Riding On Insulin founder, Sean Busby, is a professional backcountry snowboarder with type 1 diabetes who travels the world exploring remote corners of the globe on snowboarding expeditions.

In 2004, while training for the 2010 Olympics, Sean endured a complicated diagnosis of type 1 diabetes. Considering leaving snowboarding all together, Sean was inspired by reading stories he found through JDRF’s Children’s Congress. It was the stories of 5- 7- and 13-year-olds that inspired him to keep living his dreams despite living with diabetes. He founded Riding On Insulin—which is now a nonprofit organization—to honor all the kids who inspired him to keep living. Today, Sean’s wife Mollie runs Riding On Insulin and Sean makes appearances at the organization’s global action sports programs (including ski/snowboard camps) for kids, teens and adults living with T1D, while managing his personal backcountry snowboarding career. In February 2014, Sean became the first person with T1D to backcountry snowboard all seven continents. His expeditions include trips to Morocco, Antarctica (twice!), Patagonia, Iceland, Norway, Japan, Kyrgyzstan, Alaska, Tasmania, and more. Sean graduated from the University of Utah with a degree in Health Promotion and Education, with an emphasis on diabetes.

Sean and his wife, Mollie live just outside Whitefish, Montana in a yurt with their two dogs, Daisy and Glacier.

Sean in Norway

Alissa:     How old were you when you started snowboarding and how did you know that this would be your profession?

Sean:        I started snowboarding when I was 12 years old.  Growing up in Southern California, beach sports should have been my thing. But for some reason, I was attracted to the mountains. A friend introduced me to the sport and I instantly loved it, even though the mountains were more than two hours away from my home. After a lot of pleading, my father would let me leave school early so I could practice in the mountains, and I would train until 10 p.m., squeezing in homework during the long drive home, and finally going to sleep after midnight.

By age of 14, my dad challenged me to compete. I excelled in the competition scene and began to pick up my first sponsors. Two years later, I was given the opportunity to go professional with snowboard racing.  I relocated to Whistler, British Columbia to train, compete and ride professionally. I then relocated to Steamboat Springs, Colorado after I graduated high school to train further. It was there that I was diagnosed with T1D.

Alissa:      Tell me about your career leading up to the diagnosis of T1D?

Sean:        My discipline was on the racing side of the sport, with a focus on the 2010 Olympics. I trained with prestigious athletes, which included members from the US team. Up until that moment, I had been healthy for my entire life. And then during the 2003-2004 winter seasons, I noticed on and off symptoms of a mystery illness.  I figured I caught some weird bug from my teammates that were returning back from Europe.

After the U.S. National Championships in Breckenridge, Colorado, I became violently ill.  I couldn’t stop vomiting. I was scheduled to fly to Quebec the next day for the Canadian National Championships. Luckily, I woke up feeling much better so I just assumed it was a 24-hour bug. I was able to go to Canada and participated in a great competition.

It wasn’t long until the mystery illness hit me again. I was constantly thirsty. I rationalized that the thirst was caused by the start of spring, combined with warm weather and training hard. I would down gallon-size jugs of grape juice, and feel horrible afterward—causing me to miss morning training sessions. The vomiting started again, too. I clocked it – two hours after I ate anything, I would get sick. I actually became afraid to eat.  Finally, I went to the emergency room. The doctors attributed by illness to some bad bug. They gave me anti-nausea medication and sent me home.  By the next day, I was vomiting again and unable to hold any food down.   

I visited the ER seven times within two weeks. Eventually, I was admitted to the hospital. During my 12-day stay, I lost more than 30 pounds and developed pneumonia. I was discharged to my parent’s care and went home to California to be treated by a general practitioner. The doctor ordered a glucose tolerance test, suspecting diabetes. It was shocking when a nurse called 24 hours later telling me the labs came back fine.

Alissa:    They said you were fine?  

Sean:    Yeah. I have no idea why they told me that. A family friend who is a cardiologist questioned it, too. He told me to get a copy of my labs so he could consult with a few colleagues for a second opinion. I asked a nurse for a copy of records, and noticed red flags all over the place. I questioned the labs and the nurse grabbed the doctor, who apologized to me and explained that I had Type 2 Diabetes.

Alissa: So you were misdiagnosed?

Sean:        Yeah. Big time. Being 19 years old, I grew up watching TV shows like “House” and “ER” where the sick person is diagnosed within 30 minutes. I assumed the doctor was right, and had no reason to question the diagnosis. I was advised to check my blood sugar and take pills daily. But, the vomiting started … again. Knowing my blood sugar was still high, I tried adding another pill to my regimen. When that didn’t work, I tried to eat an all protein diet.  Restricting carbohydrates only led to more immense weight loss. I was wasting away. None of my clothes fit.  Laying on my parent’s couch, doing nothing – I had to face the reality as some of my sponsors cut me from the team.

I became so depressed that I was determined to return to Colorado to get back into the gym. It was on that flight back to Colorado where I almost passed out. I was rushed to a teaching hospital, where I was correctly diagnosed with Type 1 Diabetes on July 3^rd — my mom’s birthday.

Alissa:      What I don’t understand is why they couldn’t detect it in a blood sugar finger stick?

Sean:        When I was hospitalized for the 12 days, they did suspect diabetes but I also had pneumonia.  Back then, Type 1 Diabetes was labeled as juvenile diabetes and Type 2 was adult onset. I think it was the theory that Type 1 only occurred in children and Type 2 was in adults. Being 19, maybe I was in a gray area? They did notice that my blood sugars were high and I had ketones in my urine.

Alissa:       You had mentioned that you became depressed. How did you handle your diagnosis emotionally?  How did your family help you through it?

Sean:        It was a struggle. I was so angry at the doctors for misdiagnosing me. My body was shutting down, heading towards death.  I wasn’t getting any nutrition. It wasn’t until the first insulin shot that I noticed an immediate difference. It was the most amazing feeling I’d ever felt in my life.

So I set out to learn everything I could about T1D. I started going to the gym around 4:30 a.m. because I was really embarrassed by how skinny I was. I had lost so much muscle mass.

