There is an old saying – don’t throw out the baby with the bath water. Unfortunately, that is exactly what some are calling for in response to the abuse of Therapeutic Use Exemptions (TUEs). Namely, a total ban. While that reaction may seem like “common sense” to other racers that feel cheated by the abuse of TUEs in the pro peloton, it actually impacts others in an unintended way. In fact, there is one entire team that relies on valid, legitimate Therapeutic Use Exemptions to even compete. TUEs were made for a reason – and we must not let that reason be forgotten.

There is a need for TUEs and that is for someone to treat an illness or a
sickness. They are not intended and should never be used to improve
performance.

Phil Southerland. CEO and Co-Founder of Team Novo Nordisk

First – a little history

Almost all of the substances routinely (and illegally) used as performance enhancing drugs were designed to treat real medical conditions. As anti[doping controls covered more and more substances over the years, it was inevitable that would overlap with professional athletes using these substances for purely medical reasons – without the desire or intent to gain a competitive advantage.

Because of the desire to open the sport to as many legitimate athletes as possible, as well as help ensure the health of the athletes, a mechanism has been enacted to allow exceptions to standard doping rules for those that demonstrate a medical need and will not receive a performance gain from use.

Athletes may have illnesses or conditions that require them to take particular medications.

If the medication an athlete is required to take to treat an illness or condition happens to fall under the Prohibited List, a Therapeutic Use Exemption (TUE) may give that athlete the authorization to take the needed medicine.

The purpose of the International Standard for Therapeutic Use Exemptions (ISTUE) is to ensure that the process of granting TUEs is harmonized across sports and countries.

World Anti-Doping Agency

There are, unfortunately, possibilities for abuse. And one can definitely understand the anger felt by clean athletes when TUEs are abused in events. A recent publication in the academic news outlet The Conversation even went as far as suggest that TUEs are harmful to athletes by masking symptoms when they should instead be recovering.

If an athlete is ill or in pain, they should rest. Drugs which mask a health problem in order to allow athletes to push themselves for the sake of sport could have an impact in the short and longer term.

Elite sport: time to scrap the therapeutic exemption system of banned medicines

However, this argument falls very much short by refusing to acknowledge that not all TUEs are simply about managing symptoms. The most glaring example of this is the treatment of type 1 diabetes. Diabetics are forced to take insulin – not only to compete, but to stay alive. In is not an optional medication, and it is not something that is used simply to mask symptoms. Instead, in is necessary to use via daily injections in order to replace a vital hormone that is absent in type 1 diabetics. And there just happens to be an entire pro cycling team rostered exclusively by type 1 diabetics.

Team Novo Nordisk

Team Novo Nordisk (formerly Team Type 1) was co-founded by Phil Southerland and Joe Eldridge. The team has become an inspiration for athletes with diabetes world wide. And given that the team is made up entirely of athletes that live with diabetes, each and every one of them has to have a therapeutic use exemption to compete. Ban TUEs, and you ban an entire team.

Team Novo Nordisk is a global all-diabetes sports team of cyclists, triathletes and runners, spearheaded by the world’s first all-diabetes professional cycling team.

Comprised of nearly 100 athletes from over 20 countries, Team Novo Nordisk competes in more than 500 international events each year.

I had a chance to talk with Phil Southerland, as well as Team Novo Nordisk rider Sam Brand, about cycling with diabetes, TUEs, and their reactions to the call for the elimination of legitimate therapeutic use exemptions. Below are their words:

Phil Southerland – CEO and Co-Founder of Team Novo Nordisk

JustAnotherCyclist: Therapeutic Use Exemptions (TUEs) have been in the news quite a bit lately. While researching them for this story, I was somewhat surprised to learn that insulin itself is on the banned substances [list]. Does that mean that every athlete on Team Novo Nordisk has a TUE?

Phil Southerland: Yes, all riders at Team Novo Nordisk race with a TUE. Since the team’s inception in December 2012, we have always been very public and extremely proud that we race with type 1 diabetes. Additionally, we have always been open that we race with TUEs. WADA included the use of TUEs so that an athlete who has a legitimate medical condition can continue to compete. The UCI and the anti-doping organizations recognize that diabetes is a legitimate medical condition and grants all Team Novo Nordisk athletes TUEs to use insulin.

JAC: How many total athletes on Team Novo Nordisk have existing TUEs related to diabetes?

PS: As of January 1, 2018, 28 athletes on Team Novo Nordisk race with TUEs. There are16 riders on the men’s professional team, 11 riders on the development team and one professional female track cyclist, Mandy Marquardt.

JAC: What is the process for an athlete with a legitimate medical need – such as diabetes – to be able to compete while taking insulin?

PS: Our medical staff handles all TUEs, and the process with the UCI includes submitting medical records that show the date of diagnosis, place of diagnosis and the doctor who diagnosed the athlete. All this information is verified to show that our riders are racing with type 1 diabetes and need insulin injections to survive.

JAC: UCI rule 13.3.052 seems to imply that the injection of any substance via syringe in banned. However, the rule does specifically call out diabetes as an example of a permissible situation for athletes to self-inject. Is it a separate TUE for the insulin, and the administration method?

PS: There is an extensive process that we go through with the UCI to prove our riders’ need for insulin. It comes down to life or death for these athletes. The UCI grants all Team Novo Nordisk athletes long-term TUEs for insulin use. As an American-registered team, USADA serves as our anti-doping organization and recognizes and explicitly list on its website that athletes who are insulin-dependent (athletes with type 1 diabetes) are allowed to race under a TUE
while using insulin.

Currently, the only method for type 1 diabetics is subcutaneous injections. Our athletes are not choosing an injection over an alternative.

JAC: Have riders or team staff ever experienced any negative interactions from other riders or officials as a result of the possession and usage of insulin to treat diabetes during a race?

