Rowing

By Sir Steven Redgrave

Training at high level with diabetes was extremely difficult. I managed to train at the highest possible level by following some very simple rules.

Training for me was an average 16 -24 sessions per week in a highly intensive endurance sport / rowing. 90% of our training sessions were endurance based, holding a heart rate of between 120 -160 for an average of 1 hour 45 minutes.

I treat my diabetes with insulin injections, and learnt very quickly that if I had a lot of insulin in my system my blood sugar levels would plummet quickly with this form of training. We had to come up with a regime that enabled me to still be part of the same training regime as the rest of my crew, but allowed me to control my blood sugars.

Testing and Insulin

I would test my blood sugar levels first thing in the morning. Take between 1 and 3 units of short acting insulin with breakfast, a bowl of cereal and a cup of tea. Within an hour of breakfast I would be involved in my first training session. By taking such small quantities of insulin I would hold my blood sugar level at a good level without causing it to drop too low. After the first training session I would have a second breakfast, having something a little more substantial to eat and plenty of fluid; working on the same principal of just a few units of insulin. We would have about a 2 hour break between training sessions. The second session would be slightly shorter in duration, but more intensive. I would follow this principal for the rest of the training day.

Once training had finished I would then try to get as much insulin into my system as possible, trying to regain the glycogen stores for the next days training. I would be using a mixture of short acting insulin and long acting insulin. I felt that the long acting insulin was as vital as the short acting for me to succeed in what I was trying to do. The short acting giving me the flexibility to do the training that was needed, the combination of the short and long giving me stability of my blood sugar levels and allowing refueling to occur.

Minimising fluctuations in my blood sugar whilst training, just after training and during the night became crucial to the overall control of my diabetes. I tested my blood sugar before and after every training session, sometimes during a session and kept a log to assess the highs and lows that were occurring, thereby adjusting my control accordingly aiming if possible to keep my blood sugar in the same range as a non diabetic.

One problem I had due to the volume of training required was keeping the energy up. Sugar levels were less of an issue because the volume of training done dropped the blood sugar levels. There was always a refueling problem.

The Olympic Games

In the last few months leading up to the Olympic Games we tried taking, after training sessions and especially the last training session of the day, glucose drinks allowing me to take extra insulin in an attempt to help refueling. On training camps we would work to a 2 and a half day schedule, 4 sessions in the first 2 days: 2 sessions in the morning, early afternoon as a rest period, one session late afternoon and one session in the evening. On the third day we would do 2 sessions in the morning and then rest for the next half a day. This programme would be repeated throughout the training camp. The problem I found with this regime is that I would be holding my blood sugar levels all day, just taking a few units of insulin with meals; probably up to 12 units on a very intensive day. We had determined that I needed approximately 50 - 70 units of insulin per day to restore the energy used, and on this regime I could not take on board all I needed to prepare for the next day. Training camps were very difficult!

When racing refueling was much less of a problem. For major races we would taper down the training, so naturally I would be able to take more insulin to restore the body for the exertion of the race; using the same pattern of having very little insulin in the system when it came to race time. By using short acting insulin I was able to have a substantial breakfast, using insulin in the normal way, but judging its lifespan to be out of the system by the time of the race. I found managing races much easier than the problems I encountered during intensive training periods.

Now that I have retired from sport I find myself naturally needing more insulin to control my diabetes.

When I was first diagnosed in 1997 my immediate reaction was that I would have to stop training, I'm glad to be able to say I was wrong – it is possible to train at a high level as a diabetic and succeed. I can’t say it was easy though!

Oxford and Cambridge Boat Race by Fred Gill

In November 2007, my last year at Newcastle University and my third year of rowing, I was diagnosed with diabetes. This was the year when I was determined to step up technically and physically as a rower but instead I battled with increasingly poor performances. Neither my coach nor I could understand what was going wrong. I stubbornly thought it was due to a lack of fitness and so kept pushing myself even harder.

