Running in the Zone

Heading out the door? Read this article on the new Outside+ app available now on iOS devices for members! Download the app.

It was pitch-black by the time they got to the trail.  After driving nearly nine hours through the sandy expanse stretching across the border of California and Arizona, Amy Carrion and her husband, Alex, were standing on the brink of the Grand Canyon, 500 miles away from their home in Los Angeles, about to run 50 miles through one of the largest canyons in the world.

Carrion never would have considered running rim-to-rim-to-rim in the Grand Canyon two years ago. Having been diagnosed with Type I Diabetes at age 12, she mostly stuck to the safety of roads.

Breaking Down Type I Diabetes

No one knows exactly what causes Type I diabetes (see “Type I vs. Type II below”), but the disease causes the pancreas to stop producing insulin, a hormone that helps our bodies transfer glucose (sugar and carbs) from our bloodstream into cells, where it’s stored as energy. Without insulin to help the body utilize excess glucose, a person will lose energy, often becoming irritable, dizzy or lethargic, then go into a coma, and—if their condition is left untreated for as little as 48 hours—die.

“I used to be very scared of doing anything so remote,” Carrion says.

According to the American Diabetes Association, nearly 1.25 million Americans have Type I diabetes.  That’s less than one percent of the overall population, though that number is expected to rise in the coming years.

Dr. Anne Peters is one of the world’s leading diabetes clinicians and director of Clinical Diabetes Programs at USC’s Keck School of Medicine. She’s worked with a wide range of elite athletes with Type I diabetes, including runners who have traversed Death Valley, traveled across the U.S., and finished seven marathons in seven continents in seven days.

To help simulate the function of the pancreas in everyday life, those with Type I diabetes receive a constant flow of insulin at a low dose throughout the day. This is called a “basal rate.” They must also administer doses of fast-acting insulin (called a “bolus”) with each meal, to counterbalance the amount of sugars and carbs they’re consuming. This means diabetics have to be familiar with the exact quantity of sugars and carbs they’re consuming at all times (see “Managing Diabetes below”).

“They have to do a friggin’ math equation before every meal,” Dr. Peters says. “There are insulin pumps that can figure out the math for you, but you still have to count carbohydrates, and then you have to adjust [the pump] based on your exercise—the whole system is so hard.”

Type I vs. Type II

For someone with Type I diabetes, the pancreas produces very little insulin, or none at all. This requires Type I diabetics to track the carbohydrates (sugars and carbs) they consume, and deliver insulin into their bloodstream manually via injection or pump. There’s no cure for Type I diabetes.

Type II diabetes is brought on by genetic and environmental factors, like high sugar consumption and an inactive lifestyle. When muscles aren’t utilized often enough, the energy from sugar remains in the bloodstream, and when blood-sugar levels are high enough the body can build a resistance to insulin. Many Type II diabetics still produce insulin; however, they don’t produce enough to properly metabolize the amount of sugar in their bloodstream.

While there’s no cure for Type II diabetes, the effects of the disease can be mitigated by exercise, which transfers sugar from the bloodstream to working muscles. With proper lifestyle changes, Type II diabetics may not ever need to give themselves insulin.

Think Like an Engineer

Type I athletes face the added challenge of figuring out how to quantify the way their bodies react to hormonal shifts while they’re running, as both stress and adrenaline can cause blood-sugar levels to rise.

Dr. Peters says to have good diabetes control it helps to think like an engineer: collect data, analyze patterns, adjust accordingly—and understand the system’s never perfect.

“Unfortunately, or maybe fortunately, it’s happened more than once where my pump system has failed because of altitude, rain, or sweat,” says Stephen England, an ultrarunner from New York with Type I diabetes. “Or, my CGM may fall off my stomach or my arm, wherever I put it; or, it may just fail.  You can’t always control every element.”

England, who runs for Team Type 1, has completed over 50 trail races, including 11 100-mile races and the Tahoe 200. In extreme weather (hot or cold), England has had to develop strategies to keep his insulin close to room temperature. He’s also learned to have extra insulin and carbs on-hand in case blood-sugar levels drop or spike, and to anticipate be equipment malfunctions.

This past June, while England was half-way through Big Horn 100, his Personal Diabetes Manager (PDM)—which is a digital device that allows him to control how much insulin to administer—lost all charge and died.  (It was supposed to last one week.) So, England quickly switched to Plan B, which meant giving himself insulin injections from mile 55 to the finish.

“It’s really about preparing for the worst-case scenario,” he says. “And if that means I carry more supplies in my hydration pack than my competitors, then so be it.”  So far, England has been able to get to the finish line of every single race he’s started, which, he says, “is a really proud thing to have on my resume.”

Carrion completed R2R2R—her first 50-miler—that evening in May, after nearly 17 hours on the trail. It was hard, she said, and at mile 40 she hit a low; but, she had everything she needed to bring her glucose levels back within range and emerge from the canyon an ultrarunner. 

Carrion has learned to be aware of her blood-sugar level at all times; she also always makes sure she has extra food, insulin, a back-up glucose monitoring device, as well as a running partner.

“And if all those things are in check,” she adds, “then there’s no need to be scared.”

Managing Diabetes

There are two vital components to diabetes management: monitoring blood-glucose levels and administering insulin.

1. Monitoring Blood Glucose Levels: Glucose Meter or CGM
A Blood Glucose Meter requires a finger prick to produce a miniscule amount of blood, which is then put on a test strip and read on a digital monitor.

Continuous Glucose Monitors (CGM) are a fairly new invention, currently only used by a small fraction of diabetics. CGMs come in the form of a patch, which inserts a tiny sensor wire into the interstitial fluid beneath the skin. This sensor—when paired with a transmitter—takes blood glucose readings, then sends these numbers to users’ smartphones roughly every 15 minutes.

2. Administering Insulin: Injections or Pump
Injection Therapy means self injections about four times a day with a needle or pen. Diabetics need one dose of long-acting insulin (“basal rate”), which lasts 24 hours, as well as one dose of fast-acting insulin (“bolus”), which lasts roughly four hours and is taken with each meal. A “bolus” is measured against the amount of carbs consumed.

Pump Technology works with a small tube that goes into the skin and can remain in place for up to 10 days. The pump itself is a digital device that releases insulin based on pre-programmed “basal” and “bolus” rates. Pump users can also adjust their dosage in any given moment based on their activity level and carbohydrate consumption.

Claire Walla is a runner and writer from Los Angeles who recently moved to the Pacific Northwest, and has a newfound love and appreciation for her pancreas.

Want to Know What It Takes to Finish at Western States? Just Ask Hellah Sidibe.

Find out what happened when this six-year run streaker and HOKA Global Athlete Ambassador took on an iconic ultramarathon in California's Sierra Nevada