Not to be replicated without permission

Running with diabetes

Marathons and beyond

Søren Kruse Lilleøre

Copenhagen, Denmark

Not to be replicated without permission

• I’m employed by Novo Nordisk

• But I’m giving this presentation as a private person

• I have received sponsorships and speaker fees from:

• Abbott Diabetes Care Denmark

• Novo Nordisk

• Medtronic

• Roche Diagnostics

Disclosures

Not to be replicated without permission

Running with diabetes

Not to be replicated without permission

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Every story has a beginning

1st half-marathon May 2002

2nd half-marathon Sep 2002

1st sports injury Oct 2002

D-day Nov 2002

Fatigue

Thirst

Urination

Weight loss

Not to be replicated without permission

Basics of insulin therapy*

Blood glucose Physical activity Diet

Insulin

HbA1c ≤6.5%

*Based on personal experiences

Not to be replicated without permission

• Objectives

• To demonstrate that diabetes is a condition without limitations

• To show that diabetes can be managed effectively through an active/healthy lifestyle

• Outcome

• To change how people perceive diabetes

• To motivate and inspire others

Marathon running with diabetes A demonstration of control

Not to be replicated without permission

• Insulin sensitivity

• Insulin-dependent glucose transport

• Less insulin is required

• Muscle contractions

• Insulin-independent glucose transport

• Less insulin is required

• Hepatic glucose production and release

• Counter-regulatory stimuli

• Suppressed by insulin

• Some insulin is required

The effect of physical activity

*Based on personal experiences

Not to be replicated without permission

Meal-time checklist*

1

2

4

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7

Current blood glucose

Next meal? When, what and how much?

Post-meal exercise? Reduction in insulin dosage

Pre-meal exercise? Increased insulin sensitivity

Previous injection? Time, type of insulin and dosage?

Previous meal? When, what and how much?

What to eat and how much? Composition of diet?

*Based on personal experiences

Not to be replicated without permission

The effect of physical activity*

Measure Inject and

eat Measure Run Measure

Insulin dose (basal and bolus)*

Meal size and post-prandial blood glucose*

Effect of duration and intensity on blood

glucose*

*Based on personal experiences

Not to be replicated without permission

Marathon running with diabetes* Trust your senses

Finish Start Race

8-10 mmol/l 5-7 mmol/l ???

Hypo? Hyper? Exhaustion?

Perceived blood glucose

Glucose? Glucose? Glucose ?

*Based on personal experiences

Not to be replicated without permission

Marathon running with diabetes

Copenhagen Marathon 2003

Target: <4:00

Finish time: 3:40 Finish time: 3:13

Copenhagen Marathon 2005

Target: <3:00

Copenhagen Marathon 2004

Target: <3:15

Finish time: 2:57

Not to be replicated without permission

The basal dilemma* Finding the right dose is difficult

Hypoglycemia

Hypoglycemia during morning exercise

Hyperglycemia in the afternoon or between

meals

Hyperglycemia

Solution

Reduce basal insulin* Increase basal insulin*

Solution

Based on personal experiences

Polar Circle Marathon 2005

-19° Celsius

Not to be replicated without permission

World Tour 2007

February

May

April

September

November

December

June

HbA1c above target

Great Wall Marathon

Vienna City Marathon

Berlin Marathon

Thesis defense

Honolulu Marathon

Big Five Marathon

7.7 %

New Year Marathon December

Great Wall Marathon

Not to be replicated without permission

Big Five Marathon

Medical check before entering the valley of lions

Big Five Marathon Finisher

Not to be replicated without permission

Practice makes master

February

May

April

September

November

December

June

HbA1c above target

Great Wall Marathon

Vienna City Marathon

Berlin Marathon

Thesis defense

Honolulu Marathon

Big Five Marathon

7.7 %

6.8 %

6.4 %

6.6 %

New Year Marathon December

Not to be replicated without permission

Marathon routine*

CHO-rich dinner

Breakfast 3-4 hours before race start

Continuous BG measurements prior to race start

Water and diluted energy drink at fuel

stations

Energy bar: 21.1 km

Energy bar: 30 km

Energy bar: 37 km (optional)

Post-race BG target

Activity BG Basal Bolus

8 mmol/l

5-7 mmol/l

Post-race dinner

Bed-time 5-6 mmol/l

Bed-time

?