I was also doing a lot of research, reading story after story about children as young as two years old living with T1D. Those kids inspired me. I wanted to give back to them what they had given to me. Winter sports are my passion and that is where the idea of founding “Riding On Insulin” came from. I wanted to host a ski/snowboard camp for kids & teens with T1D.

Alissa:      After your initial negative experience with doctors, how did you find an endocrinologist? And, what kind of regimen did they put you on?

Sean:        I wound up staying with Dr. Ping Wang, who happens to be the doctor that correctly diagnosed me. He is the chief of endocrinology at UCI Irvine California.  It was Dr. Ping Wang who helped me recognize and overcome the burnout that comes with chronic illness. He taught me how to deal with the emotions of feeling alone and isolated. I also started seeing a dietitian.  

My insurance didn’t allow me to get on a pump immediately – which is OK because I really didn’t want it. I had read this article about a professional football player who had Type 1.  He had talked about being attached to a pump. It was that word ‘attached’ that hit me hard. I started crying. I couldn’t imagine having something attached to me, reminding me every minute of the illness I have.

It wasn’t until I started volunteering at diabetes camps that I realized if all these kids could handle a pump – so could I. If I wanted to take my performance to the next level and start gaining back muscle mass, then I was going to have to try it.  

Alissa:    Which pump did you go on?

Sean:        At first, I was on a traditional tubed pump, but I have since switched over to the OmniPod tubeless system, and it has been the best compliment to my training as an athlete, especially for winter sports.

Alissa:      Do you feel a huge difference or do you sometimes wish you could take a pump break?

Sean:        I pump has helped me immensely. In the beginning, I was constantly traveling to competitions in varying time zones and I opted to take shots. But, if the forecast was wrong then my blood sugar would fluctuate too much, causing severe lows. The pump stopped about 80 percent of the lows, giving me much better control, and lowering my A1C substantially. I could set different basal rates for different sorts of exercises.  I recognized that for each individual living with T1D, it’s all about finding the technology that works for them.

Alissa:      Do you think you’ll ever take a pump break or are you content with it?

Sean:        I used to do that when I was on a tubed pump. I would go on pump vacations. The reason I switched to the OmniPod is because it’s tubeless and can attach directly to my body. With all of my remote snowboarding expeditions around the world, I have to worry about insulin freezing. The Pod is connected to me and my body heat keeps it warm so I can focus on my performance without fear of it freezing up. I don’t have to have anything else hanging on me.  I also just recently within the last two years, started using a Dexcom CGM.

Alissa:      What do you think is the positive impact Dexcom can have on training and competing or even non competing?

Sean:        I say if you’re an athlete, you should get on it. Even if you’re on shots, a CGM can benefit your training. When you check your blood sugar with a meter, that’s like one data point. Then another two hours, you get another data point. A CGM like the Dexcom provides a data point every five minutes, so it really fills in the blanks for me.  I’ve learned so much more about my ideal basal rates at different times of the day and night. It’s just been a game changer.

Alissa:       Do you have a specific diet that you follow? Where do you like to see your blood sugars before and after training in your competitions?

Sean:        I’m a big fan of oatmeal in the morning especially when I’m going out to exercise. It enables me to maintain a nice, stable blood sugar.

Alissa:       Lets go back to your snowboarding career. When did you move away from the competition scene?

Sean:        After the correct diagnosis, I turned my focus to the Olympics. However, I was getting burnt out on snowboarding.  I wasn’t having fun anymore. After I graduated from the University of Utah and was training with the Park City snowboard team, I was invited by some pro riders to join them on a backcountry

I was so excited to be with Ryan Reed at the Texas Motor Speedway, where he was getting ready to race in the XFinity NASCAR series in Fort Worth, Texas. He was kind enough to talk with me about the process of testing his blood sugar, what he eats before a race, how he monitors his blood sugar and what his protocol is.

For National Diabetes Awareness month, please consider donating to Ryan Reed’s DriveToStopDiabetes.

Ryan Reed preparing to race!

From Ryan’s website:

Reed began his first full NASCAR Xfinity Season at the start of 2014.  He finished 9^th in overall standings, with 1 top 5 finish and 14 top 15 finishes.  His season best took place at Daytona International Speedway, where he finished 4^th.  He will start his 2^nd Season in the NASCAR XFinity Series with the No 16 team in 2015

Reed’s racing career began at a young age, capturing the Kid’s Kart Track Championship at the age of four.  The Bakersfield, California native followed that up by becoming the Junior 1 Comer and HPV Karting Track Champion at age eight.

Read the rest of his bio at DriveToStopDiabetes

Alissa:   Can you tell me a little bit about your schedule, diet and what you typically eat before a race?

Ryan:     Like many athletes, you need to develop an eating plan – which is really about consistency and making things simple enough so that it becomes routine. I usually have a turkey sandwich with mustard on whole wheat bread as a pre-race meal. I might change it up here and there, but not too much. It makes my blood sugar more consistent.

Alissa:   Racing can cause a lot of anxiety. Does this stress impact your blood sugar?

Ryan:     Yes, from time to time.

Alissa:   What is your routine checking your blood sugar and how do you self manage?

Ryan:     I check my blood sugar frequently. Even though I’m on Dexcom, I always like to start right around 100. The lowest I want to be is 90. The highest I'd want to be is about 120. I usually end a race right around 200. That seems to be a comfortable zone for me where I feel good the entire race.  (Ryan’s blood sugar pre-race was 107 and post-race 154).

Alissa:   How are you able to monitor and control your blood sugar during a race?

Ryan:     I have Dexcom in the car so I can watch my blood sugar throughout the entire race.  I keep a drink that is high in carbohydrate and sugar nearby in order to prevent or treat low blood sugar. It is important to replenish carbohydrates throughout the race.

Dexcom and high carbohydrate drink in Ryan’s No 16 Ford Mustang

Alissa:   Do you change your insulin to carbohydrate ratio or your 24 hour basal?

Ryan:     I am on long-acting insulin.  Knowing that adrenalin and stress on a race day can be hard, I reduce my insulin across the board. The worst case scenario is having low blood sugar inside the race car. Reducing the insulin is a safeguard that errs on the on the side of caution. Reality is that the race burns so many calories; a person doesn’t need as much insulin.

