Strategy keeps marathon runners on pace and in the race for more than 26 miles, but for three-time Boston Marathon runner and University of Virginia medical student Courtney Duckworth, strategy also keeps her alive.
Duckworth is balancing her training to be a physician with marathon training as she works to run the world’s six major marathons. On Nov. 7, she’ll be halfway to the goal when she starts the New York City Marathon.
She’ll do it all with her trusty constant glucose monitor, insulin pump and carbohydrate gels as she keeps a balanced blood sugar while running 7:45 minutes a mile for 26 miles.
“I have Type 1 diabetes,” Duckworth said on a break from her med school duties. “Before I was diagnosed, and especially afterward, sports were an outlet for me to feel strong. After my diagnosis, sports took me away from my disease and gave me a feeling of freedom. I’ve always leaned on sports that way.”
Duckworth will run the New York City race on behalf of Beyond Type 1, a charity partner of the event that features 50 runners living with Type 1 diabetes from 23 states and five countries. They and Duckworth are running to raise awareness and research funding.
“Courtney is a perfect example of somebody who’s living beyond her Type 1 diabetes. It’s inspiring to see how she’s used her lifelong diagnosis and love of running to motivate her academic studies,” said Jordan Jendricks, director of programs at Beyond Type 1.
“We’re thrilled to have her on the team. We thank her for her efforts to raise awareness and funds that will support crucial efforts and programs for others affected by this condition,” Jendricks said.
It all started when Duckworth was 10, growing up in Northern Virginia. A dedicated figure skater, she was diagnosed with diabetes after feeling lightheaded and having vision problems.
“I was lucky in that I had a single episode that ultimately led to my diagnosis,” she said. “I never had excessive thirst, frequent urination, weight loss, fatigue, or diabetic ketoacidosis which can be deadly.”
Beyond Type 1 officials say recognizing the symptoms early is critical.
“The disease develops gradually as the body’s insulin production decreases and blood glucose levels can become dangerously high once insulin production is outpaced,” they said on their website. “Symptoms may develop rapidly and can be mistaken for other illnesses such as the flu and a delayed diagnosis can have serious consequences.”
Early symptoms of the disease include unquenchable thirst, frequent urination, weight loss coupled with an increased appetite, exhaustion, blurred vision and fruity smelling breath.
More advance symptoms include stomach pain, fatigue or weakness, nausea or vomiting, rapid, heavy breathing and loss of consciousness.
The young Duckworth didn’t think she was truly ill. They insisted she was.
“I was trying to convince the people in the hospital that they were wrong. I didn’t want to accept it at first,” she recalled. “Once I did, my first question was: ‘will I live?’ The second question was ‘can I skate?’ I knew that if I could skate I could live.”
Duckworth continued skating through high school. But when she went to William and Mary for college, getting to a rink was problematic.
“We weren’t allowed to have cars our first semester on campus, and I had to find another sport to do. Running kind of fit the bill because it was easy, quick and convenient,” she said.
Duckworth was writing up a bucket list and put marathon on it, even though it seemed impossible. Then she discovered a college buddy shared the marathon goal on his bucket list. He said they should pick a race. They did.
“I said OK, thinking maybe he was kidding, but it turned out he wasn’t,” she said with a laugh.
Running with Type 1 diabetes is not simple. The pancreas doesn’t make enough insulin to help move blood sugar, or glucose, into the body’s cells for fuel. According to the Centers for Disease Control and Prevention, the condition is most likely an autoimmune response. But it is notoriously a complicated one.
Those with Type 1 diabetes need to take insulin either by injection or, nowadays, using an insulin pump. They must check blood sugar levels throughout the day as the levels change often.
Balancing blood sugar is doable, but add a marathon into the mix and things get hairy.
It’s like Satan’s own story problem: The average person’s body stores 500 grams of glycogen. That’s about 2,000 calories of glucose ready for immediate use. If every mile ran burns between 100 to 125 calories of glucose, how long before the body’s entire store of glucose supply has gone up in sweat?
The answer is about 20 miles, which means average runners have used up their sugar stores with more than six miles to go. That has led to runners to suffer hypoglycemia and pass out, not an uncommon sight at marathons.
“If she was just going to go for a jog around the block, it would be completely different compared to what she has to do for this,” said Dr. Susan Kirk, a UVa professor of medicine in obstetrics and gynecology.
