Endurance sports with diabetes

Janet Kramschuster, Tidepool’s VP of People and Finance at Tidepool, is an avid endurance athlete. Most recently, she completed an Ironman 70.3 race. That’s a 1.2 mile swim, followed by a 56 mile bike ride, and finishing with a 13.1 mile run. Inspired by her efforts, we’ve asked Janet to reflect on this accomplishment and share her perspective on how far she’s come since her diabetes diagnosis over 34 years ago.

Please consult with your healthcare provider before pushing through an endurance sport while managing low blood sugar.

What is your role at Tidepool?

My current title is the VP of People and Finance. I get to support all of our human resources processes and finance management.

When were you diagnosed with type 1 diabetes?

I was diagnosed on January 26th, 1987.

An Ironman 70.3, or Half Ironman, is no joke. How did you develop an interest in this kind of endurance sport?

I have participated in all three sports on and off for most of my life. I started running in junior high and high school. I gained an affinity for open water swimming as a lifeguard in college. And while I’ve always known how to ride a bike, roadbike physical endurance was something new to me. When I competed in my very first Tri for Fun triathlon—a shorter distance version of a full triathlon—I learned how to ride a road bike, understanding the proper way to sit, pedal and signal other riders and cars.

My first Tri for fun Triathlon was in 2018. I was intimidated by all the other athletes who were there, but I set a goal to just finish, no matter the time. And after I completed that first race (and overcame some panic in the water), I knew I was hooked. Since then, I’ve taken on longer races over the years which recently culminated in this Half Ironman. This was my second of three Half Ironmans and they keep getting better!

How did you train and prepare for this most recent Half Ironman (physically)?

I worked with a triathlon coach who set my workouts every week. A typical week involved training six days of the week, often with two different disciplines per day. One day might involve biking and swimming and another would be running and swimming. I had very specific assigned workouts to help build my endurance; workouts that challenged both my heart and mind. Some days were meant to be easy, and some days were were intentionally hard. The training workouts ranged anywhere from an hour a session to five hours a session depending on where I was in the training. Every Sunday evening, I knew what my week was going to look like based on what my coach had assigned. I worked closely with her and sometimes we would have to modify the assignments based on what else I had going on and how I was feeling.

My goal for every race I do is get to the starting line. Then my goal shifts to get through the swim. Then to get to my bike. Then to get to the run. I take it one mile or one stroke at a time depending on what is going on.

There are people from all different states and countries at these races. We all have our own story to tell and each and every mile is a different story.

How did you train and prepare for this most recent Half Ironman (as a person with diabetes)?

Training is a challenge as far as diabetes is concerned. Every single day is different with different obstacles depending on the discipline, external stresses, hormonal cycle, kid stress, sleep, hydration etc. Every training is an opportunity to practice what may or may not happen during the race. If I'm out on a training run and I go low, I try to handle it the same way I would if this were the actual event. Calling my husband to pick me up during a race is not a realistic option. Do I really want to drop out of the race? How can I fortify the decision I will have to make on race day? If I am 45 mg/dL while out on a training run, I am going to try to work through it and use it as a trial run for what I will do during a race. At Mile 5 during a race at 40 mg/dL, I don’t want to drop out of a race. I need the fortitude to say “I’ve been through this before, my blood sugar will come up and this is what I need to do”. The same is true with training when I am high. I am still going to try to go out and do it because what if that happens during the race? An Ironman 70.3 can be up to 7 hours of racing. I am going to hit highs and lows and I want to be ready for all of the scenarios. It’s also knowing when to call it quits during a training session - sometimes that is okay too because it just isn’t the right day or time. This is rare, but it can happen.

How do you use your data as you prepare for races?

Trial and error and scenario testing work best for me. For example, during a training session I know that I do best with no insulin on board. Running in the afternoon usually leads to my blood sugar tanking. Early mornings are always better for all three disciplines. Having done different races, I know that on race day my blood sugar will naturally spike due to the adrenaline response. Being 300 at the starting line is not an unlikely scenario. I can help mitigate some of this, but no two races are the same and no two training sessions are the same. If my blood sugars are a flat, in-range line through a long training session or race, I call that a win. But I know that more often than not, that is unlikely.

How did it go (physically)?

I finished!

I had 4 targets for this race, in this order.

1. Start the race.
2. Finish the race.
3. Enjoy parts of the process of competing.
4. Finish the race under 6 hours and 29 minutes, which was my time for my first Half Ironman.

I finished in 6 hours, 1 minute, and 59 seconds!

How did it go (from a diabetes management perspective)?

I had a wrench thrown into my planning from the very beginning. We had a bit of a walk to the start line which was a river swim, so at 5:20 am I had to leave my phone on my bike. No phone meant no data from my continuous glucose monitor. At 5:30 am we started the 1.5 mile hike into the woods to the start, and I wasn’t at the water until 7:11 am. As a backup I had grabbed my meter and Gu, but I had to dump my meter halfway through the hike. So from 6:00 am onwards I had no idea what my blood sugar was. When I started the hike I was 160 mg/dL, but I was 140 mg/dL when I had to leave my meter so I ate a Gu, just in case. I didn’t want to get into the rushing river to swim while trending down.

By the time I got out of the water and back to my bike I had been over two hours without the best tools to manage my diabetes. I was 300 mg/dL when I reached my bike and my devices all reconnected.

As I was riding my bike, the phone holder mounted on my handlebars broke. My phone went flying into the bushes as I was riding along the 56 mile course. I had to stop and find it, and from then on, hold it in my back pocket. I relied on my watch for the rest of the bike race. At Mile 50 on the bike, I started alarming that I was headed for a low blood sugar. I was double arrows down. At this point, I had 6 miles left on the bike and then a 13 mile run ahead of me. So I ate Gu gel, and Honey Stinger wafers until I was back up again, around Mile 5 of the run. From Mile 50 on the bike to Mile 5 on the run, I was in a really challenging space knowing I was going low and having to push through and make my legs do what they needed to do. Any triathlete will tell you, the first 2 miles of running after a long bike ride, is a hard enough transition on it’s own without managing blood sugars at the same time. My blood sugars made it more challenging. After Mile 5 on the run, I felt golden.

Do you have any advice or notes of encouragement?

I wouldn’t have tried this if I hadn’t seen other people with diabetes doing it and without much help from friends, family, and training partners along the way. It is so important to know these things are possible.

At the 70.3 event, I saw all levels of accessibility competing and completing the race. There was a visually impaired athlete tethered to her guide while they ran, swam, and biked together. There was an individual with one leg (and no prosthetic) competing. There were athletes recovering from cancer. There were people at all different levels of athleticism. The life stories of the competitors were truly endless, and it was so inspiring.

On the course everyone is on their own journey and so much of it is mental. On race day, most of us are not competing with each other but with ourselves. The camaraderie on race day is so soul filling as you hear people cheering you on. I love watching people come through the finish line after me and seeing them triumph over their challenges. There are few things more uplifting than seeing people succeed, especially at something they didn’t think they could do.

The spectators help so much. Whether it’s a 5K, 10K, a 70.3 Ironman or another big challenge, the encouragement of someone saying ‘You can do this (diabetes or not) is so powerful.

You CAN do hard things. I hope people can feel and know that you can do hard things with diabetes too.

Is there anything you will do differently next time?

I am learning how to better advocate for myself on the course, and in working with the race referees (who ensure that athletes do not break very specific rules on the course). I’m still figuring out how best to make sure I have full access to my diabetes data as much as I can but with each race I get better (and smarter) about advocating for myself and hopefully other T1Ds who are out on the course too.