The onset of diabetes normally occurs when the pancreas slowly decreases in efficiency to working at about 65% and often follows a large emotional shock of bereavement which causes it to stop producing insulin almost altogether. My shock was the National Indoor Rowing Championships in October 2007. I had been building up to this competition for a while and my ultimate aim was to row 2000m under 6 minutes: the desired target for all professional rowers. Despite my performance scores getting progressively worse throughout the term, I still thought I could do it. The week beforehand I lost 5 kilos, had an insatiable thirst and felt constantly exhausted. I had heard of the symptoms of diabetes and joked with my friends that I “probably” had it, but I decided to compete anyway. I “crashed” about 200 metres into my test and scraped a disappointing time of 6 minutes 25 seconds. It was after this event that my coach, Angelo Savarino, and I agreed that I should take a blood test and sure enough I was diagnosed as a Type 1 diabetic.

It never occurred to me to give up rowing: I had heard about Steve Redgrave winning his fifth gold in Sydney 2000 at the age of 38, so it could obviously be done. Furthermore, it fit well with my mentality of constantly being an underdog and always wanting to prove myself. The biggest setback at the time, however, was the end of any ambitions to join the army, but in hindsight I would have found it hard giving up rowing at that early stage.

I was surprised at how quickly I could start training again. Right from the start Angelo was brilliant. He phoned me two days after I was diagnosed and “asked” me why I hadn’t turned up to training that day. He told me about how he had coached a lot of diabetic athletes in the past and strongly implied that I should stop feeling sorry for myself and get back into the training program immediately.

As it turned out the summer season was an unprecedented success. Firstly my pair partner and I reached the “A” final of the Great Britain rowing trials and made the eight for the Under 23 World Championships later that summer. A few weeks afterwards I won four gold medals at the British University Rowing Championships, competing in 6 events and racing 14 times over the course of 3 days! The best achievement was taking our university coxed four to Henley International Regatta and winning the Prince Albert Challenge Cup.

At this stage, however, I began to not truly respect the seriousness of the disease. My mindset was exceptionally stubborn with regards to finding out more about diabetes and its effects on training. My attitude summed up would have been “its not that bigger deal, if I ignore it and carry on regardless I will be fine”.

On finishing my degree at Newcastle University in 2008, the only thing I was sure of was that I wanted to develop my rowing. A friend of mine Henry Pelly, a previous President of Newcastle University Boat Club, was studying at Cambridge University and suggested that I apply. The prospect of rowing in the internationally renowned Cambridge versus Oxford boat race is extremely appealing to many a young rower and so I applied to study Land Economy at Hughes Hall, Cambridge. After being invited to an interview, a month later I was offered a place for September 2008.

Going to Cambridge involved changing training programs from an intense Italian style program of short and high rate training, to a more conventional British program of long and low rate training. It was in adapting to this change that my ignorance of the disease started to catch up with me. I would run out of energy 20 minutes into a 70 minute training session, but I was adamant that the coaches would never use my diabetes as a reason against selecting me for the top “Blue” boat. I told them that I had diabetes but gave the impression that I was in complete control, when really I had no idea. I would always worry about having too high blood sugar levels and would give myself too much insulin before training. I remember thinking that my other teammates must be so strong to be able to walk around and chat afterwards when I was totally exhausted and hardly able to move. Throughout my first year at Cambridge my performances were extremely inconsistent. While some of my performances were good enough to merit a seat in the “Blue Boat”, underperformances, when it counted, meant I had to settle for the reserve boat “Goldie”.

After losing the 2008/9 reserve boat race in March I was extremely annoyed with my mother for organising a consultation session with diabetic sports specialist, Dr Ian Gallen. I attended what felt like an enormous inconvenience and had my life transformed in 30 minutes. Dr Gallen, who had been instrumental in advising Sir Steve Redgrave to his fifth Olympic Gold, explained all the mistakes I had been making. Consequently we sorted out an insulin regime that complemented my training: halving the amount of insulin I was taking before sessions and taking sugar at regular intervals. Without a doubt this transformed my training and racing effectiveness and made me desperate to start the 2009/10 season to put right all the wrongs of the previous year.

