Friday, September 14, 2007

Ironman Louisville, August 26, 2007

[Note: I find that I get a diverse mix of visitors to my site and blog, those that know a lot about triathlon and nothing about diabetes, and those that know a lot about diabetes and nothing about triathlon. I try to make my reports understandable for both!]

Disappointing and frustrating. That was my Ironman Louisville. I came to this race fit, having placed top 5 to 15 overall in recent shorter races this year, and feeling the fastest I’ve been since I broke my clavicle and had surgery in March 2006 that put me out most of last year. But I’ve learned from 13 Ironmans that anything can happen, . . .no, something will happen, on race day. You can’t take it for granted just because you’ve done it before. No Ironman goes exactly right, it’s too long and grueling. I guess that’s one of the reasons I love this sport - it teaches you to overcome and adapt, persevere, keep going, make it to the Finish Line.

But IM Louisville ended for me at mile 8 of the marathon, riding with medics back to the race medical tent. Severely dehydrated, hypoglycemic, and nauseous. For 8 hours I swam 2.4 miles, cycled 112 miles, and then suffered (staggered) through 8 miles of the marathon, until I physically could not go any more.

That’s okay. I’ll be back. Here’s how it went . . .

Louisville was my 14th Ironman. Racing Ironman with diabetes, especially in the 90+ degree August heat in Louisville, requires a precarious nutritional balance of monitoring blood sugar, insulin dosing, carbohydrate consumption and hydration. Monitoring carbs and hydration are important for every Ironman triathlete, diabetes just makes them really important. I also have to keep a few extra “diabetes” supplies to get me through the race:

Diabetes race day supplies:
4 One Touch Ultra blood sugar meters for
2 transition bags and 2 Special Needs bags
Omnipod insulin pump
attached to my arm
Omnipod PDM (carried in a pouch on my Fuel Belt) to administer a bolus
of insulin or change basal rate
extra Omnipod (in my swim-to-bike transition bag) if my pod gets ripped off my
arm during the swim
insulin (in the swim-bike transition) if I have to replace my pod after the swim
medi-cool pouch to keep insulin cool

Ironman triathletes are already obsessive compulsive type-A organizers (how else could we do this sport?). My diabetes stuff is just a few more things on the long list of “normal” things we all obsess about and keep up with before and during the race:

race apparel (skin suit or tri shorts and top)
swim goggles and cap
wetsuit (not today)
ankle strap with timing chip
bike (including carbon aero bars, race wheels, race tires, race cranks, race pedals, etc.)
helmet
cycling shoes
socks
sunglasses
water bottles
spare tire
CO2 cartridge
heart rate chest strap
bike pacing
cadence
power output
avoiding drafting
nutrition bars and gels
run shoes and hat

Sometimes it feels more like I’m packing for an Everest mission.

I’d been training for months in the hot, humid South Carolina summer so I was prepared for the conditions. For me racing any Ironman is a high wire nutrition juggling act I’ve done all over the world in all kinds of conditions – Florida (humid heat), Lake Placid (cool rain), Idaho (dry heat), Virgin Islands (humid heat), Australia (extremely dry heat), Sweden (cold rain) and Denmark (cool dampness). Get it right and I’m loving it (e.g., 9:47 at IM FL 2004). Get it wrong and . . . ugh, IM Louisville 2007. Just try to keep it together until about the last 10 miles of the marathon, when everyone feels miserable. Fun! Ha! At that point I just gut it out to the Finish Line and collapse with satisfaction. Nothing hurts at the Finish Line.

But in Louisville it all started to fall apart much earlier, several hours earlier, at about mile 85 of the bike, 5 hours into the race. Ironically, that’s when an Ironman race really “starts” – mile 85 of the bike. Everything before that is just 5 hours of warm up.

