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!

Diabetes, Ironman and nature's forces

Eva29by Eva29Oct 10th 2013
I found it hard to write up my experience of Ironman and Diabetes in less than a page and I appreciate that my blog is quite long. For this reason I have split the following into several bite size chunks and hope you will read some or even all of it.
Little did I know when I got up at 4am the morning of 29 September what the day of my first Ironman was going to hold. I had put so many hours into training and managing glucose levels, working out nutritional needs and insulin requirements. I went cycling in the Pyrenees, stopped counting the numerous times I was out on the bike doing hill repetitions, practised sea swims etc.
It wasn't the distances that worried me because I felt I was physically able to deal with these. I had managed sugar levels well in training but, still, my biggest worry was managing them over such a long day. Elbaman, the Ironman on the island of Elba, Italy, which I had chosen was by no means a fast course with over 3000 metres of ascent on the bike. I had anticipated a time of 13-13.5 hours in good conditions and if everything went ahead as planned. But sometimes, even well-thought plans need adjusting because this day held some rather challenging surprises for all competitors.
Pre-race/before the start: The importance of a good glucose starting level

I woke up at 4am with a blood sugar of 96mg/dl (5.3mmol/l). I wasn't very hungry and almost pleased that I was going for my usual very small pre-race breakfast with some natural yoghurt, a coffee and some eggs. I injected insulin for my breakfast as normal and didn't reduce the insulin-to-carbohydrate ratio as I knew I was still 3 hours away from the start at 7am. This meant that there would be little or no insulin left from the breakfast injection at 7am when the race started. It was unlikely that I could hypo due to the insulin injected at 4am. I was more concerned that with the adrenalin and other stress hormones released my levels would actually rise. Nevertheless, I reduced my basal rate to 60% 90min prior to race start as I had done in other races and training and hoped that it would work and I would get my levels perfectly right to start the swim.
I anticipated the swim to take me 65-70 minutes so I needed to ensure that levels were high enough to keep me swimming for an hour without falling into a hypo but at the same time the level had not to be too high because it would make me feel unwell and lethargic.
I set myself up in our little transition tent where all women had a dedicated place with a chair and a little box for belongings. Needless to say I made sure I had medical kit in there for all eventualities I could think of. It was still one hour to go and I kept monitoring sugar levels very closely to detect any upward or downward trends. Luckily my levels remained very stable around 157-164mg/dl (8.7-9.1mmol/l). The last time I checked was just before transition closed: The result showed 163mg/dl (9mmol/l). Whilst I walked to the beach where the start was I took a few glucose tablets (fast glucose release) and a half a muesli bar (slower release), about 18gr carbs in total, which I calculated should get me through the 3.8km swim. I took three Mule gels (natural occurring energy gels) and squeezed them into the sleeves of my wetsuit as emergency in case I was going to go into a hypo.
The swim: Hypo or no hypo??

It was still dark when the start gun fell. There were around 250 men and only about 30 women doing the full distance so a fairly small field of starters. It was a beach start and although I could hear the waves and knew that with the rain we had had overnight and just beforehand it wouldn't be a calm swim in the bay. I hadn't really anticipated how rough the sea was. The enormous swell made it impossible to swim in a straight line or sight to make out the buoys. We had to do two laps with a short run out of the water and back into the sea for the second lap. Conditions were simply awful. I felt I was spun around in a washing machine but tried to concentrate on sighting as much as possible and keep a rhythm which was nearly impossible with the waves coming from all directions. It didn't take long until I felt really sick. My head was just spinning around and all I wished for was something stable to hold on to. I hadn't even completed half of the first lap when something in me started thinking "Just raise your hand and a boat will get you out of this". I couldn't believe I had come all that way to already have thoughts of giving up in the swim! I dragged myself around the first lap, starting to feel sicker and sicker with every stroke and just wished for the beach. Eventually I finished the first lap thinking that the organiser will shorten the swim and couldn't believe my eyes when no one stopped me going back into the sea to do the second lap! I managed to get to the second of four buoys when things went really bad and I was physically sick in the water. I felt awful, was shaking and dizzy and started to get really worried as I couldn't tell if this was because I had been so motion sick or because I was actually in a hypo? I was connected to my CGM (Continuous Glucose Monitoring system) which was supposed to measure my glucose 24/7 and alarming me when levels would fall under or rise above a certain level. Unfortunately, it had given me an error message a minute before the swim start telling me it had lost its connection to the insulin pump and therefore wasn't working!
My awareness of hypos is extremely good and I can usually feel them coming on way before my CGM but in this situation I simply wasn't sure. I tried to remain calm and focused on just getting to the next buoy, then the next one and listening to my body if the signs of dizziness were getting considerably worse or if I was getting tunnel vision. To calm my nerves I decided to take on half a gel in case I was low. I was about 1km away from the swim finish and figured that even if I wasn't in a hypo and didn't need the extra carbs, I would then be able to check my levels again in transition and inject insulin if necessary. At last I finished the second lap, incredibly pleased I hadn't given up.
The bike: on Mother nature's whims