Alissa:   While you're racing, because it's so hot in the car, what do your blood sugars tend to run? What do they usually run after the race?

Ryan:     Dehydration during a race can result in the loss of up to five pounds due to perfuse sweating. Couple that with adrenaline, my blood sugar does gradually climb.  Since it is cool today, I'll probably end around 160-170. However, it can reach between as high as 200-210 on a hot day.  It really depends on the weather. After the race, my blood sugar drops pretty quickly.

Alissa: How does Dexcom work to your advantage when you're racing? How do you treat your blood sugar using Dexcom as recourse?

Ryan:     Dexcom tracks your blood sugar is at all times, including inside and outside of the race car. It IS the device that allowed me to get back on the track with NASCAR! This is my safety net for informing my crew of my blood sugar levels. I have a target on my fire suit that permits my crew to administer insulin, if I am too high. I also have a drink blend in my car in case it is too low. I try to monitor it the best I can during the race, but I may not check for 40 or 50 laps.

Alissa:   When you started racing again, were you on Dexcom from the start?

Ryan:     Yes, I was on Dexcom the first time I sat back in a race car.

Alissa:   How would it impact you if you were not on Dexcom while racing?

Ryan:     I wouldn’t be allowed to race professionally at my current level.

Alissa:   We're both athletes, and I try to really advocate showing fitness, diabetes and living a healthy lifestyle as a positive, not a negative. What advice would you give to a non-athlete with diabetes?

Ryan:   For me, the biggest thing was being able to find a doctor who works closely with me on managing my diabetes, both inside and outside the race car. You're the one who has to manage your diabetes. You have to take responsibility for it, but your doctor still plays a huge role by managing diabetes around the rigorous schedule of training and how an athlete eats. It can be frustrating. There can be times where you feel like it's defeating almost, but if you keep pushing through and persevere, it's definitely worth it.

Alissa :  This is National Diabetes Awareness Month and you're doing some fabulous things with Lilly Diabetes and the American Diabetes Association on the No 16 Ford Mustang. Do you want to share a little bit about what your charitable organization Drive to Stop Diabetes has done for National Diabetes Awareness Month?

Ryan:     One of the cool things is we have a special paint scheme here in Texas. You'll see a bunch of stars all over our car. The stars represent the entire population of Texas. You'll see red stars mixed in amongst those, and those are the fourteen percent of Texans living with diabetes. We also have a My Diabetes Pit Crew Sweepstakes going on this weekend. People, who sign up and get selected as the Pit Crew Champions, are going to have their names featured on my pit crew's fire suits. Just a really cool way to give back to people in the diabetes community that are living with this disease day in and day out, just gives them a way to be a part of the race team. We hope that they enjoy it.

Alissa:   Thank you so much for this opportunity - I'm excited to be here, especially during National Diabetes Awareness Month. I'm looking forward to seeing you race and do great.

Ryan:     Awesome.

Alissa:   Thanks so much.

Congratulations to Ryan for finishing the race in 15^th place.Ryan is currently 10th in the NASCAR XFINITY series championship standings after one win and 17 top-15 finishes.  His next race is at Phoenix International Raceway(PIR)

This is the second and final part of Alissa's interview with NASCAR racer Ryan Reed.  Please consider donating to Ryan's charity DriveToStopDiabetes

From Ryan’s website:

Ryan Reed began his first full NASCAR Xfinity Season at the start of 2014. He finished 9th in overall standings, with 1 top 5 finish and 14 top 15 finishes. His season best took place at Daytona Intentional Speedway, where he finished 4th. He will start his 2nd Season in the NASCAR Xfinity Series with the No 16 team in 2015.

Reed's racing career began at a young age, capturing the Kid's Kart Track Championship at the age of four. The Bakersfield, California native followed that up by becoming the Junior 1 Comer and HPV Karting Track Champion at age eight.

You can read the rest of Ryan’s bio on his site DriveToStopDiabetes

Alissa:       What team of people do you work with who medically care and support you in your diabetes while you're racing?

Ryan:        I’m mostly managing it myself with the help of my doctor. At the racetrack, one of my pit crew is trained to give me an insulin injection at a pit stop if necessary.  NASCAR has a medical team at every race.

Alissa:       I have looked at some of your videos and I saw that you have some kind of bulls-eye that gives you insulin?

Ryan:        That's a patch on my suit that’s a little bit thinner than the rest of the material. It’s to indicate where to give me the insulin injection if I need it.

Alissa:       What do you do if you're racing and have low blood sugar? What do you do to prevent low blood sugar while you're racing?

Ryan:        I have a drink inside of my car that's timed glucose. It's like a sports drink base that we add dextrose to for more glucose.

Alissa:       What is that? Does your CGM tell you when your blood sugar's high or low? How do you get the drink into your body?

Ryan:        I have a tube that runs to the front of my helmet—it's a camelback system. I have a bite-valve that's right on the side of my helmet so I can actually drink while I'm racing.  I also have my CGM that I'm looking at throughout the race, so I know if my blood sugar is high or low.

Alissa:       Does the stress of racing affect your blood sugar?

Ryan:        Yes. More than the stress, the dehydration is probably the biggest factor. Adrenaline plays a factor as well.

Alissa:       That's interesting. So what do you do for dehydration?

Ryan:        I do the best I can leading into the race to stay as hydrated as possible because there's no way around it. On a hot day I will lose up to 4 or 5 pounds in a race. On the days that I feel I didn't do as good a job as I needed to in order to stay hydrated, I pay the price.

Alissa:       I was wondering if you could tell me a little bit more about your organization. It's “Drive to Stop Diabetes,” right?

Ryan:        Yes. My personal foundation is “Ryan's Mission” and then “Drive to Stop Diabetes” is an American Diabetes Association organization, which I also play a huge part in. “Drive to Stop Diabetes” came out in 2013 and was centered around our racing platform. For me the biggest part is working with younger kids and spreading the message that you can do whatever you want despite having diabetes—don’t let someone tell you that you can’t chase your dream.

                The American Diabetes Association does a lot of work to spread general information at the racetrack—whether its risk tests or awareness information. Lilly Diabetes got involved at the end of 2013, beginning of 2014, and became a title sponsor. They have played a huge part in helping it grow, reach more people and funding.

