November is National Diabetes Month:Diabetics are Athletes Too

Gary Hall Jr. was something of a nonconformist in the pool during his gold medaled Olympic career. These days he makes waves on Capital Hill for diabetes advocacy and has made it his business to stay current with diabetes research.

Diabetics are Athletes Too: Knocking Out Old School StereotypesDiabetes and an athletic lifestyle are not mutually exclusive. Diabetics are tired of walking out of podiatrist’s office with a pair of prescribed shoes that look like Herman Munster's. They want a normal lifestyle. "Old school" doctors need to recognize that there are new and more appealing options for our patients. We must also take on the role of a coach for our patients that are athletes and those that need to become more like athletes. By helping out patients feel more comfortable and enthusiastic about exercising, we help reach their fitness goals and also help control their diabetes. High quality appealing footwear is an important component in helping our diabetic athletes and helping our diabetic patients to become athletes. Diabetic advocate and Olympic swimmer Gary Hall Jr. provides a first hand account of the problem:
"For all the efforts of removing the stigma attached to living with diabetes, the unfortunate mark of diabetes remains apparent in prescribed footwear. I dedicated my life to proving that diabetes didn't have to stop an individual from accomplishing their dreams, whatever the dream was. For me it was swimming in the Olympics. When I won gold I was able to help tear down that barrier (often viewed as liability) that separated people with diabetes from the rest of the pack. The important message was that while additional requirements were necessary in properly managing diabetes, a person living with diabetes was equal. Somehow that message hasn’t come through in shoe design. If you have diabetes you are asked to wear, let’s face it, ugly shoes.
It’s hard enough to get diabetes patients to comply with the call to exercise. Asking someone to slap on ugly shoes and exercise exacerbates that challenge. With a diabetes diagnosis we are bombarded with the mantra, “diet and exercise”. Regular exercise helps increase insulin sensitivity and lower blood glucose levels but competitions have a dramatically different effect.

The stress associated with competitions sends blood sugars soaring. Throw in endorphins and adrenaline and levels can reach dangerous and dizzying highs. My targeted blood sugar level before a major competition (last glucose test taken five to ten minutes prior) was around 140 to 150. I competed in the 50 meter freestyle; it typically took me 21 second to swim. I would test my blood sugar immediately after a competition and my levels were never less than the high 300’s. This dramatic hike associated with Game Day is common for athletes young and old, fast and not so fast and is in stark contrast to the blood glucose effects of Practice Days.

I enjoy sharing with people that as a swimmer about 60% of my training was done out of the pool. For any athlete living with diabetes, at any level, it is imperative to have a good pair of “trainers”. Is it too much to ask that a good pair of diabetes friendly sneakers be good looking too?"Fortunately, vendors that deal with diabetics are starting to get it. They are developing lines that incorporate style and function. Think about your experiences in everyday life and how that influences how you feel about the product or service. Flying Virgin Air on the way back from Seattle it struck me just how dramatic an effect style and attitude can have on an experience. The attention to lighting, elimination of listless airline stewardess safety instruction in favor of an upbeat graphic presentation on the multi-use personal movie screen convey a more relaxed, fun attitude. This will make me more likely to fly Virgin Air Again and the same holds true with our diabetic patients’ compliance with appliances, shoes and activities of daily living.

Fear has its place as a wake up call in certain cases but the unfamiliar will not help them comply when it comes to equipment. How much of what we dispense is actually worn at home? It turns out prescriptive shoes are only worn about 15% of the time in the home according to research by David Armstrong DPM. Appliances are only used about 25 % of the time.In an uncertain fast changing world people are more comfortable with things that they are familiar to them. In Martin Lindstrom's New York Times bestseller, Buy-Ology he attributes this phenomena to the ritualistic behavior that becomes attached to branding. It explains why people engage in tribal behaviors as well.

