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Medscape.com Posted 08/17/2004

Anne Peters Harmel, MD

Being in Athens for the Olympics is like being in an evacuation zone waiting for a bomb or a hurricane to strike. The town is all but deserted -- the locals have fled to make room for the hordes of Olympic fans who failed to materialize. Unfinished construction is everywhere, and clouds of dust from the fields of dirt surrounding Olympic venues blow through the roofless swimming stadium on a ceaseless wind, while the sun beats down relentlessly on the spectators who only half fill the seats. Security is omnipresent. Menacing white blimps and helicopters hover overhead, and the police are everywhere. Roads are mysteriously closed and reopened, making efficient transportation virtually impossible, and triple security checkpoints must be passed to make it into some of the fancier corporate parties. This is one Olympics to watch from home, no matter how hard Greece has tried to ready their aging city for the modern version of their ancient games.

But the reason I am here is to be the physician to an athlete, an amazing individual named Gary Hall, Jr, who competes as a swimmer in spite of having type 1 diabetes. I watched him swim this morning on the men's 4 x 100 freestyle relay team; I saw him swim a good race, unhampered by his disease. I also watched him come in second, which meant he was bumped from the final relay by swimmer Michael Phelps, who is being put into an event that he hasn't raced previously in order to increase his odds of winning a record number of Olympic gold medals. As a physician, I know I have done my job: to help control Gary's disease so he can pursue his dreams. As a friend, I am disappointed and wish he could be swimming in the relay finals, a position he earned fairly but lost to a younger, more lauded swimmer.

The US Olympic Swimming Team is an amazing group of men and women, with gifts that medical science can't fully explain. Before I knew Gary Hall, I didn't understand how different these high-performance individuals are from the rest of us, or at least from me. I, like everyone who has been through medical school, know about hard work and dedication. If I were told that I had to swim 5 miles in a pool every day in order to become a doctor, I could probably do it (providing I wasn't being timed). But that wouldn't make me an athlete, not in the way that the elite swimmers I know are athletes. Their bodies possess some different composition of muscle fibers, an attachment of bones to muscles, tendons, and ligaments that makes for fluid, exact movement. Training is critical as well, to refine what nature and perseverance have molded. But as a physician who has seen many human bodies, I know that these bodies are intrinsically different.

Gary is more different than most because he is slightly imperfect. His beta cells no longer secrete insulin. Watching his blood sugar levels rise and fall with training and racing provides a window into his physiologic needs for fuel, and an understanding of the intense stress athletes face when they compete. Working with Gary has taught me how to treat all of my patients who exercise, whether it is walking around the block in the evenings or training for and competing in triathlons. The same rules apply. Gary helped me to understand what I didn't learn in medical school.

The most important principle I learned is that every rule can be wrong in a given individual. I thought I knew about exercise, that training would make muscles more sensitive to glucose and thus lower insulin requirements. It made sense. But in Gary's case, that rule doesn't always apply. When he trains intensely he needs more insulin, largely because his carbohydrate intake is so high -- 4000 to 5000 calories per day, with 60% or so of his calories coming from carbohydrate. When he's training less hard, his caloric intake and percentage carbohydrate ingestion are markedly reduced, so his insulin requirements are less. Another reason his insulin requirements are higher during intense training is because of the catecholamine response to such heavy training. As a sprinter, he doesn't do lots of slow long-distance swimming; he does more intense episodes of training, which may be more physiologically stressful.

Gary's insulin requirements change if he is training once a day or twice a day or 3 times a day. They differ if he is doing more weight training than cardio or the other way around. Time spent training in the pool is different from time spent training on land. Calculating doses incorrectly means he's too low at night, a delayed effect of training, but giving too little insulin overnight results in fasting hyperglycemia and a bad workout the next day. An insulin pump might offer the fine-tuning of basal rates that would better match his physiologic needs, but as a swimmer Gary can't stand the drag of the tape and infusion site on his skin against the water. So he has become a master at adjusting his insulin doses, using a multiple daily insulin injection regimen that is more complex and varied than that of almost any other patient I treat.

Most of the time this approach works; the frequent insulin dosing and the 10 or more times he tests his blood sugar levels each day keep his sugars under control and his A1C level below 7%. Sometimes, as with all patients, it doesn't work as well. Hopefully, this doesn't coincide with race days. I wish it were easier to manage our patients with type 1 diabetes, but it isn't, not yet. Gary, like all my patients with diabetes, dreams of the day this disease is cured. I dream along with them. I'd like to be out of a job, at least the job of treating blood sugar levels.

Today Gary gets another bronze medal for being part of the 4 x 100 relay team, even though he didn't swim in the finals. He deserves that medal as much -- if not more -- than anyone who swam tonight. I certainly am proud of him. And, in a way, we are all part of the same team: the team that roots for our patients to live their lives to the fullest, to overcome obstacles and to be who they want to be in life. That is Gary's message, and he is always a champion to me.

Olympics Dispatch II: August 19, 2004
Posted 08/19/2004

Medscape Diabetes & Endocrinology 6(2), 2004. © 2004 Medscape