I staggered into T1 feeling awful after this epic swim and checked sugar levels straight away: 161mg/dl (8.9mmol/l). I was relieved but at the same time a little concerned that I hadn't been in a hypo and taken on too many carbs. I injected 0.5 units and decided to check again after 30 min to work out the next steps. It was raining when I started the bike and I still felt really rough. It was about 2km out of the village until the first climb. It was a very steady 8km uphill with the same descent. It was only after the descent that I started to feel better again and picked up speed. It didn't last for long when I passed a handful of guys who had all come off their bikes on the corners and bends of the windy coastal road which had turned dangerously slippery. The rain began to get heavier and heavier and as I rode on the road condition worsened and wind picked up too. Since my CGM had stopped working and I had made the decision not to bother trying to re-activate it (which involves a two-hour warm up period), it meant that I needed to check glucose levels more often than I had planned (about every 60-90 minutes). I felt fine again and my first reading 30min into the bike it showed 135mg/dl (7.4mmol/l). Perfect! I kept my basal rate at 60% and followed my usual nutrition strategy: A 2-4 pieces of liquorice/wine gums every 20min and about half a Mule bar (15-20gr carbs; natural energy bar)) every 40-50min depending on intensity on the bike. I would usually eat it spread over 10-15min). Just as I was feeling human again the bad weather had picked up properly and rain started pouring down; it didn't take long until I was totally drenched. I knew from several very wet training rides that checking glucose levels could be a real challenge in wet conditions and needless to say it turned into a little mission. I had to keep the meter in a plastic bag to protect it from the wet and I had to look out for shelter when I stopped to measure glucose because it rained so much. I couldn't get my fingers dry to do a finger prick. I had some tissues with me specifically for this purpose but after I used them a couple of times they were so wet that I could no longer use them. Luckily a helper at a feed station gave me some toilet tissue to take with me. My levels had been pretty good throughout the bike leg to this date so I was confident that despite the rain I was able to complete the course in just under 7.5 hours. Little did I know what Mother Nature still had in store for us: Torrential rain with thunder and lightning started. Roads turned into rivers with lots of debris washed onto the road. There was a very technical 7km descent which got so dangerous that people started to walk it down with their bikes. Luckily I had gone down the descent just before the torrential rain had started. However, I faced a new challenge: The display of my glucose meter had started to steam up from the inside due to the dampness inside the plastic bag. The result was still legible towards the beginning but with the continuously heavy rain it steamed up more and more so that I had no option but to ride the last two hours by feel. I had a very small spare glucose meter in my saddle bag as a back-up but didn't bother trying to get it out. The bag was drenched and I got so cold in the torrential rain that I tried to avoid stopping at all times. Eventually the rain stopped and with 40km to go the sun came out. I had managed to keep glucose levels fairly stable and couldn't have been more pleased to see the T2 sign! It turned out to be an epic 8:20 hours on the bike with 3200 metres of climbing in horrific weather conditions.
I jumped off my bike and ran towards our tent to check glucose levels with my meter I had in transition: 85mg/dl (4.7mmol/l).
Diabetes, Ironman and nature's forces
The marathon: The big unknown