PS: Early on, we had people see the riders injecting at races and report it to officials. The officials are well versed in our situation and all our riders have documentation that they carry that proves their TUEs.

In general, we receive positive feedback from riders, organizers and officials. To be honest, seeing a rider inject typically opens up a conversation. People often use it as an opportunity to ask questions, which we always welcome.

JAC: What was your reaction when Froome’s test results turned out to be a
substance he had a TUE for?

PS: What concerns me about the Froome situation and anyone else using a TUE for marginal gains or to push the limits into the grey area is that it creates a huge negative perception around the sport and can damage the reputation of the athletes who have a vital need for long-term TUEs. There is a need for TUEs and that is for someone to treat an illness or a sickness. They are not intended and should never be used to improve performance.

We are happy to be a part of this conversation and want to set the record straight by showing the valid and positive side of TUE usage. We are proud and thankful that we have the opportunity to race with a TUE. It is a great concept, and one that we believe needs to be ethically respected. Thanks to TUEs, all Team Novo Nordisk athletes can inspire, educate and empower people around the world affected by diabetes.

Sam Brand – Rider, Team Novo Nordisk

JAC: Can you describe the experience the first time you had to acquire a TUE?

Sam Brand: First, let me thank you for taking the time to talk about TUEs and the valid side of the conversation. As a diabetic and even more so, an athlete for Team Novo Nordisk, I am passionate to speak about this topic and to try and further educate and raise awareness about diabetes.

My first experience acquiring a TUE took a long time. I moved up to Team Novo Nordisk’s professional team as a stagiaire mid-season, so I needed to have it in place before then. It required a lot of paperwork, emails and calls with the various organisations (British Cycling and UKAD) in order to process the application and finally have it granted to me. It wasn’t the easiest task and certainly not as straightforward as people may think.

JAC: There are numerous stories of cheating teams and athletes going to great length to hide syringes used for illegal PEDs. As a diabetic myself I know that keeping syringes on hand wherever I go is just part of diabetes management. Do the team athletes have to jump through any hoops in regards to the handling of their insulin pumps, syringes, or insulin as a result of a UCI license?

SB: As a fellow type 1 diabetic, you understand that all diabetics need insulin to survive. Currently, the only way to get insulin as a type 1 diabetic is through injections. We don’t actually have to jump through any hoops because we aren’t hiding anything. For us, the process is applying and being granted a TUE, and then we can use insulin. If we need to inject during a race, that is fine and we do not feel we have anything to hide. 

JAC: Since the findings against Froome, some have started to question the validity of TUEs at all. Do you have any concerns that regulation changes in response may make it more difficult – or even impossible – for diabetic athletes to compete in sanctioned events? Do you feel that riders abusing TUEs for performance gains impact you in other ways besides performance in the peloton?

SB: I definitely have concerns. There are more and more high-profile athletes calling for bans on TUEs. Additionally, people are claiming that if you need one, then you aren’t fit to race or be a professional athlete. To me, all of that is quite offensive.

This current conversation is about athletes using TUEs to enhance performance, and I completely understand this concern. As an athlete with a long-term TUE, I agree wholeheartedly with the need to sort out the current system, but I adamantly don’t agree with an outright ban on all TUEs. It isn’t the answer and takes a very shortsighted viewpoint.

JAC: Have you ever had any conversations with other riders about your use of insulin at an event? If so, what were some reactions?

SB: In my experience, there are many people around the world, not just riders, who are not well educated in diabetes.  This is why the team’s mission is to inspire, educate and empower everyone affected by diabetes. I greatly enjoy that part of my job because it allows me to have conversations with people about diabetes and help educate them on the condition. In general though, fellow cyclists tend to be genuinely interested in knowing more.

JAC: Have you had to change the way you manage your diabetes to comply with the anti-doping rules?

No, not at all. While everyone’s management is different, it’s relatively straightforward how I manage my diabetes.

There was a time when the idea of diabetic pro cyclists was rare. Common wisdom held that diabetics had too many obstacles to be competitive. However, thanks to the continued efforts of Team Novo Nordisk, we’ve seen that diabetic pro cyclists can compete at the highest levels of the sport. And do it successfully.

Recently two additional riders with type 1 diabetes have made the transition to the pros. Frenchman Quentin Valognes and Dutchman Rik van IJzendoorn have moved up from the Team Novo Nordisk development squad onto the men’s pro squad as stagiaires for the remainder of the 2016 season.

Team Novo Nordisk is a unique team made up exclusively of cyclists with diabetes, so gaining two strong and talented riders is exciting for us. Quentin grew up in our development program over the past several years, starting on the junior squad. He is pure talent and he can definitely win. Now the focus will be on helping him adapt to the pro level.

Vassili Davidenko, General Manger, Team Novo Nordisk

Quentin Valognes

Quentin Valognes was diagnosed with type 1 diabetes when he was just six years old, but it didn’t stop him from chasing his dream of racing his bike. By age 12, he was competing and quickly grew into a strong sprinter on the track. In his four years with Team Novo Nordisk’s development team, the 20-year-old Frenchman earned a list of accolades, including winning Stage 5 and Stage 6 of the Tour de l’Abitibi Desjardins (2014) and a podium at the French National KeirinChampionship (2014).

It’s an honor to be selected, but I’m aware that I still need to earn my spot on the professional squad. I know this is just the beginning. I embrace my diabetes and I’m excited to have an even bigger platform to inspire, educate and empower people affected by the condition.

Quentin Valognes, Rider, Team Novo Nordisk

Rik van IJzendoorn

Rik van IJzendoorn made his pro debut in the Tour of Utah, where he is helping to support Javier Megias in the team’s efforts. Megias is fresh off of his second place finish at the 2016 Tour de Korea.

