How does Missy balance running and diabetes?
The following is a summary of an 8-part series that was posted on the website for The Diabetes Exercise and Sports Association (DESA)
(1) Summary of my athletic background
(2) Summary of my diabetes regimen
(4) How my coach and I plan my training/racing
(5) How I train
(6) How I manage my diabetes when I race a marathon
(7) Injuries and how they have affected me
(8) Where do I see myself going with all this?
Disclaimer: This is not a summary of how to get started training or how to begin a fitness program. Nor is this intended to be medical advice or coaching.
Part 1: Summary of my athletic background
I have had Type 1 diabetes for 10 years. I have run professionally for about 11 years now. I’ve qualified for and competed in Olympic Marathon Trials. I race distances from 5K to the 50 miles (I’ve run low 17 for 5K, mid 28 for 5M, 36 for 10K, 80 flat for half marathon, and 2:47 for the marathon - and I once ran 33:09 for a 6 mile race that had a net elevation loss!). I know that I can still improve some on the half and on the marathon, but I don’t see myself taking any time off the shorter races – I just don’t have the speed (my best mile is only 5:17 and that was the first mile of a race!).
I have accumulated over 70 first place finishes at varying distances, hold course records and state records at various distances, was in the USA Track and Field Elite Athlete Development Program for two years, was NC Runner of the year for two years, was a LifeScan Award winner, and went to Olympic Trials, etc. I have been able to travel a lot of places, do a lot of neat things, and meet a lot of great people with running. It has really been wonderful.
I usually run about 40 races per year with a couple marathons. I ran 4 marathons in 6 months once, but that was a little extreme, even for me. One of the guys in my training group runs (and wins) 5 or 6 marathons each year, though. I have popped off a few good races at different distances but still haven't had a marathon go really well yet. I think that's what keeps me going.
Part 2: Summary of my diabetes regimen
I have had Type 1 diabetes for 10 years. My c-peptide is 0 now; it hovered around 0.5 or so for several years (this means that I don’t produce any insulin on my own anymore). My HgbA1c is usually under 6, but sometimes right at 6 or 6.1.
I use an insulin pump along with Lantus. Usually, in the middle of the summer and sometimes in the middle of the winter, I’ll switch from relying mostly on an insulin pump to relying mostly on injections. The main reason for this switch is because of how the weather extremes ruin my insulin in the pump cartridge during these times of year. Sometimes I switch from one insulin delivery method to another for a more personal reason (i.e. injections because I’ll be laying on the beach in my bathing suit; the pump because I’m at a dinner and don’t want to pull out a needle).
I use about 20 units of insulin per day, sometimes more, sometimes less. I don’t use much insulin with the basal rate on my pump because I use Lantus along with my insulin pump. I take 7 units of Lantus in the morning, 1.5 units at about 2:30, and 2 units at bedtime. I have pronounced dawn phenomenon and the pump works best for that because I can change the delivery rate to compensate. With Lantus alone, I have to get out of bed within 9 hours of my bedtime shot and get another shot of Lantus (and sometimes a ½ unit or so of Humalog) or my blood sugar will start climbing rapidly (it can jump from 90 to 250 in 90 minutes in the morning).
My insulin dosing is completely intertwined with my training. I run every morning and I run most afternoons. As my training and level of fitness increase during a season, I can cut back on my basal rate (or Lantus) but not by much (maybe a unit or so during the day). The biggest difference I experience is in the timing of meals and boluses. The more mileage I run and the better my fitness, the longer the time needed between a meal/insulin and my training run in the afternoon. My morning runs are not affected as much (the dawn phenomenon thing).
A typical day:
5:30am, bg 67, Lantus 7 units, Humalog 1 unit, coffee
8:00am, 10 mile run easy
9:20am, bg 114, Humalog 2 units, scrambled eggs and cheese
11:30am, bg 146, H 1 unit
2:40pm, bg 102, L 1.5 units
4:15pm, ½ Met Rx bar
4:30pm, 5 mile run
5:15pm, bg 100, Humalog ½ unit
6:30pm, Humalog 4 units, dinner
8:45pm, bg 119
9:15pm, bg 137, L 2 units
I usually check my blood sugar 8 times each day, but have checked it a lot more. I feel more comfortable micro-managing my blood sugars. Despite the fact that there really isn’t any scientific data that proves that this level of micro-managing is beneficial, I FEEL better about my control (and my mental health with respect to diabetes is very important to me).