It's a lot more reassuring to trudging through the morning commute to be part of the "Apple Community" with an army of I-Phone users. The natural conclusion is that positive peer pressure and coming up with ritualistic hooks may be the key for less motivated diabetic would be athletes. The World Fit program is an example of positive peer pressure in action. At it's outset it was targeting middle school kids with a monitored walking program to combat obesity. Olympic athletes are involved as positive role models and Gary Hall Sr., also a former Olympic swimmer is one of the principal organizers. The unexpected benefit was that adults started participating in the program as well because of their kids. What happened here? In one sense a subculture was created. If we look at how strong that subculture can reinforce branding (think about a loyal legion of Harley Davidson riders) it may help us understand how we can create a subculture of diabetics as athletes instead of passive patients.

A Clockwork Orange and Compliance

The brutal movie, "A Clockwork Orange" explored how we are wired to do certain things like clockwork without consciously thinking about them and the limits to which behaviors can be conditioned. Conditioning and association can be so powerful it can even affect our memory. There was a study done where people were able to remember a series of playing cards that had normal colors and symbols better than a deck that had a reversed color scheme; red spades, black hearts etc. This helps explains why it can be so difficult to change behaviors to new ones when they are completely unfamiliar. Brain mapping research with MRI has shown that certain areas of the brain are consistently activated when it comes to making the choice to buy something impulsively or satisfying a craving such as lighting up cigarette for a smoker.
Medicine might do well to jump on the same research that Madison Avenue has been on to for some time.

Our routines are also somewhat wired. Consider the data on stopping and starting on ulcer formation and healing just presented in Seattle. New data suggest that takeoff and landing shearing is the most destructive factor. David Armstrong, DPM uses the analogy of the most dangerous periods for an airline flight being takeoff and landing. If we can change routines to reduce the number of start and stops we can improve ulcer healing outcomes. If the routine is to get up and change the channel on the TV because the remote has a dead battery a series of such routines can profoundly affect an outcome. When I related this research to a patient of mine that was having difficulty closing an ulcer he began wearing a pedometer to count his steps. The next visit the ulcer was closed. To that end, solutions that deal with that takeoff shearing would be something vendors could focus on in addition to our patients' lifestyle change.
Merging an Athletic Lifestyle for Diabetics with Technology in Training

Interest in exercise research is at an all time high. Just look at any list-serve with athletes or websites with forums on training. The following is just one example of useful training info for the diabetic athlete: A 10-second maximal sprint after moderate-intensity exercise reduces the risk of post-exercise hypoglycemia in young, otherwise healthy patients with type 1 diabetes.
Dr. Paul A. Fournier from University of Western Australia, Crawley, stated that, "It is our view that the effect of sprinting on reducing the risk of post-exercise hypoglycemia is probably not as marked in children and sedentary middle-age individuals with type 1diabetes, in part, due to their reduced capacity to engage in a maximal sprint effort.
In the area of biomechanics podiatry is starting to come out of its slumber in recognition of the research that needs to be done for diabetics and the translation of that research into product development.
Using more appealing athletic equipment may seem like a small thing however along with developing exercise networks with peer and family connections it will be the tipping point to establish an athletic lifestyle. Gary Hall Jr. recognized the importance of his own training style and being close to family networks in his competition and outside the pool in his daily life. He made it his own and that made the rigors of training more sustainable. When this attitude can be developed in our patients minds it will change everything.

Armstrong, David et al “Continuous Activity Monitoring in persons at High Risk for Diabetes Related Lower Extremity Amputation “ JAPMA volume 91 number 9 October 2001 451-455

Bijan Najafi, MD Crews RT, Wrobel JS.”The Importance of Time Spent Standing for those at Risk of Diabetic Foot Ulceration” Diabetes Care Aug. 2010
Lindstrom,Martin Buy-ology Broadway Books New York 2010
Dr. Ben Pearl is a member of the American Academy for Podiatric Sports Medicine. This article is part of a sport medicine series the Academy is collaborating with Podiatry Management.
A graduate from PCPM, he was a competitive bike racer at Indiana University riding in IU’s
Little 500. His senior thesis at IU was on sports as a vehicle for mainstreaming. He has a private practice in Arlington, VA.

Gary Hall Jr. is a three-time Olympian and a diabetes advocate who has testified on Capital Hill.
He currently is the director of business development at B2D Marketing. The Seattle based company exclusively represents a medical distribution network in China that services over 6,335 hospitals and health clinics. http://www.b2dmarketing.com/ .