søren kruse lilleøre copenhagen, denmark · marathon des sables facts • the toughest foot race...
TRANSCRIPT
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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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Marathons 2003-2013
Not to be replicated without permission
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
3
5
6
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
0
1
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3
4
5
6
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8
9
21:49 22:50 05:04 07:26 07:47 08:57 09:50 10:45 11:49
Blo
od
glu
co
se (
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
0
2
4
6
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10
12
21:40 04:00 05:39 06:50 07:42 08:35 09:33 10:29
Blo
od
glu
co
se (
mm
ol/
l)
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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09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 00:00 01:00
Se
nso
r g
lucose
(m
mol/
l)
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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09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00
Se
nso
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luco
se
(m
mo
l/l)
Time
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Marathon des Sables 2009 Daily overlay
Not to be replicated without permission
In the media
Not to be replicated without permission
Lycian Way Ultramarathon
Not to be replicated without permission
Lycian Way Ultramarathon 2011
Not to be replicated without permission
Lycian Way Ultramarathon 2011 Daily overlay… Saved by CGM
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6.00
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00:00 00:45 01:30 02:15 03:00 03:45 04:30 05:15 06:00 06:45 07:30 08:15 09:00 09:45 10:30 11:15 12:00 12:45 13:30 14:15
Blo
od
glu
co
se (
mm
ol/
l)
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
Not to be replicated without permission
Stage 6 Finish line
#129
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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Marathons 2003-2013
#100
Olympus Marathon
RunFire Cappadocia Ultramarathon
Not to be replicated without permission
Stage 5 (104 km)
Presentation title Date 55
Not to be replicated without permission
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2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Marathons 2003-2013
Not to be replicated without permission
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