When Phil Southerland and his all-diabetes cycling team convened at the starting line for the 2006 Race Across America, they carried small doses of insulin and were met with heavy doses of skepticism.
“Good luck,” other riders would say. “We love what you’re doing for charity, and we hope you make it to the finish line.” They made it to the finish line alright — in second place.
In a 3,000-mile tag-team race that lasted more than five days, the eight-person team — known at the time as Team Type 1 — fell short of the fastest overall time by only three minutes. A year later, the mood was different.
“The second year at the starting line, everyone was scared of the diabetic team,” Southerland said. “They knew we were going to win. And we did. We beat the second-place team of professional athletes by three hours.”
In the decade since, Southerland’s squad — now known as Team Novo Nordisk — has grown into a global enterprise of nearly 100 athletes, all of whom have diabetes. The group is spearheaded by the men’s professional cycling team, whose members continually prove that diabetes can be managed in even the most grueling conditions. But none of it would have been possible without some help.
“This team exists because of breakthroughs in technology,” Southerland said. “There’s no question about that.”
The technology to which he’s referring is the continuous glucose monitor, or CGM. Originally commercialized in the late 1990s by the medical device company MiniMed (which was later bought by Medtronic), the CGM consists of two parts: a tiny glucose-sensing catheter that is inserted into body tissue and a radio transmitter that can repeatedly send the glucose data to a wireless receiver.
Monitoring glucose levels is crucial for people with diabetes because their blood sugar, which takes the form of glucose, can be wildly unpredictable. All of Team Novo Nordisk’s pro cyclists have type 1 diabetes, which means that their bodies don’t produce enough insulin, the hormone that regulates blood sugar. As a result, their blood glucose levels could skyrocket or plummet during a race, which can cause a variety of complications, some of which can be life-threatening.
Because of this, the cyclists need to check their glucose levels constantly and adjust for the highs and lows, either by injecting insulin or by consuming food and drink. But before CGMs, frequent glucose monitoring wasn’t possible on the bike. Recalling the first race in which he used a CGM, Southerland describes it with the fervor of a blind man who could see for the first time.
“We learned so much,” he said. “We learned more in the first two days of that race using this technology than I’d learned in the previous 24 years of life with diabetes. Just having access to this information was so empowering to our ability to control diabetes and thus to perform on the bike.”
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Before CGMs were popularized in the mid-2000s, the only reliable test for blood sugar was the blood glucose meter, a device that analyzes a drop of blood from a fingertip and displays a glucose level reading. While these “finger-stick” tests are still the most accurate way for people with diabetes to check their glucose levels throughout the day, they aren’t very practical for athletes in the middle of competition. Australian cyclist Chris Williams, a veteran on Team Novo Nordisk’s pro team, says it was a bit of a guessing-game before he used a CGM.
“I would race basically on feeling,” he said. “Sometimes you get it right, and sometimes you get it very wrong. I remember finishing races where my blood sugar was really high, but you have no idea while you’re racing. You don’t have time to stop and check your blood sugar with a finger prick, so having a CGM is just a massive benefit. It makes it so much easier.”
Of course, nothing with diabetes is ever easy. Williams was diagnosed with type 1 at the age of 27, a later diagnosis than most. Realizing that injections naturally invite suspicion in the sport of cycling, he took his insulin shots in secret, even though he had a Therapeutic Use Exemption for the hormone.
“As soon as someone sees you having an injection, you get a million questions and then you have to explain it,” he said. That was a hassle he didn’t want to deal with. He also found out that managing his diabetes was much more complex than he anticipated.
“It’s like a mass equation,” Williams said. “You’re given the really simple version of it, when in fact it’s super, super complicated… It’s not just insulin and carbs that affect your blood sugar. It’s altitude, it’s exercise, it’s the type of food, it’s when you eat, it’s waking up, it’s sickness — it’s all of these things.”
