‘No Excuses’: Training for the Olympics with Type 1 Diabetes

This transcript has been edited for clarity. 
Michael C. Riddell, MD: This is such a privilege for me to be able to speak to both of you. We’re on the verge of another Olympics. Because diabetes is such an important topic for me and for Anne, and for you, Gary, I thought maybe we could spend a few minutes talking a bit about what it’s like being an Olympian with type 1 diabetes.
Are you okay if I ask both of you some questions?
Gary C. Hall, Jr: Sure. Shoot. 
Riddell: Gary, I’ll start with you. You’re a three-time Olympic swimmer — a legendary representative of the US team in Atlanta, Sydney, and Athens. I guess [you’ve won] 10 medals, correct me if I’m wrong, over those three games?
Hall: It’s easy to remember because I just count them off on my fingers.
Riddell: As far as I understand your story, you were diagnosed, I think in 1999, just before the Sydney games. Is that correct? 
Hall: Correct, March 1999. I’d been training for the Sydney Olympics and it came out of the blue, as these diagnoses often do. 
Riddell: What’s it like to be an Olympian and then get hit with this diagnosis of this disease that maybe you didn’t know all that much about, but still have in your mind that you want to compete again?
Hall: Competing was not a consideration initially. I think I went through the stages of grief, and there was certainly panic and what am I going to do with my life now? It was explained to me by a diagnostic doctor and the first endocrinologist that I met with that continuing on in the sport at a high level was not a possibility. It was impossible. I was reeling, thinking it’s just a matter of time before I go blind, before I lose the use of my kidneys, have my feet amputated, go impotent — a long list of all the complications.
I felt like a ticking time bomb. I went through those stages of grief, suicide ideation, and grappled with what my future was. It was scary. It’s scary for all people diagnosed with this, but this was not just how am I going to contend with insulin shots and testing my blood sugar. This was, what am I going to do, because I’ve put all of my eggs in one basket? I’m a swimmer. At this point, I’ve invested everything I have into this, and it’s gone. 
Riddell: You’re known around the world as being such a fighter, such a competitor, and also a real spokesperson for what can be accomplished with type 1 diabetes. Lucky for all of us, we’ve got Dr Anne Peters, who helps a range of patients with type 1 diabetes.
Anne, what was it like to meet Gary? When did it happen? What were your thoughts when you first met such a warrior with type 1 diabetes?
Anne L. Peters, MD: First, I always just get to know my patients. From the beginning, he was Gary Hall, the human, who was both an Olympian and someone whom I knew had type 1 diabetes.
Remember, he got this before we had all the tools we have now. It was before we really had continuous glucose monitoring (CGM). It was before we had much of the knowledge we have about sports and people with type 1 diabetes. People hadn’t been doing the things that people do now. 
I first just got to know him. He and Elizabeth, his girlfriend at the time, came to see me. They were late, and I was going to give a lecture. I threw them in my little VW bug that I had at the time and took them with me to go to see the lecture. I loved the human being that was Gary Hall, and it had nothing to do with anything other than I believed in this person. 
I didn’t know anything about sports. I still don’t, except I know something about swimming. I had no idea what anyone was talking about. I didn’t actually know how fast you had to go, or how high the bar is for an Olympian, but I believed in the person. I believed that if I helped him, he would be a role model. 
It just seemed natural to say, of course you can go and train for the Olympics, but it was actually based on way too little knowledge. I’m so glad I had way too little knowledge, because what happened was obviously what happened. I believe in giving people a chance, and most of all, that when people have new-onset type 1 diabetes, they need to not feel like it’s the end of their life.
They need to understand it is a change in their life, but if they get the right tools — nowadays, that puts people on a sensor on automated insulin delivery — it is so livable, as Gary is a testament to. I think you were one of the very first people who ever fought your way through it and just did it.
We did it together, and that was what was so much fun. I got to go to all these events and watch him in two Olympics. It really changed my life, and I adore this man. He lives 4 miles away from me, so what can you say? 
Riddell: I know that you’ve done that kind of work with other exceptional athletes with type 1 diabetes, and I think we’re really fortunate that the two of you worked together, particularly at the Sydney games, to accomplish so much.
Gary, can you tell us a little bit about how your mindset evolved once you talked to Anne and others that gave you some encouragement that you might be able to tackle another Olympic Games? How did you make the transition from frustration and fear to the elite-level training and competition that are required for the Olympics?
