Wake up, stick your finger

When people with Type 1 diabetes exercise, they’re particularly at risk of hypoglycaemic events, caused by low blood sugar (the ones that fuddle your thinking). They’re at risk immediately after exercise, and again several hours later.

When the “several hours later” happens in the middle of the night, a hypoglycaemic event can be particularly dangerous. Because the athletes are asleep, they don’t notice the danger signs and can’t take corrective action. So when athletes have exercised during the day, some have a snack before they go to bed, some adjust their long-acting insulin dose…and sometimes they still get it wrong.

And when it comes to a multi-day event, well, there just is no data (evidence, best practice…) to help. Welcome to the mHealth Grand Tour.

So our riders with diabetes wake up, stick a finger, take a blood sugar reading, calibrate the Dexcom continuous glucose monitor (CGM) they’ve got stuck into their bodies, figure out what they need to eat and how much (guessing – but at Day 9, they’re getting better at guessing), and head out on the road.

If, despite their best efforts, their blood sugar gets too low, the CGM will beep, vibrate or both – their choice. Time to pull a TORQ gel, or a banana, or a croissant they took from the breakfast buffet out of their jerseys and try to raise their blood sugar.

And they’d better do it quickly – if they get too fuddled, they could end up in a ditch almost without warning.

If they’ve gotten it wrong in the other direction (beep, beep), time for insulin. Some of our Type 1 riders are wearing insulin pumps, some inject manually, but all have to guess how much extra is needed. Experience helps – the Team Novo Nordisk riders have exceptional glucose control, so this is routine for them. We’re learning a lot from them. For the recreational riders, it was originally poke and hope.

Over the ride so far, we’re all getting better. The data we’re downloading will be the first attempt ever to compare elite athletes with recreational riders over 13 days of riding. Look for the first research results in a few months.

Lauren Sarno is the marketing manager for the mHealth Grand Tour. She welcomes your contribution to this blog!

Why are we here?

When we were waiting on a mountainside yesterday for the next van to relieve us, so we could race ahead

Our own private mountainside

with the water and fructose gels for the lead riders, and we’d been waiting for the better part of an hour, it was natural for me to say to Dr Dan, “Why are we here?”

Not in the van, on the Tour.

Diabetes is group of diseases characterised by a defect in how someone’s body either produces or responds to insulin – the hormone responsible for regulating what our bodies do with the energy we consume, particularly sugars and carbohydrates (which convert to sugars immediately in the bloodstream).

Why does this matter? For you to be healthy, the level of sugar in your blood needs to stay within a fairly narrow range. Too low, and the brain starts functioning erratically. You may have experienced this when you were too hungry to think properly. Too high, and the sugars can damage your more delicate cells, such as the eyes and the kidneys. Too high for too long, and you can develop kidney or heart disease, lose your eyesight, have a stroke or require limb amputation. Not fun.

There is no cure for diabetes, although with good management, people with the disorder can live long, healthy and full lives.

Roughly 90 percent of the people with diabetes in the UK have what is called Type 2. These are the people whose bodies don’t respond correctly to insulin, and they generally develop the condition later in life. The remaining 10 percent don’t produce insulin at all – they have Type 1 diabetes. When they eat, their blood sugar levels go up, but they have no natural insulin to bring it down again quickly enough for good health, so these people are dependent on insulin injections.

Type 1 is generally developed in childhood, although the appearance of Type 1 in previously healthy young adults is growing. As yet, we don’t know why.

A recreational rider discovers just how hard this is.

For obvious reasons, the majority of research and funding goes toward helping the 90 percent with Type 2 diabetes. For the folks with Type 1, there has long been anecdotal evidence of the value of exercise in management of their condition, but very little published research regarding exactly how the physiology of this works – when, how much, how often, how to balance exercise with nutrition and what kind of nutrition…

Mobile technologies have given us this opportunity to track the blood sugar levels and heart rates of brave athletes with diabetes as they undertake multi-day, endurance exercise, as well as chart their nutrition, distance travelled, speed, cadence…and upload all that information not just to the web portal but also to the cloud for later analysis by our clinical study team.

Empty field? Perfect place to stop for lunch.

Dr Dan West, the lead field investigator on the clinical study, is hoping to gather key information from the recreational cyclists with diabetes – those more closely related to the general population. At what times of day do they struggle the most? Under what circumstances? How does this compare with the elite riders with diabetes, who have exceptionally good control of their blood sugar levels? Can we generate clinical guidance from these data?

So tomorrow, when we’re back on the road, and we discover that the third feed stop in a row has no toilets, I’ll remind myself that’s why we’re here.

Lauren Sarno is the marketing dogsbody for the mHealth Grand Tour.

It's so corny to call them my heroes...but they are

Day 4, Baden-Baden (the town so nice, they named it twice) to Mulhouse. Day 3 marked the end of Stage 1, and I was sorry to see the first group of stage riders leave. It seems like each rider is a page in a book of equal parts slapstick humour, friendship and courage.