Van IJzendoorn was diagnosed with type 1 diabetes within the past year, but his history on the bike is much lengthier. Van IJzendoorn comes from a racing family and was competing by age eight. Since then, he has amassed several achievements, including Dutch Junior National Cyclocross Champion (1997), Dutch Junior National Road Champion (1999), runner-up at Dutch Junior National Cyclocross Championship (2004) and third place at the UCI cyclocross World Cup race in Pijnacker (2004).

I’m very happy to have this opportunity to race at the professional level; it will be a whole new experience for me racing against World Tour riders. Team Novo Nordisk has helped make my dream of racing against the best in the world come true. I’m fully focused on working for the team throughout the remainder of the season and hope to earn a contract for next season.

Rik van IJzendoorn, Rider, Team Novo Nordisk

These two riders represent the up and comers that will help drive Team Novo Nordisk towards their goal towards the 2021 Tour de France – while helping to inspire all of us that face challenges that some would dare tell us are insurmountable.

You’ve definitely read a lot about Team Novo Nordisk here on JustAnotherCyclist.com recently. The reasons for that are pretty clear to my frequent readers. But for everyone else, their results alone – aside from their mission – are worthy of note

The team, made up entirely of professional cyclists with Type 1 diabetes, have been at the Tour of California for three consecutive years now. But this year has been particularly successful for the team, driven in a large part by World Tour veteran Javier Megias. Javier took 14th overall in the general classification at the Tour of California, going head to head with some of the best cyclist in the world. In addition to the GC success in California, Martijn Verschoor was able to cross sabres in stage 1 for a 5th place sprint finish.

The Gibraltar climb and the time trial were the most defining moments for me. The climb was insanely challenging while the time trial was just brutal.

David Lozano, Rider, Team Novo Nordisk (pictured above)

But success has not been limited to California. As of June 1, 2016, Team Novo Nordisk had earned six top 5 finishes and eight top 10 finishes, including the teams first overall victory in the team classification at the Tour of Estonia.

Then came the Tour de Korea, where Javier Megias again showed his form earning the teams first ever second place podium finish in the general classification.

The Tour de Korea has been a good race to this team over the years. I am very pleased with the entire squad. It was inspiring to see how aggressive our riders raced all week in breakaways and sprint finishes. Javi finished 14th overall last month at the Tour of California against some of the best cyclists in the world. Now he earned his career best at the Tour de Korea. We’re excited to see what happens throughout the remainder of this season, especially at next month’s Tour de Pologne.

Vassili Davidenko, Senior Vice President of Athletics and General Manager, Team Novo Nordisk

The Tour de Pologne (Tour of Poland) will mark another significant first for the team in 2016: the team’s first world tour stage race. This is critical, as Team Novo Nordisk CEO and Co-founder Phil Southerland has set a goal for the team to be in the Tour de France in 2021.

Phil Southerland is a self-described “…boy that was shaving his legs at 14.” From there he taught himself the ropes racing with a group from a local bike show. He continued riding and racing through college, but eventually found himself pitching the idea of an all diabetic pro cycling team to vendors at Interbike. That idea has continued to grow towards the Tour de France goal since inception. 2016 has all the potential to be the turning point in an effort that has produced not only Team Novo Nordisk, but also the charitable Team Type 1 foundation.

2021 will mark the 100th anniversary of the discovery of insulin – a pivotal moment in history for suffers of Type 1 diabetes that depend on daily insulin injections to manage their condition. Phil Southerland cites this, along with “enough runway” to meet the necessary obligations for a Tour de France wildcard spot, as a perfect target to get Team Novo Nordisk into the most famous bicycle race in the world.

The Tour de France comes down to ranking. We know we need to be in the top 25 professional teams by 2021 to increase our chances at a wild card invitation.

Since 2014, Team Novo Nordisk has seen an annual 20% ranking improvement, but in order to achieve a top 25 ranking we will need more riders, because more riders lead to more points. We also need to get more results so we can earn more points. Finally, we need to compete in bigger races because World Tour races equal more points… a higher ranking gives us the ability to get noticed and be eligible for a wild card spot.

Phil Southerland, CEO & Co-founder, Team Novo Nordisk

With that plan in mind, the results and scheduled races of this year seem to be paving a smooth path towards Paris in 2021. It is unfortunate how often those living with diabetes hear about what they can’t do. Phil Southerland, along with the management and team members of Team Novo Nordisk, are instead showing us what they can do.

Joonas Henttala is a professional cyclist with Team Novo Nordisk. Joonas started the 2016 Tour of California aggressively. We was the first rider to attack after the neutral start of Stage 1. This created a break away with 6 other riders that was off the front for over 85 miles. The break away was reeled back in before the final 3, resulting in a bunch sprint. Joonas’s teammate on Team Novo Nordisk – Martijn Verschoor – was able to capture a 5th place finish against some of the best sprinters in the world.

We caught up with Joonas Henttala before the start of the Tour of California to ask him some questions about his life as a professional cyclist, overcoming Type 1 Diabetes, and competing at the highest levels of the sport.

JustAnotherCyclist: I understand you got started in bike racing at a pretty early age. What interested you about racing bikes?
Joonas Henttala: My dad used to be a racer and I always loved riding my bike. My hometown, Porvoo, has a strong cycling culture for Finland, so that also helped.

JAC: You were diagnosed with Type 1 diabetes at a young age too. Did that impact your racing plans?
JH: My diagnosis didn’t impact my racing plans much at all. I received some good advice from people close to me and my healthcare team and I was able to take charge of my management early on. I have always seen myself as an ambitious bike racer who also happens to have diabetes.

JAC: You’re riding in the upcoming Tour of California. You’ve raced Tour of California before, correct?
JH: Yes, I raced at the Tour of California in 2014 and 2015. It’s a beautiful race and I love that I get to come back and race here again. We are an American-registered team, so this is considered a “home” race for us. We have big goals for the race this year and I hope we can get some results and at the same time, show the world what may be possible with diabetes.

