Don't Let Diabetes Slow You Down
By Judy Foreman
03/23.2004

For ordinary mortals, just finishing an Ironman Triathlon is almost unimaginable. You swim 2.4 miles, dodging hundreds of other adrenalin-crazed swimmers, then hop on your bike to pedal for 112 miles, then don running shoes and run, jog or limp your way through an entire marathon, all 26.2 grueling miles. If you actually want to win, you do this in roughly 9 hours.

But Jay Handy, 41, a financial advisor at Merrill Lynch in Madison, Wisconsin not only  DID all this -- albeit more slowly than the winners -- but he DID it with Type 1 diabetes, which he has had since he was13. He’s training for another Ironman in September.

Diabetes, which is on the rise and now strikes an estimated 18.2 million Americans, is a nasty disease in which the body doesn't make enough insulin, a hormone made in the pancreas that helps glucose, or sugar, get from the blood into muscles. Diabetes is the sixth leading cause of death in the US and is the leading cause of adult blindness; it can also lead to kidney failure and, when circulation to the extremities fails, to amputation of feet or lower legs.

In the old days, people with diabetes were often cautioned not to exert themselves, lest their blood sugar fall too low, which can lead to coma, or rise too high, which can also lead to coma. But the thinking today is that, with some caveats, exercise is at least as crucial for people with diabetes as for those without it.

"Everybody with diabetes should be exercising as much as possible," said Dr. Christopher Saudek, a diabetologist at the Johns Hopkins University School of Medicine and former president of the American Diabetes Association. "The quip we use is that people with diabetes should ask their doctor before they STOP exercising."

In Type 1 diabetes, the body makes no insulin, which means a person must monitor blood sugar several times a day and take insulin injections. In the more common Type 2, which accounts for 90 percent of all diabetes in the US, a person becomes "insulin resistant," meaning the body doesn't respond to insulin. Excessive weight and inactivity make a person

insulin-resistant. Type 2 can sometimes be controlled by diet and exercise alone. To do an Ironman safely as a diabetic athlete, Handy must check his blood sugar every hour and either eat extra carbohydrates or give himself insulin, depending on whether his sugar is too low or too high. He's rigged his bike so that he can prick his finger, dab a drop of blood onto a test strip and put the strip in a monitoring device taped to his handlebars -- all with one hand.

It takes trial and error to figure out the specifics -- like exactly how many carbs to eat when blood sugar starts to crash. "But once you crack the code for yourself," he said, "you've got a whole new lease on life."

In people with diabetes, as in normal people, exercise makes the body more sensitive to insulin, which means less insulin is needed to escort sugar into cells. This is a good thing, but it means that diabetic athletes may have to cut back on insulin before exercise so blood sugar does not plummet.

"Think of exercise as insulin," said Dr. Om Ganda, an endocrinologist at the Joslin Diabetes Center in Boston. Exercise "makes you more insulin sensitive." With exercise, you can "get away with less insulin so the pancreas doesn't have to exhaust itself" trying to make enough, he added.

The cautions for diabetics who want to exercise:

§        Caveat 1: Because diabetes significantly raises heart disease, anyone with diabetes should have his or her heart checked by a doctor before beginning an exercise program, said Dr. David Harlan, a diabetes specialist at the National Institute of Diabetes, Digestive and Kidney Diseases, part of the National Institutes of Health. Indeed, heart disease is the leading cause of death for people with diabetes.

§        Caveat 2: Diabetic neuropathy also means that people with diabetes may not notice incipient blisters on the feet, which can become infected. Diabetes also causes poor circulation to the extremities, which means a foot infection can become gangrenous, leading to amputation. To prevent this, people with diabetes should check their feet often. Medicare will also pay for special shoes if you are over 65.

§                    Caveat 3: People with diabetes should also have their eyes checked because of diabetic retinopathy, in which blood vessels in the eye become leaky. Running or other high-impact sports can make this worse.

In some cases, regular exercise can actually get rid of the need for insulin in Type2 diabetes.

Indeed, "fitness or how much you exercise is way, way more important than how much you weigh," said Dr. Timothy S. Church, medical director of the Cooper Institute in Dallas and co-author of a recent paper on exercise capacity in diabetic men.

Joanne Miegel, a 58-year old women from Brighton, who used to weigh 288 pounds, found that exercising at the gym at Joslin allowed her to lose 75 pounds and get off insulin. "Without the exercise, I would not have lost the weight and certainly would have still been on insulin," she said.

As for Jay Handy? He finished last fall’s Ironman Wisconsin “dead last ,but still alive.” Excruciating leg cramps forced him off his bike several times and meant he had to walk large chunks of the marathon. By the time he finished – 17 hours – the race crew was literally loading equipment into trucks. But as he later would write, “I focused on the sheer ability to finish. I could never hold myself as an example to diabetic kids if I just quit.”

Judy Foreman is a Lecturer on Medicine at Harvard Medical School. Her column appears every other week. Past columns are available on www.myhealthsense.com.

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