5-6 mmol/l

1-2 U if BG >8 mmol/l

*Based on personal experiences

Not to be replicated without permission

Berlin Marathon 2007 First marathon with CGM

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08:00 08:30 09:00 09:30 10:00 10:30 11:00 11:30 12:00 12:30

Sensor

Glu

cose (

mm

ol/

l)

Time

Not to be replicated without permission

Marathon routine revisited*

CHO-rich dinner

Breakfast 3-4 hours before race start

Continuous BG measurements prior to race start

Water and diluted energy drink at fuel

stations

Energy bar: 21.1 km

Energy bar: 30 km

Energy bar: 37 km (optional)

Post-race BG target

Activity BG Basal Bolus

8 mmol/l

5-7 mmol/l

Post-race dinner

Bed-time 5-6 mmol/l

Bed-time 5-6 mmol/l

1-2 U if BG >8 mmol/l

*Based on personal experiences

Not to be replicated without permission

Athens Classic Marathon Blood glucose profile (CGM)

Not to be replicated without permission

A random marathon* July 2011

5.2

7.8 8.2

6.8

4.9 4.8 4.7 4.8

6.9

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21:49 22:50 05:04 07:26 07:47 08:57 09:50 10:45 11:49

Blo

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mm

ol/

l)

Time

Energy bar Maxim (40 g)

28 g CHO

Energy bar Maxim (40 g)

28 g CHO

Energy bar Maxim (40 g)

28 g CHO

Start: 8:00 Finish 11:41

8 U Basal 5 U Bolus

*Based on personal experiences

Not to be replicated without permission

A random marathon* August 2011

7.6

10.9

6.4

4.6 5.1 4.6

6.2

10.0

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21:40 04:00 05:39 06:50 07:42 08:35 09:33 10:29

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Time

Energy bar Maxim (40 g)

28 g CHO

Energy bar Maxim (40 g)

28 g CHO

Start: 6:00 Finish 9:33

8 U Basal 5 U Bolus

144 BPM

153 BPM

*Based on personal experiences

Marathon des Sables 2009

Not to be replicated without permission

Marathon des Sables Facts

• The toughest foot race on earth • 200 – 240 km over 6 stages • 850 participants

• Participants must carry their own food, clothing, mandatory and personal

equipment • Maximum 15 kg is allowed, minimum 6.5 kg is required • Minimum 2000 kcal/day

• Water is provided in limited amounts in 1.5 litre bottles

• 1.5 litres before each stage, 1.5-3 litres at checkpoints and 4.5 litres after each stage

• Bivouacs are made available between stages

• 8 participants in each

Not to be replicated without permission

What to bring?

Food and energy

X 3

~2750 kcal/day

Diabetes management

Insulin and devices Insulin pens • Basal (3) • Bolus (3) Needles (90) Glucose monitoring Blood glucose meters (3) • 150 test strips Continuous glucose monitor (1) • 3 sensors

Not to be replicated without permission

Stage 1 (35 km)

Not to be replicated without permission

Stage 3 (91 km)

Challenge #1

Mountain after 60 km

Challenge #2

Followed by dunes

Challenge #3

Darkness

Not to be replicated without permission

Stage 3 (91 km)

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lucose

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Time

1 U bolus insulin*

Pre-breakfast: No bolus insulin* 4 U basal insulin*

2 U bolus insulin*

*Based on personal experiences

Not to be replicated without permission

Stage 4 (42.2 km)

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Marathon des Sables 2009 Daily overlay

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In the media

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Lycian Way Ultramarathon

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Lycian Way Ultramarathon 2011

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Lycian Way Ultramarathon 2011 Daily overlay… Saved by CGM

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Time (hh:mm)

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

Marathon des Sables 2012

45° Celsius

Rough terrain

Stage 4 (81.5 km)

Stage 4 (81.5 km) More than 21 km of dunes

Sandstorm

Not to be replicated without permission

Before stage 5 Blister management

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Stage 6 Finish line

#129

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#100

Olympus Marathon

RunFire Cappadocia Ultramarathon

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Stage 5 (104 km)

Presentation title Date 55

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Marathons 2003-2013

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Concluding remarks*

• Diabetes management is a full-time job • Continuous adjustments in insulin regimen according to exercise, diet and lifestyle

are required

• Frequent blood glucose monitoring is essential

• No limitations • Diabetes is not a limitation for an “active” life

• Everything is possible, but planning is necessary

• Prepare for the worst, hope for the best!

• Practice makes master

• Nobody is perfect • Everybody makes mistakes

• Unless repeated, they are an important part of a learning process

*Based on personal experiences