Alissa:       You mentioned “Ryan's Mission.” How did you come up with that idea and what exactly is it?

Ryan:        “Ryan's Mission” was my first way of getting involved. It was just a website we put up and it was a place to go to tell my story. There is a woman who works for “Ryan's Mission” who does a lot of the day-to-day work with ADA, Lilly Diabetes and “Drive to Stop Diabetes,” but we are more behind the scene. We don't have a lot of events or fundraisers, but we'll have charities donate to “Ryan’s Mission” and a lot of the funds go back to ADA or to help fund an auction or a fundraiser.

Alissa:       Have you raised a lot of money through your organization?

Ryan:        We do a little bit here and there to help stay afloat, but most of our efforts go into the Drive program. It’s hard managing two different programs and my focus is on the Drive program because they've done a lot for me to help me to continue to chase my dream.

Alissa:       What kind of advice do you give people who want to become athletes and compete? Do they need a team of people or is it doable to manage independently? I have interviewed my doctor, Dr. Blevins, and I did an interview with him on this topic and he actually said it is doable. So I'm curious to hear what you think and what your advice would be to people.

Ryan:        I feel it's different for everyone. Meeting and talking to people like you, everyone has a different situation. Each sport, or each person, has their own challenges—not only with their own diabetes, but with whatever their passion is. A lot of it I can listen to and understand, but there is also a lot of it I don't understand and so it’s hard for me to give too in-depth of advice. For me it’s just going through it and dealing with it. With others I just try and tell them, "Don't give up."

                I still struggle with my diabetes.  I have a great doctor and I understand it, but I still have my bad days—just like everyone else. I try and give a positive message of "Don't give up. Don't let the frustrations beat you. Just continue to overcome and give 100%." That's all you can do and, at the end of the day, it’s worth it being able to go out there and do whatever it is that you love to do.

Alissa:       That's so interesting, and that's why I wanted to interview you. Those are all my questions, so I really want to thank you so much!

Ryan:        No problem.

From Ryan’s website:

Ryan Reed began his first full NASCAR Xfinity Season at the start of 2014. He finished 9th in overall standings, with 1 top 5 finish and 14 top 15 finishes. His season best took place at Daytona Intentional Speedway, where he finished 4th. He will start his 2nd Season in the NASCAR Xfinity Series with the No 16 team in 2015.

Reed's racing career began at a young age, capturing the Kid's Kart Track Championship at the age of four. The Bakersfield, California native followed that up by becoming the Junior 1 Comer and HPV Karting Track Champion at age eight.

You can read the rest of Ryan’s bio on his site DriveToStopDiabetes

Alissa:       Can you tell me about your diabetes, how you were diagnosed and what were your symptoms?

Ryan:        In 2011, I was living and loving life. One morning I woke up and was incredibly thirsty. It was so severe! It felt as if I hadn't had water in days. I was continuously drinking water and using the restroom. This went on for two or three months.

I had lost ten to fifteen pounds and didn't feel well at all. When my parents saw me they were terribly concerned and insisted that I seek medical attention. The next day my doctor checked my blood sugar which was 350 fasting. I was diagnosed on the spot with diabetes.

Alissa:       How did you handle your diagnosis emotionally, and how did your parents and family handle it?

Ryan:        My main concern was how it was going to affect my racing. My doctor said I was never going to race again and I was emotionally destitute. I started racing at age four and I was 17 when I was diagnosed. Because I had just started having a lot of success in racing, when I was diagnosed I thought my career was over. My family was very supportive.

Alissa:       Does diabetes run in your family?

Ryan:        No.

Alissa:       What kind of treatment did you initially receive, and how did you find the right doctors and medical support?

Ryan:        I was immediately put on insulin. I started researching athletes with diabetes and I found a story on Charlie Kimball, the Indy car driver. The story spoke of his doctor, Anne Peters, so I researched her. She was in Southern California, only two hours away from my home, and I contacted her and became her patient. The first time I saw her, she was optimistic and confident that I would get back into a race car. That's when things turned around.

Alissa:       How often do you see your endocrinologist and what kind of diabetic regimen are you currently on?

Ryan:        I see my doctor every three months. I used pens and I use a CGM (Dexcom).

Alissa:       You're not on a pump?

Ryan:        No. It gets very hot, about 150 degrees, inside the race car. We didn’t feel confident that the insulin would be effective at those temperatures. We decided the pen was the right treatment for me, and I’m really comfortable with it.

Alissa:       What benefits do you get from Dexcom that made you choose it?

Ryan:        I’m a huge advocate of Dexcom. I went on it very shortly after I was diagnosed. I sometimes go most of the day without checking my blood sugar, and it's always right on.

Alissa:       How did you educate your friends and family when you were younger in school about your diabetes? What kind of diabetic regimen did you follow when you were at school?

Ryan:        When I was diagnosed, I was already in the process of moving to North Carolina and my schoolwork was an independent studies program.  Although I was a senior in high school, I didn’t go to school.  My friends were not only supportive, but they wanted to understand diabetes and the changes that were being made in my life. If I needed anything, they were available. My parents were right there with me the whole time.  I had a really great support group around me!

Alissa:       What is the most common question that you're asked?

Ryan:        I get asked a lot about taking shots every day—does it hurt, or what’s it like?

Alissa:       How demanding is racing? What kind of shape do you need to be in?

Ryan:        There are guys in racing that are in great shape—they’re triathletes and world-class athletes—and then there are guys that aren't. I love being active, and I love being fit—whether racing or not. I do cycling, Crossfit and weight lifting to stay active. In doing so, it benefits for racing endurance.

Alissa:       How did you adjust your diet?

Ryan:        I was really concerned with training and diet limitations. My doctor and nutritionist made sure I could eat and train like an athlete and not have to sacrifice because of my diabetes. It actually motivated me to get in better shape and understand more about what I was putting in my body. I felt like I became healthier and a better athlete.

Alissa:       How did you persevere and become successful in this sport that you're so passionate about when you were told that you may not be able to race again?