When I don’t run, my meal-time insulin needs go up. For example, the same breakfast without running might require 4-5 units of Humalog. In the afternoon, I absolutely have to eat something before I run or I will bottom out (and sometimes I still need a little bit of carbohydrate gel if I run more than an hour). One very important item that I want to mention is that I absolutely ALWAYS wear an ID anklet that states that I am a diabetic on insulin and I ALWAYS carry a packet of carbohydrate gel whenever I go running. Carbs – don’t leave home without them!
Part 3: My physiological testing
I have agreed to participate in treadmill testing at Duke three times, following something called the Bruce protocol or the modified Bruce protocol (or some people call it “treadmill to exhaustion”). I don’t remember the exact details for the test (and each place seems to run the test a little differently) but the idea is that they start you out at an easy run and increase the pace every couple minutes until they bring you up to 10 miles per hour (6:00 minute mile pace). Then, they increase the grade each couple minutes until you completely fatigue and someone has to catch you as you fall down. Fun, huh?
I also agreed to a complete panel of physiological testing done at the Human Performance Lab at Duke University. It took 3 days to go through the whole panel of testing. The first day was the treadmill to exhaustion with VO2 max, lactate measurements, other blood chemistries, body composition, and cardiovascular monitoring. The second day was a “familiarization run” on the treadmill (they determined a 75% effort pace). The third day was a 2 hour run at 75% effort with cardiovascular monitoring, gait analysis with joint monitoring with a 7 camera system, blood lactate and blood glucose monitoring, O2 consumption measurement, and muscle EMG monitoring (with electrodes in major muscles).
My treadmill to exhaustion ended as I hit 10 mph with a 9% grade. My max heart rate was 196 (I had hit 201 and 202 before). VO2 max (a measurement of the maximum volume of oxygen your body can extract from the air to use during exercise, expressed as milliliters of oxygen per kilogram of body weight per minute) was very high. My lactate threshold (when my lactic acid accumulation rose above 2.5 millimoles which is generally regarded as the level at which your body is accumulating lactic acid faster than you can clear it) was at 9.5 mph.
The better your conditioning, the higher percent of your VO2 max you can reach before hitting your lactate threshold. I hit my lactate threshold at about 81% of my max VO2. With better conditioning, I could push that to 90% of my max VO2. The gait analysis, blood chemistries, and EMG analysis from the 2 hour run also suggested that I have good potential.
So, what did all this data tell me? According to my VO2 max, I have the potential to run well. According to my lactate threshold, I am not trained to my potential. I have a lot of aerobic conditioning work to do in order to realize my potential. While it was kind of intriguing to realize that I have all this potential, it was almost disappointing. So, why can’t I run as fast as these tests suggest that I can? Am I just a wimp?
So far, the best I can determine from the people with whom I’ve discussed my results is that the answer is multi-faceted. First of all, it can take many years to make an endurance athlete – many consistent years of training. Also, aerobic potential can not be realized without the corresponding muscle strength. Finally, these tests are just predictors of possible potential and don’t guarantee anything. Certain results are usually correlated with certain performances but not always. Sometimes people who have had mediocre results on these batteries of tests have been world class performers. And, likewise, some people have great test results but never race to their predicted level.
Part 4: How my coach and I plan my training/racing
In general, my training is broken down into 2 or 3 seasons per year and each season is designed with the idea that it will build on the previous season while serving as a stepping stone for the next season. A coach is extremely useful in keeping the big picture in mind, both in terms of the season at hand and also in terms of how the athlete’s training is progressing over time.
I never start a racing season without sitting down with my coach and outlining on paper a tentative schedule for races and a training plan. We plan out the basic components roughly, leaving open the possibility for modifying the plan as the season progresses. For instance, we may have a half marathon scheduled for halfway through the season, but my long tempo runs are going really well and we decide that I should jump into a half marathon sooner. Or, perhaps, an elite athlete coordinator for a race calls to ask Coach to send a few runners to a race and so a couple of us might go to a different race than we had originally planned. On the other hand, sometimes training doesn’t progress as well as expected and we may need to change to a marathon that is a month later.