It’s difficult to describe just how hard this ride is, if you haven’t witnessed it up close. To call our sub-elite athletes “amateur” gives the wrong impression, although the term, linguistically, is correct – they are amateur only in the fact that they don’t get paid to do this; it’s purely for love. Or madness. At some point it gets difficult to tell the difference.

On day 2, our riders cycled 200 kilometres in 30-degree heat – the hottest day in Belgium since the 1800s. The route was by no means flat – many riders learned for the first time what “rolling countryside” means to a pro rider. Among the riders, the term “rolling countryside” has now become an ironic synonym for “bloody hard work”.

We’re conducting an observational study along with the ride – this will become relevant in a minute. The researchers from Newcastle and Northumbria Universities that focus on the effects of exercise on people with diabetes are using the opportunity of this unique ride to employ mobile technology to wirelessly track three groups of riders: elite athletes with diabetes, sub-elite athletes with diabetes, and people without diabetes.

One can easily understand why the first two groups would want to participate in the study – there is so little published research on diabetes and endurance exercise that every athlete and her or his clinician are basically making history when they get it right. Taking part in the study isn’t much more than they do every day – pricking their fingers to calibrate their glucose monitors multiple times each day, inserting the needle from a continuous glucose monitor beneath their skin to keep a constant watch on their blood sugar levels while they expend energy, tracking their heart rate, their nutrition, their weight…

Pat and Hugh being typically high-minded

But for the riders without diabetes taking part in the study, this is a commitment above and beyond the punishing ride. Two of them, Hugh Anderson and Pat Montalbetti – who are putting in some of the fastest times on the route – refuse to take this whole thing seriously. Still trying to convince them to post their “Blair Witch Project” video made in the Black Forest today to YouTube.

Kinda makes you burst with admiration, doesn’t it?


Lauren Sarno is the mHealth Grand Tour marketing dogsbody and welcomes contributions to the blog – please send images, any relevant URLs and a one-line bio (like this) along with your post.

   

I’m a Canadian.

Born in Montreal, Quebec. Three months of the year are dark, mind numbingly cold with colossal amounts of snow. It’s ideal for picking up a sport such as cycling. To be fair, I dabbled in hockey (in Canada, hockey is hockey – we don’t qualify the sport as ice hockey). But at 160 cm and 53 odd kilos, I soon learned that contact sport was not my calling. I progressed to competitive alpine skiing where my low centre of gravity was a good thing but my lack of mass a bad thing.

Soon I learned that small guys can do okay on a bike – something to do with power to weight ratio – and I started racing bikes. The summers in Montreal are hot, sunny and dry but only last a few months (if we are lucky).

So, why am I telling you all this and how is it relevant to the mHealth Grand Tour? Well, as a Canadian, who grew up (as much as one can grow up when you stop at 160 cm) watching the Liege-Bastogne-Liege, The Tour de France and the Vuelta Espagna, I always dreamed of riding through the Ardennes and tackling a mur* or two. I couldn’t wait to climb a mythical peak in the Alps and descend a narrow, winding path in the Pyrenees.

Imagine my surprise and joy (and luck) when I learned the GSMA was organizing a charity ride to raise awareness of diabetes and the good that mobile technology can achieve in improving the quality of life of people suffering not only from diabetes but all sort of health conditions. It was the perfect trifecta; do the sport I love through legendary parts of Europe, help with a good cause and do it as part of my day job.

And all I have to do is ride for 13 days, cover 2,100 kilometres and climb 22,000 meters. A dream come true!

*    French for “wall” – how Belgian cycling fans refer to the short but very steep cobbled climbs in the Ardennes.

Nick Rossman works as a project manager in the GSMA Connected Living Programme, where his cheeky grin lights up the place. And really, we never noticed he was small. We did notice he was Canadian.

Limits exist only in people’s minds!

My name is Nenad Šimunko, I’m from Croatia and I work for the Croatian Diabetes Association. When I was 6 years old I was diagnosed with type 1 diabetes. Now I’m 29 and I’m living my life to the full with my motto "Limits exist only in people’s minds".

With that motto tattoed on my back I’m trying to motivate people and show them that diabetes isn’t something that should stop you in anything you want to do in life.

The mHealth Grand Tour? That’s a proper challenge. I found out about the mHealth Grand Tour while working for the International Diabetes Federation, European Region in Brussels.  My eyes popped out when I heard about the idea.

Three and a half years ago I weighed 105 kilograms and I was not satisfied about where this was going. Then I bought my first bike. From that moment, cycling was sacred. Later on, I started to train for the triathlon and three years on, I have finished lot of ultra races – Ironman, double Ironman, triple Ironman, 100 mile trail races... But I can not explain how happy I am come back to purely cycling. The mHealth Grand Tour is going to be something big, for me a more spiritual ride because we will cycle some of the routes where the legends rode the greatest batles in the history of cycling. Just to be a small part of that is something special.