From day one of the new season I put myself in the mix of the tops guys: on the rowing machine, in the weights room and on the water. I was able to use every session to improve my technique rather than simply fighting to get to the end. I would take SIS carbohydrate electrolyte and gels in the boat with me and felt bulletproof again. I had secured a place in the “Blue boat” and we found a combination of myself in the stroke seat, Derek Rasmussen behind at 7 and my old friend Henry Pelly at 6, that set up the sweetest rhythm and showed me what good rowing feels like. With this combination, I knew we could win the boat race.

My personal preparation for the boat race was poor. I found living in a house with 7 other non diabetic rowers very difficult. I felt I had no control over my diet or eating routine and I was experiencing huge cycling in my blood sugars. As the training became lighter I needed more and more insulin to bring my sugar levels down. On the Wednesday before the race, in desperation, I called a club doctor, Dr John Bernstein, to get some advice. He calmed me down and changed my diet to only low GI carbohydrates and increased my slow acting insulin levels. Immediately I had more control over my blood sugars.

Two hours before the race however, they had soared to about 25, which put me in a very difficult situation. Do I race with it this high? Or do I give myself some insulin and risk “hypoing” in the middle of the race in front of millions of people? Not to mention losing the race for my teammates who had all invested so much. I decided that I couldn’t tell anyone as I needed them to have complete faith in me as the stroke man of the boat. I gave myself 3 units of fast acting insulin and for the first time that year I took my blood sugar testing kit in the boat with me. I checked it about 10 minutes before the race: thankfully it had dropped to 14.5. I took on 10 grams of sugar and got ready to race.

The nerves were intense but we managed a solid start and settled into our long rhythm that I knew was fast, only we were being beaten. After 10 minutes I started to see Oxford alongside again and we continued to row back through them. By this stage I was exhausted, I knew I was more tired than everybody else but I concentrated on just moving and the rest of the guys supplied the power. With 100 metres to go I finally allowed myself to think we were going to win and managed to pick the pace up for a showboat finish. Across the finish line there was only the relief that the pain was over before gradual realisation for what we had done. After months of training, we had finally won the 2010 Xchanging Boat Race.

My lesson to young diabetics in sport; don’t be a stubborn fool. Take all the help you can get and you can still achieve your goals. Being stubborn is very useful for getting out of bed in the morning and pushing yourself through hard training sessions but not for learning to live with diabetes.

Kelly Whittaker

Introduction

Having been diabetic since the age of four I cannot really remember life without diabetes and so my reaction to life is possibly different from those diagnosed later. I have never questioned whether it will prevent me from doing something new, as that would mean questioning whether you should enjoy life. Therefore, when I decided to take up rowing at the age of 14 I did not give my diabetes a second thought; merely went along to the training sessions with a ‘glucogel’ and a carton of apple juice. Well two years on and the diabetes was becoming a bit of a headache-literally. At the J16 level competitions were tougher and so training was increasing. At this point I was competing and performing well and just about managing the diabetes. However, after numerous successes the year was up and I was now a junior rower. With this came increased training and tougher races. Training was stepped up to a 6 day a week programme with at least one training session a day lasting two hours if not two training sessions a day, a weekend consisted of 8-10 hours rowing in total.

The Problem

 My diabetes became extremely hard to control and I found that I was unable to go any session longer than 20 minutes if at high intensity without my blood sugars running low. This made training frustrating and even harder and it became apparent that my old regime would have to change. After many blood tests; (my fingers have gone through so many in the past 15 years that I have to use the finger pricker on the highest setting), and a lot of help especially from Dr Gallen, my diabetic nurse Miranda Higgs (a fellow rower),  and my Mum; I was eventually, after much trial and error able to get to a point where I could train fully and race without suffering a hypo towards the end of a 2km regatta  - Heads are slightly different especially when they hit the 7km marker.

Problem solved?

