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Pump it up - Adventures of a type 1 triathlete with insulin pump
Pump it up - Adventures of a type 1 triathlete with insulin pump
Please visit my new blog here: Pump it up - Adventures of a type 1 triathlete with insulin pump

Diagnosed at the age of 5, I have been a type 1 Diabetic for over 29 years; being on an insulin pump for 11 years now. I took up triathlon in 2011 and am hooked ever since! Being diabetic doesn't stop me from doing what I love - swimming, cycling and running!

Challenging times: Taper, rest and recovery for a type 1 diabetic

Eva29by Eva29Jan 12th 2014
It’s been over three month now since I completed my Ironman on the island of Elba and I feel well-recovered from it. In fact, much to my surprise, I never suffered physically that badly afterwards. Except for some blisters and sore legs (walking stairs backwards) there was little visible sign that indicated what I had put my body through. To me, it was a clear proof of how well I had been prepared by Andy, my coach.

Most of us, understandably, decide that after an IM we don’t want to touch our bike for a few weeks, throw our trainers in one corner swearing not to touch them for a month and get excited by the thought that we no longer need to see the inside of a swimming pool for a 6am training session for some time.

A number of people asked me if I was "giving myself a total rest now and putting my feet up" which would be perfectly normal. My response to this question was usually something like "No" followed by "I am doing light exercise every day to keep my blood sugar at bay without compromising on giving my body time to recover".

We often don’t realised the impact exercise - and the lack of it - has on our bodies. I only know this because I experienced it hands on with my sugar levels and subsequently the management of my diabetes. In my blogs I talk about what exercise and racing does to my sugar levels and how I manage them by eating a specific amount of carbohydrates and reducing insulin but I have never explained what actually happens when I stop exercising with training volume suddenly dropping from 18-20hrs a week to 5 or even zero hours because:

1. I taper before a race
2. I take time to recover and rest after a hard race such as an Ironman

From previous experience of training for my first half Ironman in 2012 and going on training camps (when you try and do less training before and after), I knew that taper and recovery are both phases in my training plan which require special adjustment to insulin and nutritional demands. It is important to bear in mind that I am referring to sudden and "extreme" drops of training volume for a prolonged period of days or weeks without slowly reducing volume.

None of this was known to me when I started with triathlon:
After my first training camp to Fuerteventura where the total hours of training in that week were round 30, I returned to a week of easy training (ca 5-6 hours) and was also expecting increased insulin sensitivity due to my monthly cycle. This would have normally meant that I would be more prone to lower sugar levels and therefore needed less insulin. Instead, I came back to what turned out to be a blood sugar nightmare: Sugar levels were constantly elevated and I needed additional insulin to counteract this. This "phenomenon" lasted for more than a week. It took a while afterwards for me to understand that the reason for my elevated sugar levels was to do with the sudden increase and drop of training volume.

Over time with the help of my coach Andy we learnt that taper and recovery were particular phases that needed a slightly different approach than that for a "normal" person.


Taper and management of diabetes

For the Ironman, my taper was probably shorter than usual (14 days) with 10.5 hours training the first 7 days. Only in the last 7 days before the race did my training drop down to 4.5 hours overall. Because we had seen the effects of a sudden increase or decrease in training volume, the last thing I wanted was chaotic sugar levels so close to the race. The reason for this is two-fold:

1. It is stressful. My mind is pre-occupied with keeping sugar levels at bay when actually I should be focussing on the race. Diabetes is a full-time job that I - as much as I would love to - cannot just park and leave for a day or two. When sugar levels “go wild” and despite all efforts they are barely controllable it becomes a 24-hour-on-call job and more than often I have to measure at night. Not ideal when you're supposed to relax and get as much sleep as possible.

2. The other reason why I want good and stable sugar levels before a big race is to do with positive attitude: It gets me down when I struggle to control sugar levels. Imagine you try and do everything you can possibly think of and it just feels you are banging your head against a brick wall - All diabetics out there know what I mean: I am super careful with what I eat, test sugar levels more often, have a temporary basal rate but it still feels like the diabetes has a mind of its own and it has decided to do what it wants exactly that one week before an important race. Self-doubts start developing: "How will I be able to manage my diabetes during an Ironman when I don’t seem to get it under control under normal conditions?". This is just the start of a thought process that can send you into a complete downhill spiral if you’re not careful. I have had these thoughts before and luckily I managed to put a stop to these by reminding myself of all the long and hard training sessions I had done in the past, assimilating Ironman conditions, where my sugar levels had been spot on.