The last two months I’ve been crazy. I have bought a new carbon saddle (Selle SMP), new rims, new tires, chain, brakes. All my money goes on the bike and gear. I’m training a lot and I’m hoping that this will be enough as the Tour is going to demand a lot.

I’m also looking forward also to being involved in the clinical study, wearing the continuous glucose monitor (CGM) the whole day while performing at the highest level. This is where technology will give me the opportunity to see my blood glucose level in almost real time and I think for the first time I will be able to push the pedal to max without worrying about whether I will have hypoglycaemia and have the chance to react in time. I’m really looking forward to seeing how this will work.

Most of all I’m looking forward to meeting new people and seeing the beautiful scenery. I’m sure this will be a ride that I will never forget.

See you soon.

Nenad Šimunko is a triathlete with type 1 diabetes and an inspiration to all of us. He will be riding The Epic (all four stages) and participating in the clinical study that will take place during the Grand Tour.

The Incredible Team Etisalat

For most of the teams participating in the mHealth Grand Tour, the only selection process for the riders was self-selection. Want to do it? Go for it.

Not so at Etisalat! When we at the GSMA heard what our partner Etisalat was doing to select their riders, our immediate response was mostly amazement. We were extremely impressed at the excitement Etisalat was building for the Grand Tour within their company. That was followed by a bit of confusion. Some professional teams don’t make as big of a deal out of selecting their riders as Team Etisalat was proposing. They did know this was meant to be an epic bicycle ride, not a competitive race, right? Not the Tour de France (although we’re using a big part of the route).

But it turned out they were aiming high to achieve something greater than sports glory – awareness of the importance of exercise in preventing and managing diabetes. Because Etisalat is based in the Middle East and North Africa, and that region has the highest prevalence of diabetes in the world – 11% – they meant to tackle, head-on, the challenge of changing things for the better.

When Etisalat committed themselves to creating a team for the Grand Tour, they decided their representatives would have to earn their places. So they invited any and all of their 11,000 employees to compete for the opportunity to ride one of the four stages of the 2,100km bike ride from Brussels to Barcelona. They began with training sessions in their regions with hundreds of participants. Pretty cool, right? But that was just the beginning.

On July 3rd, the eventual nominees attended a fitness boot camp at the Etisalat Academy where they were assessed – physically and mentally – to see who had the ability and the mental toughness to complete their assigned stages. The video highlights are both incredibly impressive and more than a little bit funny. The slogan for their campaign is “Ride the Bike; Join the Fight”, and these men and women were fighting for the honour.

In the end, nine employees plus alternates were chosen from Etisalat staff in the UAE, Afghanistan, Pakistan, Saudi Arabia, Sudan and Tanzania to represent their country, their region, and their proud company as champions! We hope they enjoy every moment of their time on the mHealth Grand Tour because they have certainly earned the right to be there.


Pierce Owen is the marketing coordinator for the mHealth Grand Tour, when he’s not finishing up his degree in international business at the University of South Carolina or raising money for his family charity, Curing Kids Cancer.

Why do the mHealth Grand Tour?

Why do the mHealth Grand Tour, I mean, I’ve never been a sporting cyclist (yes, I’ve commuted by bike for years but not a 100 miles a day) nor am I a huge Tour de France fan, neither do I have diabetes… and developing a rather numb posterior, day after day, seriously?

Well, let’s weigh this up…


1.       I have a passion for all things connected and new technology. As such, embedding sensors and connecting both me and my bike up to as many bits of kit as possible hold huge appeal. Roll out the inner child!

2.       Diabetes has always been around my family; cousins and my mother have it so taking part in a study to understand the role new technology and mHealth can play in the management of such conditions and allowing all ages to lead more active, fulfilling lives is of great interest to me and certainly a cause worth promoting!

3.       Raising funds for diabetes charities will ultimately help the on-going effort to support people living with diabetes and also further the research in this area – this has got to be a good thing!

4.       And what an opportunity, who wouldn’t suffer a numb posterior for this! To cycle through wonderful countryside, meet amazing people, and undertake the challenge of a lifetime…sign me up (well, clearly, I mean keep me signed up)!


So, fast forward a few months and my daily commute really is 100+ miles a day (well, a couple of days a week, Cambridge to London and back) and I’ve certainly developed that numb posterior!

The challenge is daunting but the training is great fun, whether it’s the Sunday morning “Club Run” or the hunger I feel as I cycle north through clouds of Caribbean food smells knowing I have 40 more miles before I get my dinner! And nothing quite beats watching deer in the fields at 5:30 AM or departing Ware, knowing that the past 20 miles of built up housing are now gone and it’s countryside the whole way home.

With less than 8 weeks to go fear has struck; will I get up all those mountains, will I even make it to those mountains, will I wuss out of embedding sensors under my skin, will I have enough Jelly Babies to get me to Barcelona (do they sell Jelly Babies in France)?

Roll on September 5th 2013.

Peter Montgomery is one of a team of riders from the GSMA and works closely with the Tour and Clinical Study Partners – if you wish to Partner with the Tour, please contact Pete.