To be able to perform at my best I needed to keep my blood sugars at a stable level throughout the entire session. I noticed that when the training was a long cardio session on a bike or running I was hypoing a lot less often. When I came to analyse this I realised that it was because unlike when on an ergo or in a boat I was constantly taking on fluids.  Previously I was drinking high juice, Ribena or Lucozade. However, although these are a source of carbohydrate Dr Gallen suggested I try maximuscle viper as this is a simple glucose and so can be used quicker by the body. I soon noticed a difference and was performing much better. Constantly sipping at this drink through exercise prevents my blood from falling whilst exercising. However, on long ergos and water session I still felt my blood dropping low as was unable to constantly sip at my drink. This meant that my injections and carbohydrate intake before, during and after sessions needed to be re-evaluated. I began by making sure that I was intaking enough and the right sort of food before exercise. I aimed to eat at least an hour before exercising and based the meal around a slow releasing carbohydrate. I also cut down on my insulin intake giving ½ to 1/3 of my normal novorapid amount. On weekends with the high intensity of the sessions I cut down my insulin intake even further reducing my lantus by 20% on a Saturday and Sunday and 10% on a Monday. I found this worked extremely well and I strongly preferred the fact that the changes in novorapid had a greater impact on my blood sugars.

Racing

Although this made training much easier racing was still a problem and this is when it was most important to avoid a hypo, as well as having my blood sugar in the right range so that I could perform at my best. Therefore, I tried using a different insulin in the build up to races. This is called humalin I . I cut out my long acting insulin i.e. the lantus and injected 2/3 of what I would have given in lantus in humalin I If the race was less than 2 hours after breakfast or lunch then I would cut down my novorapid with that meal depending on my blood glucose level. After racing I ate as soon as possible and gave a dose of novorapid so as to replace my glycogen stores by forcing my liver to take up glucose.

Although it took a lot of hard work it was well worth it and there was a noticeable difference in my performance after taking these steps. I would like to thank Dr Gallen for all his work and advice, my Mum and Miranda for all her effort.

Marathon Rowing

By Alex Piper, Alison Piper and Sarah Haws PDSN

Alex was diagnosed with type 1 diabetes at the age of 11 years, nearly three years ago. On Sunday September 17th 2006 he rowed in the Junior Under 15 years Coxed quad group to complete the Boston Rowing Marathon.
The Boston Rowing Marathon is a gruelling 31-mile course along the River Witham, starting at Stamp End Lock in Lincoln and finishing at the Boat House, Carlton Road Boston.The four boys from the King’s School Ely completed the course in 5 hours 10 seconds, under the instruction of their Cox who is also their geography teacher.
A fantastic achievement, and a real bonus was finding out that they had won their group.

Paediatric specialist nurse perspective

Alex has continued to compete in a wide variety of sports ever since he was diagnosed with diabetes. However when Alex and his mum came to discuss his desire to compete in this 31 mile rowing marathon, he threw out a challenge to the paediatric diabetes team too!

Initial discussions were primarily around safety, and how we could ensure Alex had access to the appropriate glucose supplies, and carbohydrate snacks whilst in the quad. Background research, and hours spent pouring over the ‘Runsweet’ website; correspondence with Dr Gallen and discussions with our dietician Jane indicated that taking on board huge amounts of fluid, and having to be 5 – 6 hours on the river was not a good option. A glucose containing drink using Polycose powder ensured Alex received 30g of carbohydrate in just 100mls of liquid. Sports drinks were also available to him to ensure he otherwise remained hydrated.

Alex recorded his blood glucose levels as frequently as possible during the 2hr 30 minute practice sessions and fastidiously monitored his carbohydrate intake (in conjunction with mum!) One significant issue with the training was that the rowing was much more intense – shorter faster bursts of activity as opposed to the very prolonged nature of the marathon. This in itself would influence the blood glucose profile. Following training sessions we would meet to discuss results and changes that could be made. We were also very aware that our final plans would still be based on a period of rowing that was half that of the actual event!

Alex found consuming food following strenuous exercise quite difficult, and late night low blood sugar levels and having to consume carbohydrate every hour to maintain levels of 4-5mmol was a problem initially. All Alex wanted to do at this time was sleep!