The basic components that we incorporate into a training schedule are: races, workouts, mileage, strength training, rest, and nutrition. The planning is already complex and it has been a real challenge to incorporate diabetes into this. Since I train almost year-round, my diabetes regimen assumes that training is the norm and my adjustments are made for breaks.
Most people with diabetes make changes in their regimen to incorporate exercise; I make changes in my regimen to incorporate less exercise or no exercise. So, when people ask me how much I decrease my insulin if I’m going to run or how exercise changes my blood sugars later in the day, I don’t have an answer. On a usual day, I run in the morning and again in the afternoon. I make changes when I don’t run.
I can empathize with the person who has trouble figuring out how to make changes to incorporate exercise because I have as much trouble incorporating breaks. I need breaks in training, of course, but I dread those breaks because my blood sugars become less predictable and sometimes quite erratic. I almost never get blood sugars over 200 when I’m training hard, but 400+ blood sugars aren’t unheard of when I’m on a break.
There are some important things I’ve discovered about being a diabetic runner. Here are a few random things I’ve learned:
* There is a big difference in how my body utilizes injected insulin at different times of the day. For example, for me, Humalog can take an hour to work in the morning, but 15 minutes in the afternoon. Also, I am most sensitive to insulin at about 3:00pm.
* A normal blood sugar does not necessarily mean that I have enough insulin on board. I can use up all my glycogen stores in a marathon. When my body starts using ketones and fat stores for energy, I still need some circulating insulin to utilize the energy and to prevent acidosis (and I’m more prone to acidosis during a marathon because I have lactic acid accumulating also).
* Even non-diabetic runners will spill ketones in their urine after a marathon.
* It’s easier for me to learn my blood sugar pattern during training and then follow that pattern during a race so that I don’t need to check my blood sugar during the race. (note: I have a very good feel for my blood sugar level).
* I need to begin using a carbohydrate gel at about 6-8 miles into a marathon.
* If I begin a run with a high blood sugar, as it starts dropping, I will have to make a bathroom stop.
* Extreme cold weather and extreme hot weather will make my blood sugar drop faster than normal.
* Having a cold can make my blood sugar rise during a run, especially if I have a slight fever.
* Sometimes I have no idea why my blood sugar is high or low.
Part 5: How I train for the marathon
There is no single correct program for training – people are different and we have different strengths and weaknesses. What works for me may not work for someone else. Also, don’t fall into the trap of thinking that running X number of miles per week and/or running X times for certain workouts will equal a particular race result. If you train according to a program that does not work well for you, you will not realize your potential and, worse, you could end up injured.
My greatest asset as a runner is endurance. I don’t have a lot of speed, relatively speaking. My coach says that I have two speeds: stop and go. I can run huge amounts of mileage with little or no risk of injury or over-training, but speed work or track work wipes me out and sometimes sets me up for injury.
I typically run 90 to 100 miles per week when I’m training. When I’m on a break, I usually run anywhere from 30 to 60 miles per week. Transitioning from lower to higher mileage should usually follow a plan of adding about 10-12% per week, but I can usually go from 60 to 80, then up to about 100 without any problem. I like to have at least 3 or 4 weeks of 90 or more miles per week before I start adding any workouts or harder runs.
There are several types of workouts that I do. I always warm up with about 3 miles of easy jogging. I usually run my workouts on either the track, a measured road near my home, or a 1,000 meter long dirt trail loop. I might start with repeats of 1K with a 90 second recovery jog. What this means is I run 1,000 meters (1K) at a faster pace and then jog easily for 90 seconds before starting another loop. Then I run 2 to 3 miles easy to cool down. Some other types of workouts are hill repeats (running hard up a 200 meter hill, jogging back down, then running hard up the hill again, etc), long runs, long tempo runs, and short tempo runs.
Different workouts are meant to work different systems and, hopefully, make me a stronger and faster runner. Tempo runs are the easiest for me, but I tend to overdo them (sometimes I end up putting in a race level effort into a tempo run – the effort would have been better spent on a race). I don’t mind hill repeats so much either. Track workouts are my least favorite. But, as my coach always says, the track doesn’t lie.
Part 6: How I manage my diabetes when I race a marathon
First, I need to clarify that I am not racing a marathon with the goal of simply finishing as my main concern. Of course, finishing is always an achievement in and of itself, but I am racing against the other competitors for finish place (and for prize and time bonus money) and so my diabetes management has to take into consideration clock management during the race.