And when you’re competing at the intensity level of a professional cyclist, monitoring those variables is even more important. One of the most frustrating things for people with diabetes is that when they wake up, their blood glucose levels could be almost anywhere. So while cyclists without diabetes can eat the same breakfast before every race, Team Novo Nordisk’s riders need to carefully tailor the meal so that their blood sugar is normal by the time the gun goes off.
Then, during the race, they need to be aware of whether their glucose levels are rising or falling. Generally speaking, physical activity emphasizes the effects of insulin and prompts muscles to use glucose as energy, which means that it has a glucose-lowering effect. However, intense physical activity can also produce hormones, like adrenaline, that have glucose-raising effects. That volatile push-and-pull dynamic is what really makes the CGM an invaluable tool.
“The readings are very frequent, every few minutes throughout every hour,” said Charlotte Hayes, the Director of Research & Education for Team Novo Nordisk. “You see a little dot for every glucose reading in a trend pattern that develops. So the riders can see what level their glucose is at right now, if it’s going up or going down, and at what rate.”
This data, which essentially appears as a graph, can be viewed on a receiver that riders usually keep in their jersey pockets or mount on their handlebars. Thanks to the Dexcom G5 System, the CGM system that Team Novo Nordisk currently uses, this receiver can even be a smartphone or smartwatch. “It’s as easy as pulling out your phone, opening up the app, and looking,” Hayes said.
And what’s even more remarkable is that the riders can share their glucose data with the entire medical team, even if they’re on a different continent. Using Dexcom’s CLARITY software, users and medical professionals can view and analyze the data within three hours of when it was collected, no matter where they are.
Using the “Share” feature in the G5 Mobile App, riders can also share their data in real-time with up to five people. Hayes — a Certified Diabetes Educator, exercise physiologist, and nutritionist who spends a lot of time looking at glucose trends and patterns at the team’s home base in Atlanta — says the technology has rapidly improved.
“We can have riders half a world away and be able to view their data,” she said. “As of just a few years ago, they would get the data in their devices and send it in an upload, and that would allow us to see the data a week after the fact. But now we can see it as it comes in. It’s pretty amazing.”
But getting to this point was a long road, for the science and for Southerland.
“I was diagnosed with type-1 when I was seven months old,” Southerland said. “That was a time when technology in the world of diabetes was really non-existent. My mom squeezed my diapers to get urine onto a strip to find out where my blood sugar was two to four hours in the past. That was what we had.”
Southerland, now in his mid-30s, wasn’t expected to live past the age of 25. Without advanced technology or even fast-acting insulin at the time of his diagnosis, he beat the odds with what he considers the best drug of all: exercise.
Southerland’s parents learned early on that when their son was active, his insulin worked faster and his blood sugar was better. Southerland discovered this himself as kid, when he developed a fondness for Snickers bars. Lacking the patience to wait two hours for his insulin to kick in, he would eat the candy bar and then ride his bike to metabolize the glucose.
“I didn’t have to check my blood sugar. I didn’t have to get insulin injections. All I did was ride. It was this really big liberation,” he said.
By the time Southerland was racing for the University of Georgia, he had become a master of managing his own condition through diet, exercise, and discipline. However, he still wasn’t active in the diabetes community, and he knew almost no other athletes with diabetes. That changed when he met Joe Eldridge, a cyclist for Auburn University, after a race. The two became fast friends, but Southerland soon realized that Eldridge wasn’t taking the time to properly manage his diabetes. So he made it his mission to help him, and it worked.
“I saw this enormous change in his personality and how he took control of diabetes,” Southerland said. “His school was better, his bike racing was better, his confidence was higher. He was just a completely different person, and he was already a really good person to begin with. And he said, ‘Thank you, you saved my life.’ So I thought, ‘Wow, there’s something to this.’”
Inspired by the way Lance Armstrong was able to raise awareness for cancer at the time, Southerland realized that he could use cycling as a platform to help people with diabetes in the same way he helped Eldridge. In a management class during his last semester of college, he started toying with the idea of a non-profit organization.