Later refinements to his Novorapid ratios (40 – 50% of usual dose with the evening meal) resulted in higher early evening blood glucose levels, but no need for additional food / fluid through the night, and a waking level of around 6mmols. Rudimentary maybe- but we were also dealing with a young man who needed to function effectively - without sleep deprivation at school the following day!

A variety of blood glucose meters were considered – those which use a pre-loaded barrel & automatic strip dispensing, and pre loaded finger lancers too – however Alex opted for the security, and deftness that surrounded his own blood glucose monitor, and on this occasion just re-used his lancet whilst on the river.

We would like to share details of how we approached managing Alex’s diabetes on the day of the race with adjustments both before and after the race.

These are not intended in anyway to be prescriptive and are not a set of ‘perfect’ or ‘ideal’ results.

They also reflect the fact that there was no trial run for the race and the only training data was extracted from the 2hr 30 minute school rowing practices!

These results also reflect the fact that in managing diabetes and sport in paediatrics, children fit into educational regimes that are not under their control- (sports training after lunch at the peak of the Novorapid profile produces a different set of results to racing on the background insulin only). Not to mention the effects of stress hormones on blood glucose levels.

“Adrenaline stimulates hepatic glucose production during prolonged intense activities by facilitating the mobilization of the precursors of gluconeogenis” (Mitchell et  al 1988 cited in Nagi 2005).

The influence of growth hormone is also an important factor within paediatric practice, and Alex’s normal daily insulin requirements at the onset of training were different to that later on towards marathon day. 

Alex Piper- Age 14 years

'The Boston Marathon is a physical and mental test that pushes you to the limit. The race was hard and there were times during the race, particularly in that period after the half way mark where physically I did not want to continue. Mentally, however there was no question of giving up and that carried me through.
 
I did not really worry about my diabetes because of all the preparation that had been done, and I thought I was carrying enough sugar in various forms on the boat. I knew that I had to avoid going low and that it would be extremely difficult to play ‘catch up’ for the rest of the race if I started low.

When the pain stopped, and I look back at what I have done, the Boston Marathon is an achievement that I will never forget.’

A Mothers Perspective

Alex was diagnosed with type one diabetes on October 6th 2003.

Starting off on a mixed insulin regime it soon became apparent that this was an ill-fitting match for his busy lifestyle and the different sports he was pursuing. Living in West Norfolk and travelling to school 30 miles away in Ely added to the problem.

Nine months after diagnosis Alex transferred onto 4 injections a day using Lantus as his basal insulin and Novorapid with food. He combined this insulin regime with a carbohydrate counting system for his food.

The transfer onto 4 injections a day was such a liberating change with respect to managing his blood sugar around sport that even the four injections and extra testing were worthwhile. Of enormous help was access to the DIGBY education programme at Addenbrookes via our diabetes nurse in West Norfolk, such that at the moment Alex has been able to achieve optimal long-term diabetes control, with his HbA1c’s all below 7.6%.

When Alex first mentioned that he would like to compete in the Boston Rowing Marathon with other boys from school, my initial thoughts were that this might be the activity we have to say ‘no’ to. To date he had done exactly the same activities as the other boys with careful diabetes management behind the scenes, however at the end of the day he still has diabetes and it is no good pretending it is not there.

Alex was quick to see my hesitation ‘Not good enough’, in true adolescent style he would only accept a ‘no’ if there was a good medical reason.

Throughout the process of contacting the doctors, there was tremendous support for Alex’s proposal and the information started to emerge about how it may be possible to manage Alexs’ diabetes throughout the race and in the period afterwards.

The local health service team wished to consult and use Dr Gallen's specialist expertise for which we were all so grateful. Our paediatric diabetes nurse, an untiring support, worked to produce the final details of the change in insulin regime and intake of carbohydrate.

The Kings School Ely took their usual calm and balanced approach to managing risk with the emphasis on how to manage the challenge giving the full weight of their support. Throughout the time Alex has been at school, there has been a strong liaison between the PDSN and the school, which is extremely reassuring as a parent. I am grateful to the teachers who pause and stop their busy schedules to find the time to learn and understand about diabetes.

