Jay Hewitt is a 39-year-old who has had type 1 diabetes since 1991. He is also an elite Ironman triathlete, tops in a demanding sport that requires a 2.4-mile swim, a 112-mile bike ride, and a 26.2-mile run. A three-time member of the U.S. National Team for Long Course Triathlon, he is captain of Team Joslin at the Joslin Diabetes Center in Boston, MA.
He is also a lawyer and a motivational speaker to diabetics and non-diabetics all over the world on fitness, nutrition, and achieving goals in life and business. Visit Jay’s website at www.jayhewitt.com.
1. How do you regulate insulin for a competitive swimmer? My daughter is twelve years old and swims 7,000 or 8,000 yards a day. We hold all insulin before practice or supplement carbs for a blood sugar of 150 before getting in the water. The problem is morning swim meets. Her normal dose is NPH 9 units, Regular 2 units. Do I adjust the dose down or feed more? She is 5 feet, 6 inches tall, and weighs 135 pounds.
My first comment is, wow! 8,000 yards a day! That’s impressive. I would feed more carbohydrate, both to make sure she has fuel to power the race and also to avoid lows. Duplicate the system that works in practice. You did not mention what problem is occurring at swim meets, but the excitement of racing and high intensity bursts of energy stimulates a release of adrenaline and steroid that can cause a rise in blood sugar. I assume she can quickly check her blood sugar between heats at swim meet. Is it rising or falling based on the last checks? She should eat or drink small amounts of carbs about 20 minutes before each race to get blood sugar up to 150, and even higher if the race will take longer than ten minutes. I would also consider switching away from NPH and Regular insulin to either an insulin pump or Lantus and Humalog or Apidra. The absorption of NPH is unpredictable and peaks whether you’re ready for it or not. I swim in the pool and open water with the Omnipod insulin pump attached to me.
2. How can I prevent low blood sugar during strenuous exercise?
Eat before you exercise. I run my blood sugar up to at least 180 before the start of the Ironman swim (2.4 miles). Drink a high carb sport drink or eat a healthy snack like Clif Bar or a banana about 15 minutes before your workout. Check your blood sugar twice in the hour leading up to the workout to see where it is heading. Also eat during workouts over one hour – 40 to 60 grams of carbohydrate per hour works for me, from energy bars, sport gels, anything quick with good carbs. On long workouts over one hour, I carry my OneTouch Ultra Mini meter when I cycle and test about every hour.
3. When I exercise, sometimes I go low, and other times I go high. Why?
Great question. When it happens to me, I play BSI Jay (Blood Sugar Investigator) to find the villain, but sometimes it is an unsolved crime. Here are some factors.
What did you eat prior to the workout? A salad and veggies has few carbs and you will go low, but bread, pasta, oatmeal, or other healthy low glycemic carbs will keep it higher longer. A banana is a great source of carbs. High glycemic junk foods like soda and candy bars will cause a rapid rise in blood sugar, but will not stay with you like low glycemic carbohydrates.
How much did you eat prior to the workout? An energy bar with 42 grams of carbs and 240 calories should last you 30 to 40 minutes, depending on the intensity of the exercise.
When did you eat? About 30 minutes or less before exercise, always eat something with good low glycemic carbs for sustained glucose fuel during your workout. Do you eat during the workout? I eat every 30 minutes training and racing Ironman, approximately 40 to 60 grams of carbohydrates and 250 to 300 calories per hour. Any less and I will go low; any more and I will go high. During long workouts or races over 4 hours, low blood sugar is hard to stop, so I have to keep fueling.
What is your insulin dose? Don’t bolus insulin before a workout unless you have eaten enough to cover it. You can control all of these factors, so find a system and foods that work and stick with them.
If it is a race, your adrenaline will often make your blood sugar go up: a quick glucose burst to fuel your body’s instinct to “fight or flight.” Frequently in my Ironman races, my blood sugar goes too high right after the swim and during the first two hours of the bike. Hard for me to figure, but it is probably due to my adrenaline getting on the bike and eating a bit too much during the first hour on the bike. During lengthy strenuous exercise, to protect you from running out of fuel (endurance athletes call it “bonking”) your body dumps glycogen stored in your liver into your blood as an emergency source of glucose to burn, which can cause you to go high. But sometimes you still go low anyway because you’re burning it up faster than it is produced or it runs out.
I know your frustration. Sometimes I will eat the same thing before and during the same workout that I did another day, and my blood sugar is vastly different. If you’ve analyzed the above factors and still have no answer, it could be stress, anxiety, illness or other factors that influence your hormone and endocrine system. Hang in there! Control what you can! The unexplained happens to all of us!
4. I am a grossly obese diabetic at age 60, with limited mobility due to severe osteoarthritis in all major joints, and limited exercise due to the need for a cane. How can I lower my blood glucose enough and not feel hungry and depressed?
Exercise and proper diet is the answer. There are many exercises you can do with little or no impact, so gradually ease into an exercise program after consulting with your physician. Anything to get your heart rate up safely. Walking is always the best exercise if you can do it. You may have to join a health club for others, but consider it an investment in your life. Water aerobics and stationary bicycles that work your arms and legs are great choices. Eat more green vegetables, salads and lean meats, and fewer carbohydrates, and fat. Eat fruit as snacks and dessert. Eat whole wheat crackers rather than potato chips and fries. Cut our fried foods, casseroles and dishes cooked in fat, butter and heavy creams. You can get full on healthy foods and the weight will come off with consistent exercise. You can do it!