Athletes with Type 1 diabetes compete in one of the hardest tests of physical endurance
Story & Photos by Blair Ryan
At dawn, a canon blast pierced the thick anticipation in the air. Signaling the start of the race, it released a kinetic wave of 1,800 triathletes onto the surface of the ocean. The Ironman course on the big island of Hawaii would maintain its reputation that day when pavement temperatures on the bike course were rumored to be 120 degrees and wind caused crashes as cyclists descended hills through the lava fields. Alex Osias wasn’t going to win the race that day, but finishing would be a statement about the roughly three million people in the United States she now represents.
Eight weeks before Osias was scheduled to race at the Ironman World Championships in Kailua-Kona, she searched Google for the words “mold” and “toilet.” She just wanted advice on how to clean her bathroom, but the search results led her to a different answer.
Osias had recently completed a half-Ironman race near her home in Denver, Colorado. She had felt particularly cruddy on the run segment of the race, but attributed her extreme thirst, weight loss, and fatigue to her training regimen. However, these are all symptoms of uncontrolled diabetes. Sugar and ketones, being spilled by her overworked kidneys into her urine, were enabling the black mold to grow in her toilet. Instead of scrubbing with bleach, injecting insulin would be the only treatment for her new problem – Type 1 diabetes.
The Ironman distance is considered by many to be one of the most extreme tests of physical endurance. Race participants have seventeen hours to swim 2.4 miles, bike 112 miles, and run a full marathon of 26.2 miles. The months, and even years, of training for a race like this are incredibly challenging, especially for someone with diabetes.
For a triathlete, there is no bigger race than the Ironman held in Kona. Osias was granted a coveted lottery spot: Her first full Ironman was her first race after her diagnosis.
“You know, we never discussed not doing it,” Osias says. “You can’t not do Kona if you get the chance.”
Type 1 diabetes makes up only 5 to 10 percent of diabetes cases and is most commonly diagnosed during adolescence. Osias, at thirty-three years old, was diagnosed much later than most. Calculating and injecting insulin to cover meals and snacks while adjusting to accommodate exercise, stress, illness, and adrenaline was now daily routine and incorporated into her training practices.
Osias had to learn a lot very quickly.
From a second Internet search, Osias found the world’s largest triathlon club for people with diabetes, and their team that trains for these multisport events.
Triabetes is a program of the non-profit organization Insulindependence.
“I’m in a pickle,” Osias wrote to founder Peter Nerothin.
Nerothin showed her that she was not the only one with a useless pancreas and Ironman goals. He put her in contact with one of the athletes on the 2010 Triabetes team who lived near her hometown. He encouraged her to join Insulindependence’s online network where active people with Type 1 share experiences regarding diabetes and athletics.
Triabetes members gave Osias advice about where to find doctors who would work with her to achieve her Ironman goals and shared their diabetes management strategies.
Osias wasn’t the only Type 1 starting in the water at sunrise in Kailua Bay. Veteran Ironman Cliff Scherb races all over the world and currently holds the second fastest Ironman time ever performed by a diabetic.
“The truth is that Ironman training as a diabetic hasn’t been going on for that long,” Scherb points out. “You can’t really ask your doctor. Your doctor doesn’t have experience about it.”
Diabetic athletes have additional worries. It is important to have some insulin “on board” so that food eaten is available to the cells for energy, but not so much insulin that the bloodstream is depleted of the glucose that the brain and nervous system need to function normally.
Scherb reluctantly admits that diabetes was the culprit for racing troubles in his past.
“Yeah, flat tires, mechanicals, things like that, they happen,” he says, “but, I’ve never had them be as dramatic of an effect as what can happen if you’re not in tune with what’s happening with your diabetes.”
Scherb says it is most important for someone with diabetes to understand the timing of calorie intake when racing an Ironman because the day is so long and the amount of food that needs to be consumed is so much.
“In the beginning, what I call it is a lot of crash and burn,” he says, citing when he was forced to walk the entire marathon at this race in 2005. Through his career as a triathlon coach he hopes to contribute to a road map that will help other athletes with Type 1 figure out how to successfully race triathlons.
Osias jokes that her race plan consists of crossing her fingers and praying. In actuality, she uses two types of insulin, carries insulin pens, and wears two continuous glucose-monitoring sensors during the race. Because everything is new to her, the calculations she must make are not automatic. She wrote blood sugar ranges on 3×5 cards with corresponding insulin doses so she wouldn’t have to worry about how much insulin to take when racing fatigue sets in.
Osias’s goals were to finish, have fun, and not end up in the medical tent.
On the bike she wanted to test her blood sugar every hour, but she accidentally dumped a bottle of water on her blood-glucose meter and it didn’t work for almost two hours. She kept riding, relying on her continuous glucose monitors for feedback about blood sugar extremes.
After worrying about making the cutoff time, she was still smiling at mile 111. She dismounted the bike and tested her blood sugar. It was a bit high, making her feet feel like lead, her stomach uneasy, her mind cloudy, and her heart rate rise. She took some insulin to correct it. She made a friend within the first few miles of the run course. Into the night, on the dark highway pavement, they ran every step of the marathon together.
Under the fluorescent lights, on Ali’i Drive, Osias crossed the finish line hearing the declaration “Alexandra, you are an Ironman.”
On her way to collect her finisher’s medal, she pulled her small pink blood-glucose monitor out of her back pocket. She cocked the trigger of the lancet device, put the tip to her middle finger, and pricked it. She squeezed the finger and touched the drop of blood to the end of a strip inserted in the meter. It counted down, five—four—three—two—one—143: a post-Ironman blood sugar that veteran Type 1 athletes would just about kill for. Scherb, who had finished many hours before, didn’t break the record for a Type 1 in Kona this time, but blood sugars were not the reason.
“I had great [blood sugars] all day,” he said after the race. “Perhaps I missed a few things in training that could have made for a more speedy day.” A few days after Kona, he was already looking ahead to racing in Germany in 2012.
Ninety-five percent of people who die from diabetic complications die because their average blood sugar level over decades is abnormally high, putting strain on blood vessels and kidneys. Exercise lowers blood sugars by making body tissue more sensitive to insulin, yet there are still people who tell those diagnosed with Type 1 that their lives will be limited and sedentary.
“It makes so much more sense when I see how other people train and hydrate and take in calories,” she says about the community of athletes with Type 1 she had access to through Insulindependence. “It was such an amazing experience and having such kick-ass support made it even better.”

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Blair Ryan

Ironman on Insulin