Hall: I credit Anne, really. I went from a diagnosing physician that said it’s impossible to Anne and her VW Beetle on the I-10 telling me, yeah, let’s give it a try. It was never with any certainty that I got back in, and there was so much learning that needed to be done in such a short period of time, and trial and error. There was a lot of error. This worked, this didn’t work, let’s not make that mistake again. It was a learning process that went up to the Olympic Games. 
I had only competed in two meets between my diagnosis — a time to qualify me for the Olympic Trials, go to Olympic Trials, and qualify for the Olympics — and so it was really like the third time I had raced since the diagnosis. I didn’t know about the spikes and the difference between anaerobic and aerobic [exercise]. I had figured out what it meant in training and the differences there, but competition was something that I was trying to figure out, even while competing in Sydney.
Riddell: That actually makes me think about this one lecture that Anne gave. I was sitting in the audience, and Anne was sharing some data about, I guess it was the freestyle 50-meter swim in Sydney, where you had done some blood sugar monitoring before. You tied for a gold medal with your teammate from the US. Anne shared the data. Can you speak to this, the two of you? The data for me were just jaw-dropping. What happened to you? 
Hall: I was getting spikes with the adrenaline. It was voted Australia’s greatest sporting moment, not just in Olympic history but in history of all sports. It was this relay during the opening night in Sydney, the men’s 4 × 100 meter freestyle relay. It came down to the anchor leg, which was the last leg of the relay. It was myself and Ian Thorpe, and he out touched me at the wall. My time was faster than his, but Australia won the gold medal. It was a remarkable race.
I tested my blood sugar after that, and it was in the 400s. You’re compromised. Your athletic performance is compromised significantly when your blood sugar levels are that high. I was terrified. In the news conference and stuff like that, I’ve never talked openly that my blood sugar was too high for that race, and that could have made the difference. 
That was for the first race. For the 100-meter and the 50-meter freestyle, I was testing frequently 20 times. It was still finger-sticks at that time. I think I was on neutral protamine Hagedorn (NPH) insulin at that time, too. I would shoot for about 140-150 mg/dL before the race. I was testing in the ready room before being walked out to the blocks, and it would be 140-150. 
My races lasted either 21 seconds or 48 seconds. I would test after the race, and I think it was 388 after one of them. It went from 150 to 388 in a span of less than 5 minutes. Immediately after the race, the first thing I was doing was testing. If it was a CGM, that would be two arrows up.
I remember after one of the races, I gave myself 50 units of fast-acting insulin to get my blood sugar back down into range.
Peters: I have so many things that I learned. First, in the very beginning of all this, I went with Gary to those meets, and I went with him to the Olympic trials. I was afraid because I didn’t know what would happen. What he described when he would swim really hard was nausea and feeling out of it. I, because we didn’t have CGM, was worried that he could become hypoglycemic. I didn’t know what would be happening, so I had to train his coach to figure out how to differentiate.
I didn’t know what to think because this hadn’t been done before. Gary didn’t get easy type 1 diabetes. Some adults get type 1 where they have ongoing beta-cell production of insulin. That’s easy. He didn’t get that. He really became immediately insulin deficient. 
In the race he’s talking about, the 4 × 100 freestyle relay, the reason [his blood sugar] was so high wasn’t just the adrenaline. It was because he caught the flu or some other viral illness in advance, and that gave him insulin resistance. Remember, you were having trouble keeping your sugars down before that race, and I realized — and I’ve since seen in other athletes — that if they develop an illness or any cause for insulin resistance and can’t normalize glucose metabolism, they end up not getting enough fuel in their working muscles. They’re not storing enough glycogen.
That race, I watched him race, but when he turned around and came back, I watched him slow [down]. I knew that was because of insulin resistance. That was the race where I said to myself, I was wrong. I can’t do this. I can’t give him an Olympic gold medal because there is something diabetes can do that, under the best of circumstances, makes racing impossible. 
Now, with subsequent athletes, if it had been the day before and I’d seen his sugars were high, I would have literally given him intravenous (IV) fluids and IV insulin to help get his sugars down, sensitize him back to insulin, and get him ready for that race.
I didn’t know that then, and I didn’t know how to get him to become more insulin sensitive. He was in the Olympic Village and I was on a boat, remember? I didn’t have the ability to do that. When I was taking care of Charlie Kimball, who was an IndyCar racer, and others, there was a tent in the middle of the racetrack where I could give them my fluids and insulin.