JAC: Do you have to think about your diabetes management differently in a longer stage race compared to one day events?
JH: There are some slight changes, but it really isn’t that different. Diabetes is a very individual condition and for me, I find it less challenging to manage my diabetes on stage races versus one-day races. It’s important to keep in mind that during race days there are many different variables that can affect my blood sugar, including stress, adrenaline, race intensity, weather conditions and altitude.

JAC: Any particular goals or targets for the team in California this year?
JH: There are a lot of climbs this year so we have Javi (Megias) and David (Lozano), who are both great climbers, ready to attack on those stages. Javi is also the rider who is designated to go for the overall win (General Classification). For me specifically, I’m on the hunt to get into breakaways and I’ll help the other guys like Martijn (Verschoor) and Andrea (Peron) to get into good position for the sprint finishes.

JAC: Do you get assistance from Team Novo Nordisk support and medical staff monitoring your diabetes during the races?
JH: For optimal performance, I need to keep my blood sugar in a target range. If my blood sugar is out of target, I may need to make adjustments and the medical staff is on site during the race support us if we need any assistance.

JAC: Does riding with diabetes present any additional concerns when the UCI talks about banning radios from professional races?
JH: Radios were banned, but they are actually back. Just like other teams, we use race radios for team tactics and can always radio back to the car if we need anything. Even without radio, we always have a member of our medical team in the car and we can drop back to the car and ask them a question if we need anything.

JAC: How did you come to be involved with Team Novo Nordisk?
JH: I visited Team Novo Nordisk’s development team in 2012 and did a few races with them. Based on my time there and some earlier results from that year, it was enough to convince the management to offer me a pro contract for the 2013 season.

JAC: Have you encountered many other Type 1 diabetics out there racing, aside from Team Novo Nordisk?
JH: Growing up, there was a really good masters racer in Finland who also had diabetes. I really looked up to him. I believe he even won the Scandinavian championships. Unfortunately, he passed away from cancer a couple years ago but he was very instrumental in my growth and knowing that I could still chase my dreams following my diabetes diagnosis.  One of the things I love about Team Novo Nordisk is being able to serve as a role model to help inspire, educate and empower people affected by diabetes all over the world.

Read other JustAnotherCyclist.com posts about Team Novo Nordisk, or the 2016 Amgen Tour of California.

Team Novo Nordisk will be returning to the Amgen Tour of California this year with a whole new look that will be exclusive to the US races. The new green kits feature Tresiba^®  – a long-acting insulin produced by title sponsor Novo Nordisk.

Team Novo Nordisk is a global team made up of nearly 100 endurance athletes with diabetes, including cyclists, runners and triathletes. The men’s professional cycling team includes 17 athletes from nine countries, 8 of which will be on the starting line for the Amgen Tour of California.

The Amgen Tour of California is the biggest cycling event on U.S. soil and it’s definitely one of the most important races of the season for Team Novo Nordisk, so we are excited to introduce our new U.S. kit at this prestigious race. This year marks our third consecutive appearance at the Amgen Tour of California, and we are eager to use this opportunity to show the 415 million people around the world living with diabetes what may be possible.

Phil Southerland, co-founder & CEO of Team Novo Nordisk

In addition to the 8 riders traveling to California, directeur sportif duties will be handled by Vassili Davidenko and Pavel Cherkasov. Team medical duties will fall on Dr. David Castol.

Our strategy is for the riders to be in peak performance around this race and so far, everything is going according to plan. The team is strong and ready to race. Our climbers will be ready for the new challenges, and we believe our sprinting duo, Andrea and Martijn, are in good shape and ready to earn top results. Charles is coming up very strong and while Javier has had a bumpy season so far, he should be ready for California.

Team Novo Nordisk Senior Vice President of Athletics Vassili Davidenko

Team Novo Nordisk has had successes in the Tour of California in the past. In 2014, Charles Planet (FRA) wore the race’s Breakaway from Cancer Most Courageous Rider jersey in Stages 2 and 3, while teammate Kevin De Mesmaeker (BEL) sprinted to third place on Stage 4. Over the past two editions, Team Novo Nordisk athletes earned three top-10 finishes and rode in major breakaways on five separate stages.

This race is one of my favorites of the season and I hope I can make the podium this year. One of Team Novo Nordisk’s main goals is to win a stage and show the world what may be possible with diabetes

Team Novo Nordisk rider Martijn Verschoor

Look forward to more interviews with Team Novo Nordisk riders as the Amgen Tour of California progresses.

^{Tresiba® is a long-acting insulin that is manufactured by Novo Nordisk. For more information, go to www.tresiba.com.}

It is, without question, extremely challenging to reach elite levels in any sport. Cycling has its own unique challenges. Couple that with the demands of managing a life long disease like type 1 diabetes and challenging can quickly turn into “daunting” or even “prohibitive.”

However, US track sprinter Mandy Marquardt is a fantastic demonstration that type 1 diabetes is not something to keep people from achieving their goals. Along with the help of Team Novo Nordisk, Mandy is spreading the word that diabetes does not have to be a limiting factor in our lives. We caught up with Mandy via email to talk to her about her experiences as a diabetic athlete.

Mandy Marquardt: Cycling has brought me to all areas of the globe, but my home is in Allentown, Pennsylvania, where I train at the Valley Preferred Cycling Center with Andrew Harris and his program, Sprinter’s Edge. I graduated in 2014 from Penn State Lehigh Valley, and I’m currently the Cycling Coach at Penn State Lehigh Valley and training full-time for UCI track races, UCI Track World Cups and the Olympic Games. I’m also part of the Team Novo Nordisk, a global team of nearly 100 endurance athletes with diabetes, spearheaded by the world’s first all-diabetes professional cycling team.