With 85mg/dl I needed to get more food on board so took on half a Mule gel and half a Mule bar whilst heading towards the run course. It was good to see a few familiar faces and to know that despite a few falls on the bike no one had been seriously injured. A large number of competitors had already dropped out due to the bad conditions or crashes on the bike so I was pleased I got off the bike in a fairly good state. Having had problems with malfunctioning glucose meters in the past due to wet and damp I decided in T2 that I wanted to take the meter I had in Transition with me on the run (this later turned out to be a blessing). I had practised to run with a meter in the pouch of my SPIbelt (which was also my race belt). On race morning I had handed in both my special needs bike and run bag with spare medical kit such as a glucose meters, spare infusion sets and ketone testing strips. I was reassured that both bags would be delivered to special dedicated tables along the bike and run course for me to have access to them every time I pass the tables. For some reason still unbeknown to me, the run bag never made it to the dedicated table on the run course. It wasn't there! I was so relieved to have taken my glucose meter from transition with me on the run course! I don't know why I made the decision there and then but I had received generally mixed messages from the race organisation as to the deposit of my spare medical kit so preferred to be safe rather than sorry.
The first 26km of the marathon went really well. I felt great running off the bike. I tested glucose every hour and levels ranged from 73-112 (4-7.2mmol/l). I still kept my basal rate at 60% although I was very conscious that I had been running the pump on reduced insulin for nearly 12 hours when I began the run. My biggest worry about the marathon leg had been to develop ketones* due to a lack of insulin. As I progressed on the run however my levels remained steady so I kept eating a little but just enough to not go into a hypo (usually half a Mule bar and a 1/3 of a Mule gel every 45-60min). Then, from kilometre 26 to 31, I totally hit a wall. With every step I took, my inner self got talking to me, telling me how awful everything was and that I couldn't do this anymore. I felt sick and dizzy again (this time I knew it was nothing to do with sugar levels). I hated every meter of the run. This was my low point number 3 after having been sick in the water and cycled through torrential rain. I couldn't face any more sweet food but knew I had to keep taking on sugar to keep my glucose levels up. I don't quite remember how I got over this but as with the swim I tried to just focus on getting to the next feed station , and the next turning point and so on. I am fairly sure it was the determination and to a certain extent my stubbornness to finish the race that kept me going. I had gone into a little run-walk but managed to run again for the last 12km and picked up speed. I stuck to the same nutrition and insulin strategy that I had used for completing half marathons. With about 45min away from the finish I ran my basal rate on 100% again to counteract any effects of rising levels in case my glucose levels would rise afterwards.
I finally crossed the finish line in 14:48 hours, came 2nd in my age group and 11th woman overall. The bad conditions had meant that my time (as everyone else's) had been much slower than expected but I didn't care. None of these numbers mattered to me: It was the 85mg/dl (4.7mmol/l) which my glucose meter showed immediately after crossing the finish line!
Post-race: How will my body react to the long endurance exercise?

Incredibly relieved to have crossed the finish line with next to perfect sugar levels throughout the entire Ironman, I knew I still had to watch what levels where doing. My experience from long training days (+6 hours) was that due to the reduced basal rate, levels were likely to rise after the exercise, particularly when I had a carb-rich post-race meal. I had learnt to eat very few or no carbs in the first two hours after I stopped exercising to counteract the upward trend of glucose. Some people observe a drop in sugar levels post-exercise due to muscle glycogen replenishment but I never really did. Although extremely tired I kept checking levels throughout the night. Luckily they remained very stable between 102-143mg/dl (5.6-7.8mmol/l). I didn't have anything to eat after the race that night so woke up the following morning with a huge appetite and the biggest finisher smile on my face

Below is a graphic representation of my glucose levels during the day:
Diabetes, Ironman and nature's forces
Graphic not to scale as time spent during run and bike is not proportional.
Note to above graphic:
Under non-exercise conditions, levels should stay between 80-120mg/dl (4.4-6.7mmol/l). Prior to exercising, I aim to have levels around 160-180mg/dl (8.9-10mmol/l). I hope this demonstrates how well I managed my glucose during the entire Ironman. At no point did levels rise above 190 mg/dl (10.6mmol/l) or drop below 70mg/dl (3.9mmol/l) risking a severe hypo.
Diabetes, Ironman and nature's forces
*Ketones = an acid remaining when body burns its own fat. It occurs when the body doesn't have sufficient insulin to help fuel the body's cells and thus starts burning fat instead to get energy. For a diabetic, a lack of insulin and the subsequent development of ketones can lead to a so-called diabetic ketoacidosis (DKA) and can be fatal if left untreated.
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