I realized that you can’t compete if you’re insulin resistant. You can have your sugars go up because of stress-induced hyperglycemia. Competing with insulin resistance is really hard. 
Riddell: I’ve heard of other physicians dealing with athletes with type 1 who’ve had similar experiences, like Sir Steven Redgrave, a rower with type 1 diabetes in the Olympics. He required IV fluids and IV insulin just to get his sugar down when he was competing. It’s an interesting story about that. 
I don’t think that diabetes is an advantage in the Olympics. Gary, do you want to speak to whether you think it’s only a disadvantage, or are there some things about your diagnosis that changed you a little bit in your training or your mindset? 
Hall: I don’t like it when I hear people say it was an advantage. I had teammates — a world champion for Team USA, a guy I considered a friend, Bill Pilczuk — and he was openly, among peers, accusing me of cheating.
Riddell: By taking insulin, the hormone that keeps you alive?
Hall: Yes, because I was taking insulin, I should be banned from the sport. That hurt a lot. I never felt that there was an advantage to having diabetes.
Peters: There was so not an advantage, but I had to prove to the International Olympic Committee (IOC) that you could compete on insulin because it’s a banned substance. The way I did it is I said, he’s not giving enough insulin. He’s not giving extra because his A1c is 7 and because he’s having these glycemic excursions. I said, if he was giving extra insulin, that would enhance performance; he’d have lower sugars. They actually believed me. 
You were doing nothing wrong. This is an amazing athlete, and diabetes did not give an advantage. 
Riddell: An inspiration for every young kid out there who’s diagnosed. I know, Gary, you do a large amount of work and advocacy for type 1 diabetes awareness and making people feel like they can accomplish their dreams, which is really something that’s important to all of us.
Do you want to share what you’re doing right now, or any tips or tricks for those of us who would love to be in your shoes, at least in our dreams? 
Hall: I’m not very good at accepting compliments, and there were many thrown at me right there, so thank you for all that. 
We do what we can. This is a diabetes community, a tribe of sorts, and we all serve a role and play a part. I threw myself into patient advocacy. It’s strange because I don’t know, maybe this is a different time, but when I was diagnosed, it was in the newspaper the next day on the front page of the Arizona Republic, where I was living and training at the time.
There was no patient privacy stuff, so I didn’t have a choice in whether I was going to hide this or not. Immediately, within 3 months of being diagnosed, I went to the very first JDRF Children’s Congress in 1999. I took up that torch and met other kids with diabetes.
I didn’t really give it much thought, but walking out to the starting blocks of the Olympic games, I knew that I represented the United States of America. It was a tremendous honor, but I also represented all people around the world with type 1 diabetes. 
It became apparent after having the initial conversation with Anne that if I didn’t let diabetes stop me, if I could even retain some level and make nationals or make the Olympic trials, let alone make an Olympic team, that it had the potential of encouraging a newly diagnosed kid and making the diagnosis a little bit less scary.
That was so appealing to me. We’re motivated by gold medals as swimmers, but I was able to achieve, in accomplishing that and inspiring kids with diabetes, so much more than any medals. 
Peters: I’m a doctor and I have thousands of patients, and Gary took all of that, and all of that noise and Olympics, and he basically internalized diabetes as something he could manage. I find that fascinating. 
I don’t know if that’s something to do with the fact that he figured all this out as an athlete, but I have to say that, years later, he’s doing great. He’s been somebody who’s made diabetes just part of his life. I know it’s not easy, don’t get me wrong. 
I’m so proud of him because I’ve seen all sorts of people go haywire over things. Gary didn’t go haywire. He’s just been Gary and he’s taken care of himself and he’s never, ever, ever used diabetes as an excuse about anything. I just feel like you integrated it into you in a way that I think is very mentally healthy. I consider you a role model on every level.
That’s why I was willing to help you way back when, when we sat in that car. I was right. You were the right person for the job, which I wanted you to do. You never let me down. 
Hall: We did it together.
Riddell: Maybe we could end on a couple of elements that could help people who are watching the video and maybe are in Anne’s chair from time to time or in Gary’s chair.
Let’s say that, Anne, you want to give some encouragement to a physician who is trying to help an athlete with type 1 diabetes. What are the things that you would ask this patient, this individual, to make sure that you are on the right track to helping him or her? How do you start with an athlete as a physician?
Peters: First, I know about how to help athletes with type 1 diabetes, largely because you taught me so much. I consider it an art form, and I consider, particularly with higher-level elite athletes, that no one athlete is the same as any other. It always has to do with insulin on board, but it has to do with how to adjust it. The more regular someone’s workouts are, the easier it is for me to adjust insulin.