JustAnotherCyclist: According to your bio on the Team Novo Nordisk website, your started cycling competitively at a very early age. How did you get started, and how did you balance training with school and other “normal kid stuff”?
MM: I was born in Mannheim, Germany and moved to Fort Lauderdale, Florida when I was six years old. My father is German and my mother is originally from Florida. My parents encouraged me to participate in sports when I was young, so it has been a big part of my whole life. I was either at swim practice, taking tennis lessons or running 5k’s with my dad throughout my childhood. In 2002, I did my first triathlon and began focusing on cycling and started competing in endurance road and track events at the Brian Piccolo Sports Park and Velodrome in Cooper City, Florida. Since I was always busy competing on the weekends, I rarely had time for sleepovers.  In school, I was known as the “athletic girl”. As I got a little older, I started to learn how to balance my sport and social life.

JAC: How old were you when you were finally diagnosed?
MM: In November 2007, my world turned upside down. I went in for V02 testing and blood work connected with my training.  They quickly became concerned about my elevated blood sugar levels and I went straight to the hospital. At 16 years old, I was diagnosed with type 1 diabetes.  

JAC: Your […] initial indications of your Type 1 diabetes came through routine testing as part of your training. Did you have any suspicions at all prior to that point that something might be changing?
MM: When I look back at it, I would get headaches after eating high carb meals, and during training and racing, I always took forever to warm up and often felt tired and sluggish. I never thought anything of it. I thought maybe I was just tired from all the hard training, and I needed more sleep or a change in my diet. I was never aware that they were unusual symptoms, so I was surprised.

JAC: The moment when you actually understood that you had Type 1 diabetes, what was your immediate reaction?
MM: I was confused, overwhelmed and frustrated. I questioned if there was something I did to get diabetes. I’ll never forget when a doctor told me, “Mandy, you will never be able to race at a high level again.” I felt like everything I worked so hard for was gone. I felt empty, and physically and emotionally drained.

JAC: What were the immediate impacts from the diagnosis on your training and competition?
MM: I spent the next two weeks in the hospital, seeing multiple doctors and working with my healthcare team to learn how to manage my diabetes. I was determined to get back on the bike and eager to race again. When I began training again, it was tough learning what foods, stressors and training intensity affected my blood sugars. I sometimes neglected taking the best care of myself because I was upset, and at one big race weekend, I left all my diabetes supplies at home, and couldn’t even perform in our team event. It was a pivotal point because I not only let myself down but also my teammates. My parents supported me through it all, but it was ultimately up to me to put in the effort to manage my diabetes. I began to improve on monitoring my training and diabetes regime because I was motivated to win bike races again.

JAC: Did you ever fear that the diagnosis might mean an end to your competitive career plans?
MM: [See question above] It was discouraging when I was told I might have to stop racing. Also, due to all the people who were concerned about me, I felt that having diabetes was a bad thing. Back then, I never heard of any other athletes with type 1 diabetes. One of the reasons I love being part of Team Novo Nordisk is because I think we can serve as role models to young athletes with diabetes and show them you can still pursue your dreams.

JAC: The additional challenges of living with diabetes are talked about a lot. But what challenges do you face due to diabetes in regards to competitive cycling specifically?
MM: During racing, there are many variables that affect my blood sugar, including stress and adrenaline. Since sprints are so short, I’m able to monitor my blood sugars before, during, and after racing. I continually check my blood sugar on race days and work with my health care team to adjust my diabetes regime with these extra variables. Racing with diabetes is just another variable that I factor in, but when I’m on the start line, I’m no different than my competitors

JAC: How does the team support you in the additional challenges?
MM: I’m grateful to be a part of Team Novo Nordisk. Since I joined the team in 2010, we’ve grown tremendously. All the athletes on the team are racing with diabetes and as teammates, we really want to see each other succeed. The team has brought us all together, and the ability to connect with one another on that same level, sharing our ups and downs, is really special.

JAC: How long was it between your diagnosis and joining Team Novo Nordisk?
MM: Approximately three years after my diagnosis, I joined the team. It was 2010 and I was inspired by the other athletes racing with diabetes. It was the first time I didn’t feel ashamed and embarrassed about my diagnosis. Due to the team, I have been able to learn to share my story and fully acknowledge that living and racing with diabetes is possible.

JAC: Do you feel that Team Novo Nordisk has created opportunities as a Type 1 cyclist that you otherwise may not have had?
MM:Absolutely! When the team and I aren’t racing, we are out in the community sharing our stories and meeting other people living with diabetes. One of my favorite experiences with the team was traveling to Rwanda in 2011. The Men’s Professional Team was there to race the Tour of Rwanda, and a group of us were riding all the stages ahead of the race. Once we arrived at the finish, we would go and meet with a local diabetes group. It was by far the most memorable experience of my life, both on and off the bike. It was touching to see the world and inspire people.

Growing up, I told my parents that I didn’t want to be just someone, but somebody. My dad always reminded me never to do anything half-heartedly so when I would do something, I did it with my whole heart and I continue to approach life the same today. I am a firm believer that everything happens for a reason and that sometimes we don’t always know what the reason is; you might not know today, tomorrow or even a year from now. To be honest, if I had a choice, I wouldn’t choose to have type 1 diabetes, but I’ve accepted my diagnosis. Now, I am proud to be living with diabetes. I’m thankful to be alive, healthy, racing my bike, and inspiring, educating and empowering people affected by diabetes.

JAC: If you could say anything to other young competitive [athletes] that have recently been diagnosed with Type 1 diabetes, what would it be?
MM: The most important thing to remember is that you can still pursue your dreams, no matter what they are.

JAC: Any specific goals for your career going forward?
MM: One of my biggest goals is to represent my country and Team Novo Nordisk at the 2020 Olympic Games. Not only would it be the pinnacle of my athletic career, but it would also be an incredible platform to inspire, educate and empower anyone affected by diabetes to pursue their dreams.