I was slightly concerned that with a reduced taper period I wouldn't be rested enough for the Ironman. It was a balancing act of keeping volume higher but low enough to not be totally exhausted going into the race:

With my daily insulin demand being highest early morning I had learnt that this is the best time for me to do training as it helps keeping levels normal. Anyone knowing about diabetes will confirm that bad sugar levels in the morning are the worst ones to correct and I absolutely agree with a statement a consultant made when I was in my teens: "The sugar level immediately after you get up in the morning determines how the rest of the day goes". Meaning, if it is bad already, the rest of the day is likely to be a rollercoaster, too. Luckily during my taper for the Ironman with training volumes slightly higher I didn’t need to make greater adjustments to insulin rates or any nutritional changes.

Having managed the period of tapering pretty well, it was the post-Ironman sugar levels which turned out to be a diabetic’s nightmare.


Rest and recovery with type 1

For the first few days after my Ironman my sugar levels were pretty good and stable. My explanation for this is that there was still muscle glycogen replenishment (which is part of muscle recovery) taking place whereby muscle cells are much more receptive to insulin, hence I didn’t need more insulin during those first few days.

It was on day 4 when things began to get messy. I had not done any exercise (obviously) in those 3 days after the Ironman and noticed that levels were starting to rise particularly after meals and in the mornings despite no changes in my diet or insulin rates. At first I started to counteract this by running my pump on a higher basal rate from 6am to about 11am (so-called temporary basal rate). This is what I always do when my body seems to require more insulin due to certain hormonal changes during the monthly cycle or illness. I started out with an increase of 20% of insulin per hour during this time. However, it didn’t seem to make any difference so I increased the rate by another 10% to 130% and eventually extended the time span from 6am to about 3pm.
My total basal insulin demand is around 13.5 units over 24 hours which is not very much. Of these 13.5 units, 6 units alone are released by my pump between 6 am and 3 pm. So nearly half of my daily basal rate is already released during these 9 hours. With an increase to 130%, another 2 units would be released on top of the 6 units during these hours. This all may sound complicated but what I am trying show is how much insulin my body needed in the morning hours for the first weeks after my Ironman!
At last rising the temporary basal rate by 30% had covered the additional insulin requirements in the critical morning hours. However, there was another factor that seemed to be at least also partly responsible for increased sugar levels: My breakfast.


Keeping a careful watch on carbohydrates

On a normal day I struggle to eat large amount of carbs AND keep sugar levels in a normal range particularly in the mornings. During IM recovery any carbohydrates would send me sky-high despite injecting insulin generously to cover the carbs consumed for breakfast.
After several days and even with adding light morning exercise before breakfast I finally had found a solution to the issue: I would not have any carbohydrates at all except for a coffee with milk until about 10:30-11:00 am past the time when I needed most insulin. It worked! Since I am used to a low carbohydrate diet it didn’t require much change but just shifting times of meals a little.

It was two weeks that I had to manage my diabetes in such a way and it was the most nerve-racking period I had for a long time with my diabetes. It required constant glucose monitoring and my resilience was tested to the max. By week two though I had pretty much worked out how to adjust insulin and nutrition and I noticed that my insulin demand was slowing going back to normal.

Diabetes in the context of triathlon or any other endurance sport is not just about managing sugar levels on race day. There is so much more going on in the body when you taper, recover, overtrain etc that has an impact on glucose levels and diabetes management overall. It can be frustrating at times because it is no exact science and what works one day may not work on the second day.

Long-term impact on blood sugar levels

I want to stress to any diabetic who is concerned about bad blood test results that the adjustment I had to do was something I had expected and it was short-lived in the grand scheme of things. I made necessary changes in a relatively short space of time and it has not had any long term effects on my overall long term blood test results (so called HbA1C*) which I have to get done on a quarterly basis. My HbA1C was at 6.4% in November and has been at that level for the past ? years(!) during all my training.
I share this information to give proof that endurance sport is perfectly feasible for a type 1 and should not cause concern about long-term diabetic complications resulting from bad sugar levels - as long as you listen to your body, adapt when necessary.
Definition of HbA1C:
I found below link from Diabetic Retinopathy UK which explains in a simple way what HbA1C means:
by guest: Richard King, Feb 11th 2014 12:10
Absolutely fantastic blog Eva. I've been coaxed into completing a standard triathlon in May this year and after reading your blogs I am more optomistic about managing my diabetes whilst training/competing.

I am considering transfering to using an insulin pump and found your blog by searching this on google.

Thank you and well done. You're an inspiration.
Eva29by blog author: Eva29, Feb 21st 2014 12:24
Thank you Richard. I have been on a pump for over 10 years now ( been type 1 for nearly 27 years and used to be on pen injections). Although I only started Triathlon when I already had my pump, I was pretty sporty beforehand but there is no way I woudl be able to do this kind of long endurance stuff on pen injections. Being on a pump is as much work as on injections BUT it gives you so much more freedom when it comes to managing sugar levels when exercising. NO way I woudl ever want to go back to pens. drop me a message if I you have any questions: evakapp(at)web.de
by guest: Jacek, Mar 29th 2014 20:16
Tkank you - good news for all of us. Greetings from Poland.
 
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