Ryan:        It was horrible to be diagnosed and told I couldn’t race. At 17 years old, you take things for granted. My diagnosis motivated me and made me appreciate what I had.

Alissa:       Were you aware of any other colleagues of your race car drivers living with diabetes? If so, were they able to provide you with support or advice?

Ryan:        No one besides Charlie. He was always open to giving advice and I talked to him whenever I was first diagnosed. There really aren’t many people in racing with diabetes—some crew guys, but not any drivers. 

This concludes Part I of II, interview with Ryan Reed.  In the next(and final) part, Ryan talks about how he manages his diabetes while racing, whether or not he uses a CGM, what he does for dehydration and much more!  Register now to be notified when An Interview with Ryan Reed Part II is published!

I’ve been fortunate to have Nicole Brent as been my dietitian.  She has worked closely with me while training for my competitions to manage my diabetes through proper diet and exercise regimen.  Since I’ve known her, I’ve become much more knowledgeable and successful with regulating my blood sugars.  She has always been helpful with diabetic issues that have arisen.  It is such a treat that she has agreed to be interviewed on diabetes, her area of expertise.

Alissa:     Please tell me a little bit about your credentials and how you got involved consulting diabetic clients?

Nicole:   I'm a registered dietitian. I have a bachelor's degree then did an internship; Diabetes is very nutritional-related. Medication, exercise, and diabetes all go together and it's something that I was very interested in and felt that I could be helpful. You need 1000 hours working with patients to be able to become a certified diabetes educator. I attained that goal and became a Certified Diabetes Educator All of this education and experience has provided me with the skills needed to help my patients.

Alissa:     What would be the best way to find a dietitian who specializes in treating diabetics?

Nicole:   The National Certification Board for Diabetes Educators website is http://www.ncbde.org . Your zip code will give you a list of all the Certified Diabetes educators in your area.   Also, if you talk to your endocrinologist, then he/she may have a dietitian that they work closely with. We work very closely with Texas Diabetes and many other physicians and endocrinologists in Austin.

Alissa:     Cost is always a factor when making medical decision.  There are so many expenses that diabetics incur that create financial difficulties. If somebody needs to see a dietitian and they can't afford it for some reason, how do you advise somebody to be able to get that dietary care?

Nicole:   Usually, your insurance covers it if you have diabetes, but it just depends on your insurance.

Alissa:     Are there alternative methods of coverage if insurance doesn't pay for it?

Nicole:   I don't know about that. That would be up to your employer. 

Alissa:     Where can I find a dietitian who works with diabetic patients? Are there special certifications needed for this?

Nicole:   There is a certification, which is not just for dietitians, but for practitioners who works with diabetics. It is called a Certified Diabetes Educator or CDE. You can go to their website, http://www.ncbde.org, to find a CDE.  Practitioners working with diabetic clients, including nurse practitioners, physician's assistants, and dietitians should be a Certified Diabetes Educator or CDE.

Alissa:     Are there specializations or certifications for dietitians to work with children with diabetes?

Nicole:   There's not a certification for a diabetes educator to just work with children, however, there’s a Certified Specialist in Pediatrics or CSP.  You can find board certified specialists in pediatric nutrition at The Commission on Dietetic Registration website, www.cdrnet.org.

Alissa:     Craving sugar is a symptom of diabetics, but could something else cause this?

Nicole:   I don't know that craving sugar is necessarily a symptom of diabetes. It depends on the person. Sometimes, it will come from the fact that someone knows they shouldn't be eating a lot of sugar causing them to want it more.  That’s just human nature.  One thing that will cause craving more sugar is if we are getting inadequate carbohydrate in our diet.

Alissa:     What are the biggest differences between diets for diabetics verse non-diabetics?

Nicole:   If I’m working with a diabetic patient and their goal is weight loss, we would be focusing on carbohydrates, so the emphasis would be carbohydrate counting and making sure that their carbohydrates are under control. Not only does carbohydrate counting help with weight loss, but it also helps to reduce calories because the carbohydrates have the largest percentage of our calories. If diabetes is not a factor, I will still teach carbohydrate counting because it is extremely helpful in weight loss. For non-diabetics total calorie intake and getting adequate exercise are priorities.

Alissa:     What tips do you recommend for measuring carbohydrates?

Nicole:   There are many great apps available to help figure out the carbohydrate content of while eating out.  It is also helpful for foods that don't have labels on them like apples.

Alissa:     The size of apples can vary greatly.  How do you carbohydrate in an accurate way?  Do you need to weigh it with a scale?  Do you need to measure with cups?  What are your suggestions?

Nicole:   Either way.

Alissa:     Is there a rule of thumb, 15 carbs for certain vegetables or fruits?

Nicole:   No, because there are so many different amounts.  The best way to learn is to measure your foods for a little while. You will learn from practice and experience.  If you measure a cup of rice several times then you are able to eyeball it down the road. 

Alissa:     Are there any danger foods or unsafe foods for people with diabetes? What are good treats and desserts for diabetics?

Nicole:   There is no list of food that is off limits because you are diabetic.  Certainly there are foods that are better choices.  I know that there are certain triggers for me which can be danger foods if you are diabetic. Same thing with safe foods. 

               I teach my diabetics to try to keep their snack to around 15, and for sure less than 20 grams. 

Alissa:     What would you recommend if somebody with diabetes wanted to have a dessert?

Nicole:   Sugar-free Jell-O is carbohydrate free. Sugar-free pudding has only 15 grams. A granola bar that is high protein is a good choice. Desserts and snacks that range @ 15 grams of carbohydrates are wonderful options. 

Alissa:     What if somebody wanted to have a piece of cake or cookie - what would you recommend?

Nicole:   Keep it small, and then if you're on insulin, you have to cover it. You need to be mindful about checking your sugar and making adjustments with insulin. 

Alissa:     Is NutraSweet or saccharin?  Which would you recommend?

Nicole:   According to the Food and Drug Administration, they are all safe, so that's something that I leave to the client. Some people feel more comfortable with Splenda because it's made from sugar. Some people feel more comfortable with TruVia, green leaf, or SweetLeaf because they are from a leaf, so they feel it is more natural.  Be aware of the amount of these sugar substitutes that are being used, so they are not overused. 