SWIM

The swim was in the Ohio River, a very large river usually filled with barge traffic, not swimmers. Even had signs along the bank that “Swimming is Prohibited.” Ha! Nice. (Not exactly the pristine mountain waters of Ironman Lake Placid, NY.) On top of that, heavy rains and flooding upriver in Ohio had increased the current so much that the swim course was changed 2 days earlier. We now started ¾ mile up river from the transition area in a narrow strip of protected water for a small marina, shielded from the main current by a long island. So narrow that it would not accommodate the usual 2000 athlete “ultimate fighting” mass swim start, so it was a “time trial” start, the first in Ironman history. We’d dive one-by-one into the river like parachutists jumping out of the back of a plane. For this reason I got to transition early at 5:15 am so I could walk ¾ mile to the start and be close to the front of the single file start line. At transition I quickly dropped off my run and bike Special Needs bags with blood sugar meters and nutrition, my bottles at my bike and a vial of insulin in a special medi-cool pouch just in case my awesome waterproof Omnipod insulin pump got ripped off my arm during the swim. Warm waters (80+ degrees) so no wetsuit to protect my Omnipod from flailing arms and hands. That would end my day real early (can’t race 9 - 10 hours without insulin), so I had placed a spare pod in my swim-to-bike transition bag for just that emergency. But Louisville’s hot temperatures meant I had to keep the insulin cool overnight and while I swam.

At 7:00 a.m., the cannon blew and the line moved quickly, athletes diving in every second. We swam up river but the current was not too bad for the first ½ mile in this protected channel. I chose to swim a little to the right of the main line of swimmers, sacrificing the drafting benefit, but I preferred and needed the safety of clear water to prevent anyone from accidentally ripping my Omnipod off my upper arm. The island ended and we veered left into the main channel, now fighting the real current for what seemed like forever. After 1.2 miles I rounded the turn buoy and headed back down river, loving the current now. I felt pretty good during the swim but expected the swim times to be a bit slow given the hard current we fought going up river. I exited the water in 1:09, a little slow for me, but I was okay with that. It’s a long day and I’d make it up on the bike.

TRANSITION 1

As usual my waterproof Omnipod insulin pump performed
flawlessly during the swim and was still rock solid secure on my left triceps. (See picture of the swim exit.) A quick check of my blood sugar on my One Touch UltraMini meter said my blood sugar was 150. Perfect. I swigged a few swallows of carbohydrate drink to give me about 30-40 carbs as I ran to my bike and then the mount line among the roaring crowd. I’d stored my Omnipod PDM in a small pouch on my bike and just before mounting I paused to reprogram my Omnipod to reduce the basal delivery rate by 40%. I did not do that before I left transition at 5:30 a.m. because I wanted more insulin injected during the swim so it would be peaking in the first hour the bike (insulin starts working in 15 minutes and peaks in about 2 hours). I have had problems with high blood sugar in the first half of the bike (see below).

Just as I left transition, I saw my wife, Anna, and our baby girl Janna (4 months) in the crowd. I had left them in the dark at 5:30 a.m., 3/4 mile up river prior to the swim start, and often do not see Anna all day in the chaos of the race. I yelled to them as I raced out. Feeling great. All was good. I love the start of the Ironman bike. The intensity is indescribable, then we’re off for 112 miles on our own.

BIKE

The first 12 miles were flat along the shore of the river. I felt really comfortable averaging about 22 mph. There were few athletes on the bike course at this point, so no worries about drafting or congestion. I immediately started my hydration and nutrition plan. Each hour I needed to drink at least 50 ounces of sport drink or water (i.e., 2 bottles), and at least 50 but no more than 80 grams of carbohydrate. Too few carbs = low blood sugar. Too many carbs = high blood sugar. I took a bottle of water and/or Gatorade Endurance (approx. 40 grams carbs) from each aid station every 10 miles. The first 3 hours of the bike before the Special Needs bags at mile 68, I planned to eat 2 Clif Bars (each 240 calories, 42 grams carbs) and 2 sport gels (each 100 calories, approximately 20 grams carb). With the calories and carbs from the sport drink, that would give me about 900 calories and 250 grams of carbohydrate in the first 3 hours.

The hills started around mile 12 and I still felt good, but did not have the fire power in my legs I usually do. Because cycling is my strength, I usually pass many athletes (the faster swimmers) in the first 20 – 30 miles of bike, but today the road was very open because many speedy swimmers started after me in the time trial swim start. A few athletes passed me early in the bike, but I know from experience that many (most) triathletes go way too hard in the first 50 miles of the Ironman and pay for it later. I was patient and would not let these guys tempt me, so I let them go. It’s a long race.

