so I can optimize the training
effects. I plan to eventually calculate calories burned
per hour and use this to estimate the drop in insulin
requirements for the next 24 hours.

In any case, I'd be interested to know if anybody has
used the level of stress in a workout to modify insulin
dosing requirements. I'm currently thinking of using
miles travelled, time duration, elevation climbed (sum of
upward movement in feet) and average BPM. All this info
is in the bicycle computer and is downloaded to the PC
(Specialized PeaBrain computer on the bike). As an
example, let's say I use distance travelled and average
heart rate to estimate increased insulin sensitivity.
This would give:

S is proportional to D*(H - 72 BPM)

where S is insulin sensitivity, D is distance and H is
average heart rate.

So I think I could use the total distance times the
average heart rate as a proxy for the stress level of the
workout. Then set up some curve fit for this data. As I
get stronger, my heart rate will lower and my insulin
sensitivity will lower as well. If the workout is light,
the heart rate will be low and insulin sensitivity will
be low as well. If my average heart rate falls below a
baseline of 72 BPM, then the workout is trivial and there
is no increase in insulin sensitivity. This baseline will
lower with training as well.

Any ideas or suggestions?

Bay Area Dave said:

yeah. get an insulin pump.

You still have the same problem with a pump.

So how do you handle variable workouts with your
insulin dosing?

But you have to exercise more than just a jawbone to see
this.
--
Jim Dumas T1 4/86, background retinopathy, rarely
hypoglycemic: <1/mo. lispro+R+U+NPH daily, moderate
exercise, typically <6% HbA1c

Quoted message said:

Just the one Jim. Get real man!!!! Do your bike riding and
ENJOY it rather than turn it into an exercise in maths,
logic, extrapolation and guesswork.

Beav, you do realise don't you that some people enjoy all
that complication - it's like model railroaders - some of
them go through all kinds of complicated "realistic"
running sessions, others do it for the realistic scenery
that they build over many, many hours, and others simply
"run trains" ....

Thanks, but no thanks ..... you're not really my type ....
:-))

--

]- "I am a man of many parts, ]- unfortunately most of them
are no longer in stock" ]-
------------------------------------------------------------
----------
To reply by e-mail, move the Gnu from the address to the
subject line.
------------------------------------------------------------
----------

tee hee! you wrote "sort of" what I was thinking about all
the complex scientific jargon he throws around. I wonder if
he thinks that jazz impresses anyone? All it tells me is he
is obsessed.

dave

Beav said:

Just the one Jim. Get real man!!!! Do your bike riding and
ENJOY it rather than turn it into an exercise in maths,
logic, extrapolation and guesswork.

[censored] ME!!!!

(Sorry Jim, but sometimes you REALLY overcomplicate thing
to the extreme.)

Beav

Beav wrote:

No thank you, Beav. My wife an I are quite happy. But ask
BAD.
--
Jim Dumas T1 4/86, background retinopathy, rarely
hypoglycemic: <1/mo. lispro+R+U+NPH daily, moderate
exercise, typically <6% HbA1c

Tonya said:

In short, you're trying to solve a problem with too many
variables which change due to factors you cann never
control with the accuracy you're striving for. The math
and equatations are interesting but ultimately probably a
waste of time, given the inherent uncontrollable
variables.

Hi Tonya,

I agree that there are many unknown variables in SC dosing.
But with short-acting insulins like Humalog and Novolog, the
injection site issues or delays are almost nonexistant.
Next, in my case, I've estimated the insulin action profiles
for Humalog, Novolog and R for my metabolism, i.e., with
antibody binding delays via the Glucose Transform. So I have
eliminated much uncertainty, (in my case, antibody binding
delays govern insulin action [this is the case with most long-
term T1s, BTW, since antibody concentrations continue to
rise for T1s on pumps or MDI]), by jumping directly to the
glucose uptake stage in the cascade of insulin transport to
target cells. What is interesting about my antibody binding
to R, for example, is the peak insulin action of 5.7 hours
post dose is extremely predictable, thanks to the antibodies
in the bloodstream. This tends to eliminate other less
important influences like injection site location or
temperature of the injection site, for example.

In any case, I beg to differ. My argument is: _Any_ math
model is better than tossing darts for dosing post-exercise,
as we T1s seem to do now.

So let's refine the math to improve this "back-of-the-
envelope" dosing approach many T1s are currently using.
Moreover, by discussing this on MHD, we exchange ideas and
move toward the best model for this effect.

Finally, this is a good time to discuss exercise effects on
insulin sensitivity with summer activities on the horizon.
(There are certainly gender specific hormonal influences
that I will not address. But the framework of the male model
will still apply to the female as a starting point.)

And thanks for input, of course.
--
Jim Dumas T1 4/86, background retinopathy, rarely
hypoglycemic: <1/mo. lispro+R+U+NPH daily, moderate
exercise, typically <6% HbA1c

Jim Dumas wrote in message ...

mike gray said:

I think yer trying to measure insulin/glucose utilization
to a level of accuracy that is impossible with the human
body and the Florida weather.

Hi Mike,

You use insulin. So how do you handle this variable workout
issue now?

I hope you have some method,
--
Jim Dumas

I'm a retired engineer. I use my wife's cast-off computers; I don't even
use a digital watch.

I don't "handle" the variable workout issue. Instead, I strive for
constant workout at constant time-of-day with constant food in my belly and
constant H + U in my fat layer.