Alissa:     Is there a limit on how much sweetener you can use per day? Do they have carbs?

Nicole:   They do not have carbohydrates in them.  Some of them are equivalent to 20 to 22 diet sodas a day, so be aware.

Alissa:     Do sweeteners have long term side effects?

Nicole:   Everything in life is about moderation. That's the key. If you're not comfortable with it, then don't use them.

Alissa:     I really, really appreciate you, Nicole, as my dietitian and how much you've helped me through my competition season.  I have learned so much from working with you.  I thank you so much for giving me your time and helping me so that I can help others.

Nicole:   You are very welcome, my pleasure Alissa. 

I’ve worked with Dr. Joe Klemczewski over the last year in preparation for my figure competitions.  He has helped me lose weight and regulate my diabetes. 

Alissa: Can you tell me a little bit about your background, credentials and how you
are able to help somebody diet in a healthy way to compete in a fitness
competition like myself?

Dr Joe Klemczewski:   I became interested in nutrition when I was about 12 years old. I changed schools in the fifth grade and new friends pulled me into sports, but I was a chubby inactive kid. I wanted to catch up to my peers—I was inspired by performance, athleticism, and the sheer fun of sport. That led to weight lifting and it was a very positive turn for me. By the time I graduated with a degree in physical therapy, I was on my way to becoming a professional bodybuilder. I pursued a masters in health and doctorate in nutrition to support my hobby, but it naturally pushed me into a career in the fitness industry. After owning a health club for 10 years, I created The Diet Doc, LLC, went back to school for another PhD in health education, started writing and publishing nutrition books, and licensing our program around the world.

Alissa:   Do you believe an athlete with diabetes can compete in a professional sport?
What are the pros and cons?

Dr Joe Klemczewski: It’s absolutely possible, but can be extremely dangerous if the athlete isn’t careful and responsible in monitoring the condition. It’s easy to get caught up in training or performing and end up in a compromised state. The pressure of achievement—especially if others depend on the athlete—can push the condition further away as a priority, symptoms can be ignored, and bad things can happen. The pros, of course, is that activity and exercise is a great benefit to a diabetic. It can prolong life, increase quality of life, and reduce complications.

Alissa: What kind of diet would you use that might be different from somebody who
doesn't have diabetes?

Dr Joe Klemczewski:      I’m a fan of healthy, balanced eating and dieting, so there’s no difference in the way I would treat a diabetic. I constantly emphasize that blood sugar and symptoms are more important than the objectives of a diet. If a diabetic is following a diet of any sort, and they ignore symptoms because the diet they’re following wouldn’t allow for a deviation, it’s more than wrong—it’s irresponsible and can be fatal.

Even though my nutrition practice is naturally diabetic-friendly, I would always be careful to not reduce carbohydrates to levels that would compromise the condition.

Alissa:   What are the health advantages of following your diet regimen as opposed to
other diets commonly used?

Dr  Joe Klemczewski:   I’m always going to include an appropriate amount of protein, but not too much. Diabetes can cause the vascular system and fragile tissues to degenerate and excess protein exacerbates that process. I like to include enough dietary fat to allow for flexibility, but also so that healthy fats can be a consistent part of nutrition. That leaves, carbs, and since I’m not going to suggest a faddish or impractical diet (like very-low-carb diets), there is always room for a good, safe amount of quality carbohydrates.

Alissa: How do you advise competitors or athletes to have a healthy lifestyle
(whether or not they are diabetic)?

Dr Joe Klemczewski:   There’s a growing fascination in the general population diet industry and in physique sport with “flexible dieting.” What was once seen as simplistic—counting calories versus using a hyper-specific, restrictive diet—has become the new trend. I think the original problem with tracking calories was that it wasn’t specific enough. Twenty years ago, the programming I introduced into the industry used flexible dieting principles, but included guidance based on goals and circumstances. I created ranges for protein, carbs, and fat, and offered help in meal planning, but the client could select foods they liked. It took a generation, but now it’s becoming the norm, even with big-box diet chains.

Alissa: What type of foods do you recommend? Is it possible for diabetics to have a
variety in their diet?

Dr Joe Klemczewski:   Absolutely. Just like the premises I began with 20 years ago for non-diabetic clients, it’s important for anyone to enjoy flexibility. It just takes a little dedication to learning what is in food.

Alissa:  Are there any healthy splurge foods a diabetic can enjoy?

Dr Joe Klemczewski:   Even a diabetic can process high-glycemic, sugary carbs, but like anyone, it’s not healthy to make that the norm. Small indulgences are, I think, a normal, healthy part of life. If someone decides never to eat something that would be considered “bad”—ever—that’s their choice. I don’t think it’s possible, and it can lead to obsessive or compulsive issues like bingeing, so I prefer to include small, manageable amounts of decadent foods.

Alissa:  Are there any foods that a nondiabetic can eat differently than a diabetic?

Dr  Joe Klemczewski:   A non-diabetic can certainly get away with abusing food without the acute health consequences, but look at our society: there’s still a cost. That’s why type-II diabetes has become such a health crisis.

Alissa:  Can you can help explain what an athlete, or physique competitor, eats during in-season training and the differences off-season?

Dr  Joe Klemczewski:   Someone trying to accomplish body composition goals—getting leaner or gaining muscle—will need to be objective and consistent. They’re going to eat higher-quality food and avoid deviations as much as possible. But, the goal of anyone should be health regardless. Someone who is diabetic or non-diabetic shouldn’t let their weight deviate greatly, and I would hope their eating habits are healthy year-round. Again, someone not in the acute phase of a training need might enjoy more margin for error and not be quite as diligent, and that’s where flexible dieting comes into play, but I don’t consider there to be dramatic differences. 

My daughter Molly shares her experiences and gives some helpful advice

Today is my birthday.  I received the best birthday present I could have possibly wanted when I woke up to my 2 children’s love, hugs and kisses!  I’m blessed to have two beautiful children to celebrate my special day!

As diabetics, my daughter and I can’t share in the tradition of eating birthday cake; so instead of cake, Molly gave me the gift of working on this blog together.  I interviewed her on what it’s like to live with diabetes during her first year of middle school. 