I have had trouble with really high blood sugar (250+ mg/dl, normal/ideal is 100) in the first half of the bike, and have worked really hard with my insulin and nutrition strategy to prevent that. But some of that is caused by adrenaline ending the swim and transitioning to the bike. Adrenaline causes a blood sugar spike (the body’s natural “fight or flight” reaction), but it’s too risky to bolus (inject) insulin anticipating it. If I’m wrong and don’t get the adrenaline spike, the insulin will cause my blood sugar to crash (hypoglycemia). In previous Ironmans I have not been able to detect the high blood sugar until I check my blood sugar at the 56 mile midpoint about 2.5 hours into the bike. By that point it is too late because my kidneys have been flushing my system of vital hydration attempting to flush the glucose out of my blood for the last 2 hours. But at Louisville I was happy to catch it going up early, 45 minutes into the bike my BG hit 200. I figured it was still rising so while riding I immediately gave myself a quick small bolus of insulin (2 units) from my Omnipod insulin pump, and kept motoring. But I still needed to eat a Clif Bar (still have to fuel the body to race) and could not afford to dump those carbs on top of a 200+ rising blood sugar, so I gave myself a little more insulin (3 units, only about 3/4 what I normally would for a Clif Bar when not racing). But 45 minutes later (about 30 miles and 1½ hours into the bike) my BG had still skyrocketed to 340!! 3½ times what is normal!

Yikes! “Patience!” I told myself. I knew I had bolused insulin 45 minutes ago and it would soon be coming down. Chasing high and low blood sugar is a dangerous and difficult experiment. You must be patient and give the insulin, or carbs, time to be absorbed and work. Overreact/overcompensate and you’re doomed. You can’t get the insulin or carbs out of your body once they’re in. Doing this chemistry calculation while cycling 112 miles at 21-22 mph in the Ironman triathlon is, uh . . . challenging.

The bike course was a mix of rolling Kentucky hills, a bit hillier than I had expected, but similar to the roads I train on in the foothills of South Carolina and North Carolina. The short little hills did make it difficult to settle into a rhythm, constantly shifting gears. At mile 38 we rolled through the little town of LaGrange, Ky and thousands of people lined the course screaming wildly as we raced by. Cheering crowds are always nice when the rest of the 112 miles is just you, your bike and talking to yourself . . .“this kind of hurts. . . should I drink now?. . . I hope I don’t get a flat . . . wonder if can I catch that guy?”

By the Special Needs bags at mile 66, about 3½ hours into the ride, my blood sugar was a perfect 125. That’s a good number, but in 2 hours it had dropped from 340 to 125, even though I’d consumed about 100 grams of carbohydrate in that time. I could only hope it would not keep dropping, so I immediately stuffed a Clif Bar and about 40 grams of carbohydrate sport drink in my mouth to stop the slide. I also felt like I was properly hydrated, having drank consistently (and stopped twice to urinate) in the first 70 miles. I was in the top 10% of the field and felt pretty good about my position.

But around mile 80, I began to notice a loss in my power and speed. My legs did not have the same zip and I was struggling a bit more on the rolling hills. It’s normal to feel a bit tired after 80 miles, but when I began to get passed by a few athletes, I knew that something was going wrong. Around mile 85, approximately 4 hours and 30 minutes into the bike, nausea began to creep in. I checked my blood sugar and . . . 65 mg/dl. OH NO! I tried to stuff more carbs into my mouth, but my queasy stomach could not take much more sweet Gatorade, sport gel or another Clif Bar. I tried to drink several swallows of Gatorade while riding, only to choke and vomit it right back up, all while pedaling at 21 mph.

At this point, I stopped again and suspended all delivery of insulin (i.e., stopped the constant “basal” flow of insulin) from my pump. I could not tolerate more insulin going into my body when I could not eat to correct the already low blood sugar. (In fact, the rest of the race I never turned the pump back on and got no more insulin after this point.)

Miles 85 to 112 became a 1½ hour death roll, my blood sugar never getting above 65, out of breath, no strength, and nauseous. My average speed for those 27 miles dropped to 19.3 mph, at least 2 -3 mph below the average for the first 85 miles, and I was passed by what felt like 100 athletes. I stopped one more time (my 5th time!) to check blood sugar, feeling like I was going to vomit. It took me about 1 hour 30 minutes to cover those mostly descending and flat 27 miles. My nausea was so intense I wondered if I would even be able to start, much less finish, the marathon. I coasted into transition with a bike time of just over 5 hour 58 minutes, well beyond my target of 5:15. (Stopping 5 times also did not help.)