Two seconds can mean the difference between winning and losing and the difference between making a championship team and not making one. I say that because two seconds has placed me 4th before and meant the difference of not making a team (top 3), having a payday of $1,000 less, and having all of the ESPN audience view me tripping over the 3rd place woman at the finish line (after she collapsed). Two seconds…at the end of a 26.2 mile race.
I can’t take the time to stop and check my blood sugars while I race. I can’t carry a meter and test strips. I’ll be disqualified if anyone even hands me something while I’m racing. I have to be prepared and practiced on race day. I run practice runs, testing out carb products, water ratios, insulin requirements, etc, etc, etc. I have my pattern mapped out and I have a strategy worked out with contingencies built in.
Then, on race day, I follow the plan. Usually, the plan works fine. But I’ve had miscalculations and errors. One time, I was trying to take my insulin before the race and didn’t want to take off my sweats yet so I gave myself a shot through the pants. To make a long story short, I didn’t get the shot in deep enough, I ended up with too little insulin, my blood sugar skyrocketed during the race, and I ran the worst race of my career, short of dropping out. And it was very painful! I’ve had other goofs and I’ve had things go wrong before where I never could figure out why.
My basic strategy goes something like this:
I wake up about 2 hours before the race, check my blood sugar, and take a shot of 7 units of Lantus. If my blood sugar is over 100, I might take a half unit of Humalog. About an hour before the race, I’ll start drinking some coffee. Typically, the race staff has my travel to the start line and stuff like that planned out for the elite athletes and they take us to the elite athlete center about an hour before the race (usually in some building near the start line). I bring all my running and diabetes stuff with me.
About 40 minutes before the race starts, I take 2 units of Regular, and eat half a bagel (preferably with butter) or maybe half of a MetRx bar (I’ve found those Slim Fast protein bars to work well also). Then, I start jogging toward the start line and get about 10 minutes of light jogging in (and a bathroom stop or two). About 5 minutes before the start, I’ll take off my sweats, eat a piece of chocolate or two (or 10 m&m’s) and do some strides on the road until the start.
It’s so important that I start out at an easy pace! I’m better off starting at a pace slower than what I plan to run. I usually start the race with my blood sugar around 200 and I don’t want to do anything that might cause me to build up any lactic acid, so I need to let my blood sugar begin dropping before I pick up the pace (usually a mile or two). Sometimes I feel a little stiff and slow until my blood sugar starts to come down.
You might wonder why I don’t just start the race with a lower blood sugar. For a shorter race, like a 5K race (3.1 miles), I would start with a near normal blood sugar, but not exactly because of the shorter length of the race; rather, I start with a lower blood sugar because of the more anaerobic effort for a faster paced race like a 5K. For a marathon, I need to start with a higher blood sugar or I will crash.
I’ve tried different strategies and the one that works best for me is to start with a blood sugar around 200 and then begin using a carbohydrate gel at about 6-8 miles. I take in about 100 calories of carbohydrate gel every 6 miles for the rest of the race (about 3 packs of GU or 2 packs of Crank). I kind of nibble a little bit at a time as I go. Sometimes I might use a little more than 3 packs of GU. I usually carry 4 packs of GU with me just in case. I clip 2 packs in my sport bra with those little black office binder clips and I carry one pack in each hand.
I drink water at every water stop. Elite athletes are able to have special water bottles placed on special tables so that we can have our own concoctions available, but I usually just carry my GU and drink the same water out of the same paper cups as everyone else. I’ve seen people put together the weirdest brews of drinks! The strangest one was flat Coke with salt and a half of a caffeine pill. Yuk!
Part 7: Injuries
Being injured is one of the worst things an athlete can experience. You have to deal with self-doubt, worry, frustration, etc. Diabetic athletes also have to figure out how to adjust blood sugar control in the face of an altered exercise schedule. Do you cross-train, how will that affect insulin dosing, how many more/less carbs does swimming take, will your injury heal slower if your blood sugars run high?????
There are endless extra questions that we have to deal with as diabetic athletes and injuries or illness nearly send me over the edge! I generally try to take the approach of being conservative so as to avoid injury at all cost. You can’t train if you’re injured and if you can’t train, you can’t compete….