Even though I sometimes feel sad or upset that Molly has diabetes and wish there was a cure, in a strange way I feel blessed to have a child with diabetes, because of the way Molly handles it.  Diabetic children face many limitations and adjustments. Molly’s challenges living with diabetes includes learning to independently care for herself and thrive emotionally. My daughter has embraced her diabetes with such a positive outlook.  She educates her peers in school about what diabetes is, advocates to groups of people by speaking publicly, and attends/fundraises for the JDRF Walk for a Cure each year with such pride.    She has demonstrated such self control by accepting that she can’t have the yummy treats and making good choices, including counting her carbs beautifully, and always making wise choices with her meals.  She handles other children eating food she can’t at holidays and birthday parties with such grace. She is such a special and loving child, and it makes me proud that I have a child who can be a positive example for others. 

Diabetes is hard for children, but it’s not easy for parents either. Parents have the responsibility of supporting and teaching our children positive, healthy choices, and always letting them know we are here for them. 

It gives me great pleasure to share with you this interview with Molly.

Living with Diabetes in School

Alissa:   What do you do if the teacher is talking and you feel your blood sugar is low or high?  How is your teacher educated handling your diabetic care in their class?

Molly:  I have a 504 medical care plan that Austin Independent School District requires for any student with special needs or accommodations that my teachers are required to follow in their class.  My teachers are all educated by the school nurse and are aware of the warning signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar).   The teachers are provided with juice and snacks and have a phone in the classrooms for emergencies.  I am allowed a medical pass to go to the nurse even if I’m in the middle of a test or lesson.     I go up to the teacher and tell her, “my blood sugar feels low (or high) and I need to go see the nurse”.

Alissa:  What do you do for your lunch time routine?

Molly:   I leave class 2 minutes early, go to the nurse, hand her the paper with my carbs, test my blood sugar, and while I enter the carbs in my pump, the nurse calculates the math to check that my pump is right.

Alissa:  What do you do if your blood sugar is high (hyperglycemia)?

Molly:  I go to the nurse and test my Blood sugar.  If it’s over 300, I correct for a high, test for ketones, then I drink a lot of water and retest 2 hours later.  Many people have never heard of ketones.  Ketones are substances that are made when the body breaks down fat for energy.  Normally, your body gets the energy it needs from carbohydrates in your diet.  But stored fat is broken down and ketones are made if your diet does not contain enough carbohydrates to supply the body with sugar (glucose) for energy or if your body can’t use blood sugar (glucose) properly.  I check my ketones with special strips called ketostrip from a local drugstore.  I urinate on a stick and use a color pattern located on the test strip bottle to measure my ketones from trace to high ketones. 

Alissa:  What do you do if your blood sugar is low (hypoglycemia)?

Molly:  I go to the nurse, check my blood Sugar, and then if it’s 70 or below, I get preferably a juice box or glucose tablets with 15 carbs, but sometimes a snack with 15 carbs and then recheck 15 minutes later.

Alissa:  Do other kids ever ask, “Can you have this?”, when you know you can’t?

Molly:  People do that all the time, like in the theater for Valentine’s day we got donuts and everyone asked, “Can’t you just have one?”  I explain briefly what diabetes is and although usually they don’t understand they support me or try to bring in something sugar free.

Alissa:  Have you ever been acknowledged by some mean diabetes name?  How do you handle any negative comments?

Molly:  From 1^st grade up until 4^th grade a mean boy called me diabetes girl.  I didn’t tell anyone, because I thought nothing would be done about the bullying.  I also thought he wouldn’t stop calling me names and telling someone would only make him do it more. 

Alissa:  Do you ever feel your friends are avoiding you because they’re scared of you (and your diabetes)?

Molly:  No I don’t, but it happens to a lot of other diabetics

Alissa:  Do your friends not invite you over secretly because they’re worried about your diabetes?

Molly:  Most likely, but I don’t know for sure.  It’s hard when I hear about the foods kids are having at birthday parties and all of my friends who attend, and I am usually the only friend left out.  I’m told that there was a limit on who they can invite.  It does hurt my feelings, but I’m use to it and accept it and know this isn’t a good friend but an acquaintance and just accept them for who they are. 

Alissa:  Do you ever feel left out in school activities, experiments, or holidays because of diabetes?

Molly:   A lot of the time, because people will get to eat things in class during parties or for fun, and I don’t.  I am accustomed to knowing I have to pass on the treats.  I feel upset, but I know I need to stay healthy and make the right choices.  I’m used to it, but it still is hard.

Alissa:  Do people ever go, “Is diabetes contagious?”

Molly:  Yes! All the time!  This is the worst comment out of all comments, it’s so annoying and I hate it! People get scared thinking they are going to get diabetes and step away from me. – almost every new person I meet asks” isn’t diabetes contagious” and I say, “only in genetics”. 

Alissa:  How do you handle ketones?

Molly:  I handle ketones by drinking water non-stop throughout those 2 hours and DON’T EXERCIZE IF THERE ARE SMALL OR ABOVE!

Molly you are an incredibly special girl and I’m always so proud of you.  You are a gift, and such a

good, well mannered daughter!  I couldn’t be more proud of you!

I found out today my insurance provider doesn't pay for insulin at full cost and that I'm responsible for 50% of it. If I had to pay out-of-pocket it would've cost me $193 a month each for Novolog and Lantus. My test strips were also covered at 50% and that would've cost me $100 a month.

It helps to have a good rapport with your local pharmacy as well as your insurance agent. I spent a good amount of time today working with the insurance company, the doctor, and the pharmacy to help me find a medication that will be covered. With patience and persistence, I was able to find out that Humalog, and Levemir, were covered at full cost. This insulin is the exact replacement but different manufacturer.  Although change is always difficult, I felt pleased that this is one less expense I have to carry.

If you find it's too hard to continuously pay for your diabetic medication, I'd like to suggest calling your insurance company and working with your local pharmacy to find ways to lower your cost of expenses.

There are many challenges that we face as a diabetic and even more so as a diabetic figure competitor. It has been a tremendous growing and learning process for me to continuously monitor my basal insulin, short-term insulin, carb counts, as well as changes throughout the process of competing. The closer you get to the competition, the lower the carbs and amount of basal insulin needed. Previously I had blogged that my sugars were continuously high. Now I have the opposite - hypoglycemia.