What did you say Doc?, Anal Retentive? Who, me?

Regards
Old Al (Happily watching 35 years in R & D recede in my rear view mirror)

Charly Coughran said:

Quoted message said:

I hope it works for you. I've found that in my case
insulin sensitivity is affected by exercise at a variety
of time scales (hours, days, weeks) and is noticeably
nonlinear. Sensitivity increases that express as
required basal rate changes seem to occur as threshold
or step function events rather than smooth proportional
changes. This was one of the major reasons I went to the
pump with which basal alterations are fully functional
in order 4 hours rather than order 24 or 48. My exercise
is variable and given the various lag times I alter
dosages fairly often.

Hi Charly,

I've been thinking about using two exponential decays summed
to simulate glycogen store rebuild (one for muscle and the
other for liver) after a training session, as the basic
insulin sensitivity modifier for exercise effects. One could
have 5 tau (time constants) set for 12 hours and the other
for 36 hours, as an example. Then adjust the ratio for the
mass of glycogen in each type of tissue. Lastly, normalize
the function using AUC to duplicate the "observed time
averaged insulin sensitivity" we see in our dosing
adjustments. But I haven't put pencil to paper on this yet.

Quoted message said:

Quoted message said:

There is a converter from % heart rate to % VO2 max at
brianmac.demon.co.ukmaxhr.htmOpen ↗

This was helpful. Thanks.

Quoted message said:

Quoted message said:

I would imagine everyone doing any kind of serious
exercise factors the intensity level and length into
their short term bg management strategy be it insulin
modification, carb increase, or a combination.

So what is your method to compensate for exercise effects?

Quoted message said:

Quoted message said:

In addition to any increase in insulin absorption with
exercise, non insulin mediated glucose transport pathways
are opened up with exercise. These and total glucose
storage within the cell are affected by fitness level and
throw another non linear effect into the equation.

Glycogen stores increase with training. But I don't think
this will have much impact on the double exp model
mentioned above.

In any case, I still think the total distance * average BPM
is a minimum measurement to capture the required stress
level data. How do you quantify the stress level for your
current exercise method? You must have some numerical
approach if you're adjusting your dose for exercise.

Thanks for the info,
--
Jim Dumas T1 4/86, background retinopathy, rarely
hypoglycemic: <1/mo. lispro+R+U+NPH daily, moderate
exercise, typically <6% HbA1c

"Jim Dumas" <[email protected]!mindspring.com> wrote in message "]news:[email hidden]...

Quoted message said:

Bay Area Dave said:

yeah. get an insulin pump.

You still have the same problem with a pump.

So how do you handle variable workouts with your
insulin dosing?

Simple, he does not excercise.

I myself find this really hard. Every morning, I bike 24 km
to the train, the train uses 35 mins into town, then I walk
for about 25 mins to work. Same rutine on the way home.
Often I have a low, which in turn brings a high when I am on
my way to work.

Share your finding and I will be happy!

br

Steinar

using nothing but quick acting insulin, it is fairly easy to
regulate active insulin for my activity levels. heavy
exercise means cutting back on basals to approx 50-60% of
normal for that time of day. If I'm going to exercise right
after bolusing for food, the rule is that one take 1/2 of
the usual bolus. I find that's pretty darn accurate!

dave

Jim Dumas said:

Bay Area Dave said:

yeah. get an insulin pump.

You still have the same problem with a pump.

So how do you handle variable workouts with your
insulin dosing?

But you have to exercise more than just a jawbone to
see this.

"Jim Dumas" <[email protected]!mindspring.com> wrote in message
"]news:[email hidden]...

Quoted message said:

mike gray said:

I think yer trying to measure insulin/glucose
utilization to a level of accuracy that is impossible
with the human body and the Florida weather.

Hi Mike,

You use insulin. So how do you handle this variable
workout issue now?

Hi Jim, I'm not Mike, but.. :-)

I work out the variable workout issue REALLY simplistically.
I work 'til I feel just a TINY bit "off", then I test. I'm
ALWAYS going to be low, so I eat something which I normally
wouldn't DREAM of eating. A cream and jello filled doughnut
for example. WONDERFUL they are and if I work too hard at
trying to STOP that low, I'm not going to have that
wonderful doughnut am I?

Does it make me fat? Not on your life, because I've burned,
and will continue to burn all that lovely glucose:-)

So... I enjoy the work that brought about the need for the
doughnut and I enjoy the doughnut even more and not ONCE did
I need to do even simple maths LOL. All in all, a MUCH more
fun way to deal with BG's.

Beav

"Bay Area Dave" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

tee hee! you wrote "sort of" what I was thinking about all
the complex scientific jargon he throws around. I wonder
if he thinks that jazz impresses anyone? All it tells me
is he is obsessed.

Jim's comfortable with his maths, but I doubt many others
are as comfortable. I don't think he's trying to impress
anyone, but I've been wrong before now :-)

I think that obsessive behaviour IS something he should
consider though.

Beav

Bay Area Dave said:

All it tells me is he is obsessed.

It tells me you don't have a training schedule for
exercising. This variability in insulin sensitivity, post
variable exercise period, is a major problem that you
haven't a clue about. So take a seat.

Some people just can't be quiet (i.e., don't know when
to listen).
--
Jim Dumas T1 4/86, background retinopathy, rarely
hypoglycemic: <1/mo. lispro+R+U+NPH daily, moderate
exercise, typically <6% HbA1c