While conducting surveys at the Mall of Georgia for market research, Southerland received an unprompted $400 investment from a man outside a Starbucks. Southerland refused to take the money, but the man put the cash on the table and insisted.
“He said, ‘Kid, go start your business. Otherwise, someone’s going to have a great day at Starbucks,’” Southerland recalls. “And so I took those four Ben Franklin bills to the bank account on February 22, 2005, and Team Type 1 began.”
Soon after, Southerland and Eldridge were at a charity ride for the Juvenile Diabetes Research Foundation (now simply known as JDRF), when someone suggested that they ride their bikes across the country to raise awareness. Despite having limited time and a lot of student debt, the duo liked the idea, so they set their sights on the Race Across America.
“That was really the first time there had been a team of multiple people with diabetes taking on a challenge like this,” Southerland said. “And I wanted to win — the team wanted to win — but no one believed in us.”
First, no one thought they could raise the money, but they raised $250,000 in the first year. Then, no one thought they could find a team, but they were able to recruit six other cyclists who had diabetes. And even after that, no one thought they could compete. But after coming in second in 2006, Team Type 1 would go on to win the Race Across America in 2007, 2009 and 2010. That’s when the group began to garner media attention, and Southerland recognized the impact it was having.
“I’ve been to diabetes conferences, I’ve been to diabetes camps, and these kids had heroes for the first time in their lives,” he said. “They had people living with diabetes who were taking pride in having diabetes, were embracing it on a public stage and saying, ‘If you control it, you can dream. If you control it, you can do it.’ And I knew we had to bring that to the world.”
With the help of Novo Nordisk, a Danish pharmaceutical company that focuses on diabetes care products, he did bring it to the world. In 2012, Southerland began a partnership with Novo Nordisk, which allowed him to carry out a worldwide recruiting mission. Although Southerland himself hasn’t raced professionally since 2009, Team Novo Nordisk’s pro team now has 18 cyclists from eight different countries, along with a development team and a junior team that form their talent pipeline. That model has bred success, in and out of racing.
“We are the single most improved cycling team in the world over the last five years,” Southerland said. “And if you look at our development team and our junior team, I’ve got a hero factory. I’ve got athletes from 16 different countries on my pro and devo teams who are bona fide heroes for the people in their communities. But it’s only possible to do what we’re doing today because of the diabetes technology that now exists.”
And the technology is only getting better. Before last year, CGMs were not considered accurate enough to be the basis for insulin-dosing decisions because, unlike finger-stick testing, they measure interstitial glucose rather than blood glucose. However, last December, the FDA approved Dexcom’s G5 System for those types of decisions. While CGMs still need to be calibrated with blood glucose meters on a daily basis, CGM-users can now base their insulin-dose calculations directly on the values from the device.
Researchers are also now attempting to integrate CGMs into a larger fully automated system, commonly referred to as an artificial pancreas. An artificial pancreas would essentially combine a CGM with an insulin-delivery system, like an insulin pump, using a computer program that would automatically monitor glucose levels and adjust the insulin dosage. Because the body’s immune system destroys the insulin-producing cells of the pancreas in Type 1, researchers hope that an artificial pancreas can act as a substitute and make life easier for people with diabetes.
But no matter how good the technology gets, living with diabetes will always be a challenge. “Once you get diagnosed, everything you do from that point forward has a consequence on glucose in one form or fashion,” Southerland said. “It’s a heavy burden to carry for a lot of people.”
His goal is to ease that burden. Through his Team Type 1 Foundation, he gave 91 scholarships to NCAA athletes with type 1 diabetes this year. And through Team Novo Nordisk — which now includes runners, triathletes, and a type 2 cycling team — he is showing that people with diabetes can accomplish anything when they manage the condition properly.
“Diabetes can never be an excuse,” he said. “You won’t hear it from any of our athletes, and we take pride in that.”