TRANSITION 2

As always, there are thousands of people cheering at us as the athletes enter the bike to run transition, but I could not run. I slowly walked into transition, grabbed my transition bag and sat (collapsed) in a chair in the change tent. It must have been 115 degrees in there, sweaty athletes rushing in from the bike and out for the run. Normally that is a frenetic 2 minute drill for me to check my blood sugar, throw on my running shoes and head out for the marathon. But not today. My One Touch Ultra Mini meter told me my blood sugar was 62 mg/dl. I was weak, hypoglycemic for the last 1½ hours, dehydrated and felt like I could throw up at any moment. I set a new record for slow transitions, sitting in that tent for 25 minutes, sipping my carbohydrate drink, trying to keep it down, trying to get my blood sugar up. No way would I be able to raise it after starting the marathon. 100 athletes must have entered and started the marathon while I could do nothing but watch them come and go.

I remember seeing the cool comfort of the medical tent outside through the opening, with several athletes being attended to, their race over. I did not want to stop.

After 25 agonizing minutes, my blood sugar had risen to about 120, and I began to feel slightly better. I was a bit surprised, but figured I would see how far I could run. You never know what happens. I started the marathon.

MARATHON

The run course was hot. HOT! 95 degrees and steaming humid at 2:30 pm. My first mile was a slow trot at about an 8 minute pace. For about 5 miles I kept dumping cups of ice under my hat, and cold wet sponges on my shoulders. But my strength and blood sugar kept dropping, until I slowed to a walk. I walked from about 3 miles, nauseous, dehydrated and somewhat delirious. Finally at mile 8 at the furthest point out on the 2 loop run course, I asked the medics for a blood sugar meter. My blood sugar was 70. I was sick and could not run. They recommended that I not continue. I wanted to try, but I could barely walk and definitely could not run. At about 4:30 pm, 8½ hours into the race, I had to withdraw. I climbed aboard the ambulance for the ride back to medical tent at the finish area, receiving 1 IV bag of fluid, until I was strong enough to stand.

POST RACE

As usual, after the IV I was remarkably recovered. I walked back to the transition with Anna and Janna in the stroller to get my bike and headed for our hotel. Yes, this race was a disappointment, a failure, but that happens sometimes. But I’ve had victories and defeats. Failures and successes. That’s why you must go for challenges that have “Failure Potential” (see my speaking video: http://www.jayhewitt.com/speakers_video.php). You have to keep getting back in the race, back in “the arena.” As Teddy Roosevelt said speaking at The Sorbonne University in Paris in 1910:

"It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming . . . who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never rest with those cold and timid souls who know neither victory nor defeat."
Today was a defeat, but I’ll be back racing at the Half Ironman South Carolina September 30 and the Miami Half Ironman Nov. 11 hoping to qualify again (as I did in 2004-2006) for the 2008 US National Team for Long Course Triathlon.

In September I’ll be doing some testing at the Gatorade Sports Science Institute
hoping for information about my hydration and electrolyte needs.

See you next time!

5 comments:

Wingman said...

Jay,

Thanks so much for sharing all of this - as an aspiring diabetic Ironman you provided years of knowledge and experience in one blog post. It is also comforting to know perhaps the most in shape Type 1 person alive runs into the same issues as me.

Were you also using your CGMS during the race or do you only use that during training?

After cutting work out after work out short b/c of being hypo I can only imagine the furstration you must have felt good luck at the half!

bwelbo said...

Anybody who does endurance events knows that hydration and stomach problems perplex even people who are non-diabetic.

I remember an interview with a top marathoner one time before a race and he said anyone of 20 people could win, because in any given day you have no idea how your body will react to the pounding, the food, and think drink intake.

You are a hero Jay. You got passed by hundreds of people, but those hundreds of people didn't have a care in the world. They were probably consumed with terrible problems like 'are my shoes tied too tight' and 'is my race number clearly visible'.

We just 'celebrated' my 5 year old daughter's 4 anniversary with diabetes. I hope she is able to test herself in anything she wants, and its people like you that lay a foundation and set examples so others know it is possible.

Remember, DNF means Did Nothing Fatal. :)

Brett Welborn
Mt. Pleasant, SC

Emily said...

Thanks so much for sharing all of this ,You really did a good job.

Dr. D. said...

I will be in the Louisville 2008 Ironman. Thank you for your wonderful information on the race and your dedication to the sport. You are a winner and I agree, you DNF, but you are a winner! Again, thanks for the drive!

Anonymous said...

Jay,
You are a true inspiration!!
My daughter is an avid swimmer. What do you recommend to keep the Omnipod secure to her in the water???
Thanks,
Khanh