JAC: When you look forward to your future as a cyclist, does the fact that you have Type 1 diabetes influence your plans or aspirations in any way?
MM: I only see it influencing my future aspirations in a positive way. I am hard on myself and very detail-oriented when it comes to the way I approach my life, work (Penn State Lehigh Valley Cycling Coach) and cycling. I want to reach my highest potential in track cycling and inspire other athletes and people living with diabetes. The support and encouragement I’ve received throughout the years from family, friends, teammates and the community has been incredible, and I want to make them and my country proud.

• Follow Mandy Marquardt on Twitter, as well as her own website at https://mandymarquardt.wordpress.com/
• Team Novo Nordisk is a global team of cyclists, runners and triathletes with diabetes, spearheaded by the world’s first all diabetes pro cycling team. The team’s mission is to inspire, educate and empower everyone affected by diabetes. Find more at http://www.teamnovonordisk.com

Type 1 diabetes sucks. Cycling, however, doesn’t suck. So how do we put the two together? With hard work, diligence, knowledge and a sprinkling of modern technology. At least – that is my approach.

First off – a disclaimer. I’m not a doctor. Please read my Standard Medical Legal Mumbo Jumbo. Did you read it? I’ll wait…

Training for cycling events at even the moderately-serious recreational level takes a lot of fine-tuning. In a sport where a few watts can make a huge difference, things like diet, sleep patterns, and training scheduling can separate the mediocre from the truly awesome. Throw in a metabolic disorder like diabetes and it can feel like 10 times the number of variables to try and manage.

But before we get all doom and gloom don’t forget that there are Type 1 diabetics performing at the highest level of almost all sports. And cycling has an entire world class team full of diabetic riders. So no, diabetes is not an excuse not to excel at cycling if you want to.

But… it doesn’t hurt to have some tools. If you are a diabetic, you’re undoubtedly already aware of these devices.

CGM

CGM stands for Continuous Glucose Monitor. It is a device that does what finger-stick blood tests do, but constantly and throughout the day. However, they do it in a slightly different fashion. They (generally) do not measure your blood glucose levels directly, but rather infer it by taking measurements in the interstitial fluids – the fluid that surrounds the cells of our body. These all involve some sort of device that is inserted under the skin that takes the measurements. They then transmit this data – usually wirelessly – to some external receiver.

Since they are not measuring blood glucose (BG) levels directly, there are some trade offs. First, these devices generally lag behind about 15 minutes or so from actual blood glucose (BG) changes. What does that mean? Well, if my BG was actually 85 mg/Dl 15 minutes ago, and has now plummeted to 50, my CGM may incorrectly tell me that it is currently a safe 85.

To help alleviate this, many CGM manufactures are now employing software algorithms to predict BG trends in advance and thus mask this lag.

In addition – a CGM is not a replacement for sticking your finger for traditional BG measurements. Again, since the CGM is not measuring directly some calibration of the numbers are needed. This means that most CGMs have a small amount of “learning” that the devices need to do to correlate the data from the sensor with actual, real BG levels. Part of this learning involves traditional finger sticks, and feeding that “real” number into the CGM so it can help fine-tune the algorithmic calculations.

However, with this data streaming in near real time, CGMs can alert you when BG levels are dangerously high or low. And – perhaps more importantly – they can even alert you when they are within range but are changing rapidly. This can be invaluable when you are on the bike and training hard – giving you enough time to get some carbs into, and absorbed by, your body before being impacted from an energy sapping hypoglycemic event.

Personally, I can not imagine riding the way I do without a CGM. This is especially true for folks like me that have an insensitivity to the symptoms of hypoglycemia. Even if I do feel the symptoms, they very much resemble the same sensations I can naturally induce with a really hard, pushing the boundaries type effort. This can make it extremely easy for a diabetic cyclists to completely ignore a hypoglycemic event until it is so severe they become incapacitated.

Impromptu survey:
Do you use a CGM?
If so, which one?
Scale of 1 to 5, 1 being hate it and 5 being wouldn’t ever change brands, what do you think of your CGM?

I recently did a bit of an impromptu survey on a Type 1 Diabetic Athletes group I belong to on Facebook. The overwhelming response (like 20 to 1 in this very unscientific poll) was that these folks had a CGM and loved it. In addition, almost as high of a percentage of the respondents reported using a Dexcom CGM in specific. This is, incidentally, the same CGM that I use.

Insulin Pump

Type 1 diabetics – in contrast to the very different yet similarly named Type 2 diabetics – have to inject insulin. Period. No insulin, no life. As in going to long without insulin will literally result in your death. There is no amount of diet control, exercise, or lifestyle choices that will change that.

Type 1 diabetes – so goes the current scientific research – is an autoimmune disorder. It is the result of the diabetic’s immune system attacking and killing off the cells in the body that would normally produce the hormone insulin. That is why Type 1’s need to inject insulin – there simply isn’t any other source.

However, how those injections are physically carried out is another matter. Traditionally, this has been via syringes. This is sometimes referred to as MDI in the diabetes community – Multiple Daily Injections.

But this is where things get a bit tricky. There are actually two different functions performed by insulin.

Bolus

Bolus insulin is the insulin that is delivered in direct response to eating. This is actually what most people will probably think of – if they think anything at all about diabetes. If I eat anything with carbohydrates, I then take an amount of bolus insulin in direct response to those consumed carbs. I want this insulin to be very fast acting – it needs to be in my blood stream to counteract the glucose that my digestive tract is going to start dumping into my bloodstream. Count carbs… take insulin… eat. Count carbs… take insulin… eat. This is a huge part of the diabetic’s day. How much insulin to take (the insulin/carb ratio in treatment terminology) can actually be very much impacted by your exercise levels. You see, exercise makes it easier for glucose to get into your cells – meaning less insulin for the same effect.

But let’s take a step back and address what we haven’t yet. What the heck does insulin actually do?