“Endurance exercise, and something like a marathon, is particularly challenging for someone with type 1 diabetes because you need a pretty fine balance of insulin, carbohydrates and other hormones as well, which all affect blood sugar levels,” she said.
Kirk said most type 1 diabetics will reduce their insulin substantially before an endurance event, consuming carbohydrates to keep blood sugar high enough to feed their bodies.
“People without type 1 diabetes can just go out and run and the sugar will come out of their muscles and liver just fine and they’ll probably take some carbohydrates, but it’s not as critical,” she said.
Running like Duckworth takes commitment. She’s run eight marathons since hitting the streets a decade ago, including three in Boston and one in Chicago. Each run, whether race or practice, requires that she balance her glucose and insulin levels while running.
“I quickly learned that I had to be systematic and have a solid strategy in place,” she recalled. “After one particularly scary run where I had to call 911 for an episode of hypoglycemia, I started keeping a log and treating myself like a science experiment.”
Duckworth listed the variables in her life and training that could be problematic during a run. She kept a log and changed them one at a time to find the best method of preparing and completing her training sessions.
“I would wake up at the same time. I’d eat the same thing in a set amount of time before a run. I would only change my level of insulin and I’d keep track of how that worked. Then I’d change something else,” she said.
When she first began running, she would monitor her blood sugar by the finger prick method, sticking her finger for a drop of blood every three or four miles.
“At the time we did not have the technology we have today. We did not have continuous glucose monitors,” she said. “I was not on an insulin pump and was still doing multiple injections and was checking my glucose level with a pricker and a meter as I running. It was very complicated. I had a couple of very scary incidents while I was learning to run with type 1.”
Technology has changed in the last decade and it’s made Duckworth’s runs easier.
“With a continuous glucose monitor you don’t have to prick your finger and the monitor can estimate your blood sugar for you every 5 minutes. With the finger prick, it was really just a snapshot of my blood sugar. If it was 100, I didn’t know if it was 100 going up, 100 steady or 100 going down. With the continuous monitor, I know,” she said.
Duckworth is not alone in the struggle. Brian Herrick, director of mission and volunteer communications with the JDRF, which was previously named Juvenile Diabetes Research Foundation, is both an avid runner and has type 1 diabetes, or T1D.
“Life with T1D as an athlete is definitely easier than it used to be, thanks to the invention of continuous glucose monitors and automated insulin delivery systems, but it still isn’t easy,” Herrick said.
Like Duckworth, Herrick plans his day and his run.
“You have to consider so many variables that impact blood glucose levels. What you ate for breakfast and the insulin you took for it has effects that last hours. If you’re excited or nervous, adrenaline can cause blood sugar levels to skyrocket,” he said. ““Aerobic exercise makes blood sugar levels come down while anaerobic can cause it to spike. It all has to be considered and planned for.”
Herrick said his schedule for running included eating a complex carbohydrate two hours before the run and taking less than usual insulin. He’d check his blood sugar just before the run and eat something if it was on the low side of normal.
Every 10 minutes, he’d check his glucose levels, eating some food he carried on the run, if needed.
“There are so many factors you have to account for. Exercising and performing at a high level is possible, it’s just tougher,” Herrick said.
When Duckworth found her strategy, she entered her first marathon and ran well enough to qualify for the Boston run. That became her next goal, which she met in 2015.
A few Bostons later, she set a goal of running all six major marathons in the world. After she runs the New York City race, she’ll have Tokyo, Berlin and London to go.
She still has her strategy in place.
“I have a special profile on my insulin pump that decreases the amount of insulin delivered to me as I’m running. I have a very precise number of carbs and will take insulin for those carbs, even though it’s a reduced amount, and every three miles I will check my glucose reading,” she explained.
“Based on that reading, I will give a little insulin or none at all through the pump. And every 4 miles I have these goo gels that provide about 20 carbs or so and then I repeat that cycle over and over for 26 miles.”
Duckworth posts her strategies and discoveries from races and training runs on her Instagram page, hoping to promote safe exercise strategies for the Type 1 community. Her medical colleagues can view it to see what effort goes in to exercising and others with diabetes can glean advice to bounce off their physicians.
“It’s not a prescription. I’m not giving medical advice,” she said. “I’m just trying to help. I know what it means to me. Running is really my escape and my release. On rainy days coffee is tempting but usually I’m pretty jazzed to get out and run.”