On the day of the race I was confident that Alex was safe, his diabetes could be managed on the river, and just immensely proud to have a son who is prepared to undertake these challenges and it doesn’t really occur to him not to do it.

As the boys came sprinting down the final stretch of water and I could hear the voice of their Cox Mrs Thomas, there was a mixture of pride and relief.

I had enough glucose in the car to feed the whole of Boston (it’s a mother thing, you always take extra in case you need it).
Alex finished the race with a blood sugar of 9mmol/l.

Summary

1: Alex’s background insulin (Lantus) was reduced down by 30% on the day before the marathon, and by 43% on the day following the marathon.

With the data available we would consider keeping these basal dose reductions the same if he was to do the marathon again.

A low level of plasma insulin is required to allow hepatic glycogenolysis, and an increase in glycogen concentration is required for glycogenolysis and gluconeogenisis. (Nagi 2005)

Alexs’ Novorapid Insulin was reduced down by 50% for breakfast on the day of the race and we would also repeat this adjustment given the same situation.

We also suggested that Alex did not change to a completely new injection site for the race due to the potential effects on insulin absorption. (Colberg 2001)

2: Glucose ingestion during the race was essential, however we would in the future try and persuade Alex to follow a regimen whereby his intake was more relative to his blood glucose level. i.e if his blood glucose test was 14/15mmol/l he would take in 30g of carbohydrate - thus producing a more even spread of blood sugars throughout the race.

The use of carbohydrate- electrolyte solution was used for its glycogen spearing effect, but also for the prevention of dehydration and proposed improvement to performance during endurance events.

3: The post race snack was covered by only 45% of Alex’s usual Novorapid Dose. In hindsight next time we may have increased this to 70-80%. We would still keep the teatime Novorapid at around 70% of the usual dose. This would hopefully better balance the increased rate of glycogen repletion immediately after exercise without resulting in hypoglycaemia, and lessening the period of hyperglycaemia that Alex experienced in the early evening.

We were hoping to be able to record Alex’s blood glucose levels once off the river by means of a continuous glucose monitoring system that our team has recently purchased, however logistics meant it did not arrive in time, so we will have to save that for his next adventure!

Alex completed the marathon through a combination of his own physical & mental strength, & the dedicated support of his family. He did not once consider that having diabetes would prevent him from competing in this arduous event! Picture 259 (Group) and/or picture 215 (Alex) ß Clodagh

 Alex’s Marathon-A Team Effort

 Thanks

Enormous thanks to the boys on the boat 

            Robert Deamer

            Max Hutchins

            Laurence Dugdale     

            And their coxswain Mrs Jane Thomas

 

And to the team from the Health service and Kings School, Ely who made the Boston Marathon possible. Their knowledge, support, and professionalism gave us the confidence to go forward.

 
Dr Gallen, Consultant Physician. Buckinghamshire Hospitals NHS Trust.

Sarah Haws, PDSN, West Norfolk PCT

Jane Little Chief Dietician Queen Elizabeth Hospital, Kings Lynn

Dr Dennis Barter, Consultant Paediatrician Queen Elizabeth Hospital, Kings Lynn

Dr E Nicholls, Dr P Tasker GP’s St James Medical Practice. Kings Lynn

 

Mrs Jane Thomas, Head of Geography, The King’s School Ely. Coxswain for U15 Quad at Boston

Mr Edward Davis, Master of Biology, History and Rowing Coach, The Kings School Ely

 

Miss E Knibb, Senior Mistress, and Risk Management Co-ordinator. The King’s School, Ely.

 

Finally Thank You Mr Jeff Elms Chairman of the Race Committee, and his team of Marshals at The Boston Rowing Marathon, for welcoming Alex into the competition.

 

www.bostonrowingmarathon.org.uk

 Photographs by Clodagh

www.clodaghphotos.co.uk

 

 

References:

 

Colberg S (2001) “The Diabetic Athlete. Prescriptions for exercise & sports” Human Kinetics. USA.

 

Nagi D (2005) “Exercise & Sport in Diabetes” 2nd Ed. Whiley. England.