There are 101 really great explanations about insulin out there on the web. But the huge oversimplification: insulin allows your cells to use glucose as fuel. Glucose is the gasoline for the engine of your cells. And insulin is like the release for the fuel door on your car that allows more gas to get into the tank and fuel the engine. No insulin, and it is as if the fuel door is locked despite you standing there with a gas pump in your hand. Eventually, the engine will run out of fuel and stop running. (Please people. This is just an illustrative analogy. Don’t sit at the gas pump with your car running…)

So, continuing our crude “fueling up the car” analogy – exercise makes the nozzle you use to fill the fuel up flow a little easier. You can think if it a slightly different way and say that exercise makes your body use insulin more efficiently. Because of this, the diabetic cyclist has to be aware of this change and modify their bolus levels when they are out training. Oh…. and don’t forget, that exercise potentially impacts the interaction between carbs and insulin well into the next day. This is, unfortunately, one of those things that you will need to work with your doctor to figure out what is right for you. Human bodies are extremely varied, and diabetes management unfortunately requires a fair amount of trial and error to get right.

But adjusting bolus rates isn’t the hardest part of this this. Remember when I said there were two different functions performed by insulin?

Basal Insulin

Basal insulin is probably the trickiest part for any diabetic athlete. Our bodies naturally introduce a slow, steady trickle of glucose into our blood stream. This is the fuel for our bodies “baseline”… one of the most important of which is brain function. Because of this, our bodies need a slow, steady trickle of insulin to match it. This is basal insulin.

Traditionally, this was accomplished by manufacturing a completely different type of insulin to be injected separately from bolus insulin. The basal insulin was engineered to release slowly, over time. This allowed Type 1 diabetics engaged in insulin therapy to take one, maybe 2 injections per day to account for this basal function – instead of a new injection ever 30 to 60 minutes.

However – remember what I said above about exercise changing how much insulin is needed for a given level of glucose? That same thing applies to basal insulin. And if I’m filling my body up with the proper amount of basal insulin for a day I’m sitting on the couch, but instead go out for a hard physical effort… bad things can happen. Or, conversely, if I go for bike rides every day, but take a day or two off for some reason, I may find that my basal rate is way to low for my lower activity level. Result: high blood glucose levels.

But, technology to the rescue. Insulin pumps, unlike multiple daily injections of combinations of bolus and basal, provide much more flexibility. That is because they can actually utilize the same fast-acting insulin used for bolus injections, but also slowly trickle it in to address the basal needs. This simply would not be practical with multiple daily injections. And that can be a game changer.

If I am simply trickling in insulin in near real time for my basal treatment, and I decide to go out for a bike ride, I have a new option. I can dial down my basal rate temporarily while I’m exercising. I’m not “committed” to that big, slow-release basal insulin taken via injection. I can adjust things – on the fly!

And this is something I often do. If I know I am going out on a good ride I will use my insulin pump to reduce my basal rate. For me (again, through trial and error) I’ve found that reducing my basal rate to 50%, starting an hour before my ride and continuing an hour after it, works really well. Why an hour before? Keep in mind that these are human bodies, and insulin released into the blood stream isn’t immediately delivered to the cells that need it. Furthermore, insulin injections are also not delivered directly to the blood stream, but rather are injected into the fatty or muscle tissue to be slowly absorbed into the blood stream. This delay provides a valuable buffer that can “smooth out” the insulin reaction. But it also means that us T1Ds need to be patient at times. We need to think about how much insulin is already floating around in our bodies before we go cramming more in.

Frankly, this basal rate adjustment is quite possibly the most important tool I have in managing my diabetes on the bike. I’ve often wondered, if I was forced to give up one of either my pump or my CGM, which would it be? I don’t honestly know…. but I feel like in the overall scheme of things as a cyclist the pump is more important.

Caveats

I wouldn’t be surprised if any non-diabetics that have read through all this (which would be fantastic if they did, by the way) are thinking “Great! CGM. Insulin Pump. You’re set!”

Yea. I wish.

Truth is, all the trial and error leading to carefully planned regimen in the world will fail some days. Human bodies are complex beyond our ability or current knowledge to predict. Just like a 70% chance of rain tomorrow may end up with bright blue clear skies all day, that 50% basal rate adjustment before a ride might go horribly wrong one way or another.

There is however one specific issue I’d like to bring to the attention of diabetic cyclists out there. It is something that it took me years – and finally a helpful diabetes educator – to understand.

Our bodies have evolved to conserve fuel as much as possible. And glucose is that fuel. But our bodies also know when it is important to pour the fuel on for that big effort. And that big effort in this case is going anaerobic.

The liver sits on some huge stores of energy, and is willing to release them into the bloodstream if the muscles need them. Grinding up a hill, sprinting to the city limits sign, turning into a gnarly head wind… these are all things that can result in your muscles screaming for glucose.

Now remember above… all those carefully calculated reductions in basal insulin rates that resulted in a lower quantity of insulin in the blood stream during exercise? What happens if our body decides to release a flood of glucose to meet the demands of our muscles.

That’s right – high blood sugar. While exercise usually results in lowered BG levels compared to the non-exericising baseline, there is a tipping point where the exact opposite can happen.

I’m not going to go into more details on this. It is something to discuss with your healthcare professionals. But I really do wish someone had made me at least aware that this was something that could happen much much earlier on in my life. I spent countless time thinking that I had simply adjusted my basal/bolus rates incorrectly before I understood this concept. Since then things have definitely improved for me.

But there is on inescapable fact. Until they give us an artificial pancreas or other treatment option, Type 1 diabetes will be a hard, challenging, time consuming demon to live with. And while it is true that it is not an obstacle that can not be overcome, it is still a colossal pain in the ass.