I have had two major injuries in my running career and one illness. I have had lots of interference with training and racing because of work, school, family matters, etc, though, and, like everyone else, I have had minor injuries from time to time and nagging aches and pains, but I have managed to stay fairly healthy for a runner. Neither of the two major injuries I’ve had in my career were from overtraining.
My first injury was something called an avulsion fracture on the lower part of my left tibia due to a severe ankle twist while running on trails. An avulsion fracture is when a muscle or tendon is pulled away from its attachment to the bone, taking part of the top layer of bone with it. It was painful. The x-rays also showed that I had arthritis in my left ankle (talo-navicular arthritis). The timing of this injury could not have been worse – ten weeks before Olympic Trials.
My second injury was in the Fall of 2002. The initial injury occurred during a track workout when someone just walked out in front of me as I was rounding a turn during an interval.I pulled my hamstring trying to avoid him.
I may have been okay, but over the next several weeks I continued to train hard and developed something called obturator neuritis, which is an inflammation of a group of muscles and the nerve bundles imbedded in those muscles. The muscle group, the obturators, travel through your pelvis; the obturator bundle of nerves and your sciatic nerve are imbedded in the muscles. Inflammation inside your pelvis is not a good thing. I was out of running for 4 months (the first 5 weeks I couldn’t even cross-train). I still have occasional residual pain that flares up when I over-do things a little.
Rehabilitation was very different for each of these injuries. The avulsion fracture seemed awful at the time, but was nothing compared to the obturator injury. I was able to run through the avulsion fracture (I even ran 100 mile weeks), but I could only handle running slowly. I kept my leg wrapped and was allowed to let pain be my limiting factor. I have a pretty high pain tolerance, though, and ran 100 mile weeks on what was basically the same as a stress fracture.
It was not much fun, but Olympic Trials in ten weeks served as a pretty good motivator. I needed a lot of physical therapy for the obturator injury and as much as I can tolerate pain, I literally could not run with that injury. Walking was difficult. Actually, many things were difficult with that injury.
Although not an injury, I have had one other major training set-back: the flu. I am not talking about a little virus or a cold that gets a little nasty. I had the real thing and I was sick! I really did not recover completely for almost 6 months. Everyone with diabetes should get the flu shot every year because the flu is so debilitating that it takes months to recover. I will also always stay up-to-date with my pneumovax. The flu was definitely worse than any injury I’ve ever had.
As I had said earlier, I have minor injuries here and there: tendonitis, tight hamstrings, IT band soreness, a little plantar fasciitis, blisters, toenail injuries, etc. I take steps to try to prevent any of these nagging problems from turning into major injuries. I stretch daily (usually 20 to 30 minutes every night before bed), I get sport massages as often as I can, I lift weights for core body strength, I practice form drills to prevent imbalances, I try to get plenty of sleep, and I eat healthy and take vitamin and mineral supplements.
I think that the stretching and weight lifting are really important for me, but sleep and nutrition really make a difference, too. I keep track of how many hours of sleep I get each night. I don’t let it get out of hand. I’ll take a day off from training if I have to and sleep later and go to bed earlier.
Part 8: Where do I see myself going with all this?
The main reason that I had originally put this 8-part series together was because I thought I might actually have something useful to share with other diabetic athletes. I can remember how frustrated I was when I was trying to figure this out on my own.
I was afraid to try and I was afraid to give up. I wasn’t even sure what I should be afraid of! I learned almost everything about managing my diabetes on my own – I even learned injection technique from a book! I was the epitome of the patient who fell through the cracks.
While all of us really want to pick up information that will help us figure out our own little problems and help us tweak our own little programs, we really have a responsibility to help each other out.
I remember the first diabetes conference I ever went to was a DESA conference (it was actually IDAA then) and one of the presentations was by a young lady who was a diabetes educator and she did this interactive thing with everyone telling things they had learned about diabetes that nobody taught them. She started out by saying that she had learned that even though Humalog was supposed to start acting in 10 to 15 minutes, it could take as long as an hour for her. I remember thinking to myself, “wow, me too!!”
One person after another had stories and discoveries to share.And a light bulb went off in my head…. If there are things that I cannot learn from anyone other than another person with diabetes, then I have a responsibility to disseminate information also.
Why is living and running with diabetes difficult?