The first thing I get to do, like I did with Gary, is get to know them. I get to know someone’s schedule: When do they like to work out, and how can I help them? How can I help with nutrition? How can I adjust things that work out towards their goals? Obviously, I have to always address the variability because what happens one day may not happen the same as another day.
It’s just about listening. I think that’s what you’re supposed to do as a doctor with anybody. 
Riddell: Also interpreting all the CGM data you must be looking at now for these patients. 
Peters: It’s more having the person interpret it. To me, I don’t care what the time and range is necessarily. You could have many lows at some point in the day when you’re working out, and that’s going to limit you, or some lows overnight and still have a good time in range. To me, it’s how do I keep glycogen fuel to working muscle? How do I keep you from going low at night? How do I balance this so you can train in a way that’s most effective for whatever you want to do?
Then you have to change the regimen for competition. You have to figure out how to deal with competition because sugars will go higher. It’s a large amount of investment as a doctor and time, but isn’t it the best thing to help someone with their goals, whatever they are? 
Riddell: You become part of a team. I guess in Gary’s case and others who are striving for the Olympics or maybe competing in Paris, I know there are a few Olympians with type 1 diabetes that are on teams. 
Gary, you’ve got a network of people to support you. You’ve got probably coaches, you’ve got dietitians, you’ve got all sorts of people. How do you make the best of your time with your endocrinologist, let’s say? How do you prioritize their expertise? What do you say to them, or how do you encourage them to help you? 
Hall: It takes trust. You have to have faith as an athlete. Swimming is a unique sport because it takes a team to get you there, but then at the end of the day, you have to step up on the blocks by yourself and do it yourself.
You can have the best endocrinologist in the world. She can tell you to do all the right things or he can tell you to do all the right things, but if you’re not willing to do it yourself at the end of the day and take those measures, it doesn’t do any good. I can have the best coach in the world, but if I’m not listening, it doesn’t matter. 
I had already very selectively chosen a strength and conditioning coach, a sports psychologist, and a swim coach. I had a team around me already, so it seemed natural to me to adopt Anne into this comprehensive team to address every level of competing, training, and sport.
Riddell: Any final words from either of you? That was an outstanding few minutes, but I want to leave it up to you to finish it. Anne, go ahead. 
Peters: I think, as a physician, you’ve got to look at the team just like Gary did. Gary and I became a team. That was kind of unique because many times diabetes providers use more providers and they have diabetes educators and everything else.
People have asked me about this in the past, but Gary had to become trusting of me really fast because it wasn’t very long until the Olympics. I remember walking behind him like a little duckling and saying things about carb counting and everything else, and he did and didn’t want to hear me. It was very adorable. 
I was like the Little Engine That Could because I so believed in him. It’s about a relationship. This isn’t typical as a doctor with a patient, but that’s just our relationship. I was willing to donate all my time and energy and everything else to this project because I believed he would pay it forward. It was unique.
I think that people from a diabetes perspective need to be sure to work well with their diabetes team and choose it. I don’t think you can trust 20 people. You had many people on your team, as you mentioned already, but we really developed this connection.
That’s, I think, what people need is a connection to another person — whether it’s a doctor or an educator, or even a peer mentor. There are all sorts of ways to find connection. You don’t just have to find an endocrinologist because in this world that’s us being bludgeoned to death by prior authorization forms, we don’t have much time.
We had time and we did it, but it’s not what everyone could do. 
Hall: She didn’t have time. She did it anyway. 
Riddell: That’s Anne. 
Hall: Yeah. 
Riddell: Final words to you, Gary. Thanks so much. 
Hall: I love Anne. I’m so appreciative of her role in my life and everything that she’s done for me.
I have so much respect for the work and the research you’ve done. When I was diagnosed in 1999, there weren’t internet forums, there weren’t groups, there wasn’t information that was readily available. In my advocacy work that continues on through today, here right now, when I’m approached by somebody and they’re asking me a thousand questions about exercise and diabetes, I always refer them to Anne and Mike, the foremost authorities on diabetes management, exercise, and physical activity.
Thank you. What you’ve contributed to this tribe is tremendous. I recognize it and appreciate it, maybe more than other, because I was around when it didn’t exist. Thank you for all your work, both of you. 
Riddell: Thanks to both of you for that flattering end. We really appreciate this time with you, Gary and Anne.