Which brings me to my final point. Like diabetes management, diabetes research is hard, and expensive. And the companies that make our pumps, our CGMs, and the insulin are, unfortunately, not motivated to find real cures that would ultimately undercut what is a very lucrative business for them. One can easily spend the equivalent of a good commuter bike a year on diabetes management with really good insurance. And the price of a stable of Pinarellos if you don’t have good insurance (…or Colnagos, or Cannondales, or whatever the cool kids are riding these days.) As such, funding for diabetes cure research has to come from other places.

Those are places like the American Diabetes Association, that have a long history with cycling. They put on events like the Tour de Cure. In fact, Tour de Cure was the first public cycling event I ever took part in. I highly encourage you to find a local Tour de Cure ride and take part. I’m doing two of them myself this year. Or, if you prefer, find a rider and sponsor their efforts (like me, or maybe even… me.) Every little bit helps. While you may be throwing a donation to Just Another Cyclist, you may ultimately help save a life.

…now there’s a mouthful. The low carb high fat lifestyle (LCHF) is a way of eating that has been applied to many different goals. Also known by the synonym ‘Ketogenic diet,’ the idea is to switch your body from burning carbohydrates to fats. While also sometimes compared to the Paleo diet, there are some subtle differences there.

For some, LCHF is a temporary transition with the sole purpose of causing your body to burn off body fat. Here, the primary goal is weight loss, and often it is adopted only for a short period of time – weeks to months. In addition, many athletes have adopted the approach for performance reasons only. As with all things diet related however, there is ample conflicting information regarding the success of this approach.

There is, however, a third group that has adopted this lifestyle for completely different reasons. That group is Type 1 diabetics.

Cue Dr. Richard Bernstein. He has reached near-celebrity status among some in the diabetes community by touting the advantages “Intensive dietary management” of type 1 diabetes. As a type 1 diabetic myself, that also just happens to fancy himself something of an endurance athlete, I thought I owed it to myself to at least give this a try. After about 4 months, I’ve made my decision.

But first, let me be very clear here. There are many factors that come into play here. Everybody has different metabolism, different bodies, different dietary needs. What works for me may be terrible for others (or vice versa.) I’m also not a doctor. Like… at all. I’m just relating my own, personal experiences here. Do with it what you will.

Living with and managing type 1 diabetes is a continual balancing act. While maintaining proper blood sugar levels is indeed important, it must also be balanced against quality of life, as well as other (sometimes competing) overall health choices. With this in mind I started down the LCHF road.

The first couple of weeks were exactly as expected. The absence of carbs sent my metabolism into a tail-spin. Energy levels were at an all time low. Time on the bike switched from something I enjoy to something I just worked through to get to where I was going. But, also as expected, that extreme seemed to taper off.

Soon I was cruising along, pedaling more normally, and… my blood sugar levels were way more stable then they had been. Perhaps ever. One month went by… two went by. Before adopting the LCHF lifestyle it was not entirely uncommon for me to have swings of 80-100 within 30-45 minutes. Now, I was within a range of +/- 20 mg/dL throughout an entire day. Things were looking good.

But then something different started creeping in. My overall blood sugar levels were rising consistently. I found myself needing to correct for high blood sugar levels more and more. I started bumping my basal levels up. Things came back down… only to creep back up again.

One of the adaptations to the LCHF lifestyle I’d learned from others I talked to is the need to transition to taking bolus insulin in response to proteins as I previously did for carbs. I started experimenting here too, but it soon became clear that meals weren’t my problems. I would wake up in the morning and find a steady, consistent rise in blood glucose levels throughout the night on my continuous glucose monitor.

Interestingly enough, it was a completely different source that finally lead me to understand what was happening. That source: Strava.

Turns out that I simply in the same number of miles I had been previously. Initially I attributed this to a number of things. Office had been relocated, cutting my daily commute in half. The route also cut out most of the hills I’d been climbing to the office before the move.

But the most startling fact I learned from Strava was that I simply was not riding as often as I used to. I’d take public transportation a lot. Even when my commute was longer, I used to intentionally go out of my way to tack on miles, just to get some extra riding in. I didn’t do that at all any more. In fact, I began to realize that I was simply suffering through the ride to get to where I was going.

I wasn’t riding nearly as strong as I had before, and therefore was not enjoying it as much. By not enjoying it, I was avoiding it more and more. By avoiding it more and more I was losing the blood glucose management benefits of all of that exercise.

Without me being conscious of it, the diet change had impacted my cycling in a negative way. I’d traded energy and enjoyment on the bike for better control of blood sugar. That trade was beginning to have negative impacts on all aspects of my life – health, happiness. And, somewhat paradoxically, was now also beginning to undermine the very benefits to blood sugar management that I had hoped to gain.

For me the choice was clear. I’d given it a good go over several months. But my experiment with LCHF didn’t provide the overall results I was hoping for. It may work wonderfully for some. But with all things being considered it simply wasn’t a good fit for me.

And that brings us back to the balance I was speaking of earlier. Managing diabetes is a lot more than tracking blood sugar levels on a meter. That is a big part, but not necessarily even the most important part. Cycling provides a great deal of joy in my life. It is my primary stress management technique. It has positive impacts on personal relationships in my life. It has a positive impact on my professional life – I do better work on the job. Removing that from my life at this point would have a large number of negative impacts. And for me, maintaining a tighter control of my blood sugar is not worth sacrificing all those positive benefits. That doesn’t mean I won’t continue to monitor my blood sugar closely. I will continue to strive to understand how specific foods impact my blood sugar levels. But I also hold on to the belief that allowing my blood sugar levels to creep up to 140 or 160 after a meal is far less detrimental to my overall quality of life than not riding my bike any more.

My most important lesson out of this, however, is to always question. Always reevaluate your assumptions. It is good to experiment with different ideas. Just try to remember that a good life is an extremely complex tapestry. Focusing entirely on one particular thread can easily distract you when the other side of the tapestry is unraveling.