I could easily say forget about it, I don't care anymore, this is horrible, why me, why do I have to live like this. With diabetes, it's the choices we make that will help us grow and thrive. I am a fighter – strong, determined, motivated and driven.  This isn't a natural instinct – it’s learned behavior that you can control. You have to be at the point where you want to mentally make that change such as a diet/weight loss, or exercise and a healthy lifestyle. This has to come when you are ready. I enjoy blogging because I want other people to know they’re not alone – we’re all going through the same issues.

What most people don't know about me is that I'm like everybody else - I've struggled with eating, weight, and lack of energy to go to the gym. I've struggled as a single parent with children and as a person who's had to move from one lifestyle to another. Change has affected me as much as anyone. The last six years of my life has been a work in progress. Unfortunately, there have been more negatives than positives, but with a lot of hard work within myself and motivation, I have picked up the pieces to the point where I know where I’m going and I'm not stopping until I get there.

I’ve realized I need to see my endocrinologist regularly, listen to their advice, and keep clear notes of what I'm doing. I also see the dietitian weekly now - I give them my weekly diet, exercise routine, and log every single thing I do. I'm going to take a picture and show this - it might help you to learn what can be done to regulate and control diabetes by taking notes.  You’ll see in the log my hypoglycemia, and what my dietitian today has done to help me change and prevent low blood sugar from here on out.

A question I get asked frequently is what my diet is like. I deviated from my regimen last night . I went out for my trainer’s birthday for about an hour at a later time than I usually go out.  My life is very routine - I try to eat at the same times every day, work out at the same times, and wake up and go to bed at the same time.  In the time that I was out, I danced briefly; however, my last meal had no carbs and left me with an empty stomach.  In other words, I didn’t have any food in me when I went dancing, so my blood sugars went low.

When your sugar goes low, you go into panic mode.  You worry about fast acting carbs , when will they work, will it be enough, is it going to affect my weight, my sleep, my morning routine.  Unfortunately my body required more than 60 carbs overnight which left me exhausted this morning.  Not only did I lose an hour of sleep due to Daylight Savings, I didn’t have energy to go to the gym, which I do every Sunday morning.  I never sleep in because my first meal was at 7 am in the morning.  So what did I do about breakfast?  I ate my morning breakfast as planned but I removed my second meal.  I had the opportunity to go back to sleep and I did as it’s important to keep your body well rested.  I had to go to work this afternoon.  Daylight Savings affected me and I was exhausted, but I got through the day as we all do when we’re tired.  It’s very common to ask ourselves, I’m tired do I need to skip the exercise today? As I’ve mentioned in a previous blog, it’s the days that I’m tired that I feel the most productive with my workout.  After work, I went to the supermarket, to buy my key staples for the week.  This leads me back to what does my diet consist of.  Keep in mind a healthy eating and exercise regimen, I pushed through my fatigue, focusing on the key staples I eat on a daily basis as a diabetic.  I thought I’d share these healthy choices with you.  These products are all great complex carbs, low in sugar and high in protein, that are good staples for your diet, whether you’re a diabetic, athlete, or anyone who’s trying to watch their weight.  I always eat a complex carb with a protein, use portion control, and read the labels on the packages. 

My blood sugar dropped low while shopping for groceries.  I went back to my most recent blog about the hypoglycemia rule of 15.  This time, I used glucose tablets that I had on hand.  This required me to use 45 carbs within a 30 minute period.  As I sat in the parking lot waiting or my sugar to go up, it was around 4 pm in the afternoon, I was tired, hungry from low blood sugar, daylight savings time-lagged, yet knowing I need to do a work out. I did self talk using my own blogs to help motivate me and get the energy to do a workout at the gym.  I could have used exhaustion or low blood sugar as an excuse to not exercise. Instead I used it as a positive, and went to the gym despite my exhaustion.  I had a very productive workout, I feel refreshed, and I’m glad that I was able to give myself the positive reinforcement using self talk.   This is why I like to blog; I take my own life experiences, which you might be experiencing too, so that we can all learn together.  All of us are in the same boat.  Managing Diabetes is a science.  There’s no explanation for the highs or the lows, but there are healthier ways to self-manage.

Alissa interviewed Dr. Blevins, M.D., Endocrinologist, Texas Diabetes & Endocrinology on the effects of balsamic vinegar on blood sugar

Alissa:  For the last two weeks, I've experienced my blood sugars increase and I realized today after doing some research it was balsamic vinegar.  How does balsamic vinegar affect blood sugar?  Do you recommend using it and how much should you use if you use it?

Dr. Blevins:  Balsamic Vinegar does certainly have calories and it depends on how much you use.  Tell me this – how much were you using?

Alissa:  I use the big bottles you get at Costco – I was using a bottle every 4 days, so probably a quarter bottle a day

Dr. Blevins: I have to admit I don’t know what those bottle look like but, how much is in a bottle? 

Alissa: Let me check… 1 liter

Dr Blevins:  Vinegar can be formulated in different ways, but usually a cup is about 40 grams of carbs or so, but what does it say on the label?

Alissa:1 tablespoon has 2 grams of carbs and 10 calories and 2 grams of sugar

Dr Blevins: A liter is 1000 CCs, so you’re talking about 70 tablespoons.  There’s definitely carb in balsamic vinegar.  The story here has more to do with being very careful about food and look at the label carefully. 

Alissa: Yes

Dr Blevins:  It’s low fat and that’s good, but it’s pretty high in sugar.  It’s liquid, readily absorbable, and it could spike your sugar since it does have a lot of sugar.  So 1 tablespoon is 2 grams, and you’re taking 250 ccs/day, a quarter of the bottle per day.  The math on that would be about 17 tablespoons, so you’re getting mid-30s of grams of carb per day.  That’s quite a bit of quickly, readily absorbable carb.

Alissa: Yes, I’m cutting it out of my diet permanently!

Dr Blevins: Although it’s not hidden, I think the perception many people would have is the same as yours which is that it’s not a high carb source.