Blood Sugar and Recovery: Why Post-Epic and Post-Op Don’t Seem Too Different

Sebastien Sasseville Completes RAAM as a Solo Cyclist

Recently, Type 1 Diabetic ultra endurance athlete Sebastien Sasseville, who is also the first person with T1D to run across Canada, completed the Race Across America (RAAM), a grueling 3000-mile bike ride in which competitors must first quality, then have only 12 days to finish.

If you do the math, that’s 250 miles a day, over double what Ironman competitors must do. Repeatedly. Each day. For almost two weeks.

I’d like to talk about Seb’s quick post-race FB update here, and I’m hoping to read his race report soon. But first, a little background on why his story fascinates me so much.

Background: Factors that Affect Blood Sugar during Exercise

As you may already know from my recent posts (read my article, “The No Wake Zone“), keeping blood sugars balanced during exercise can be a challenge with deadly consequences for getting things wrong. Most of us living with T1D are aware of increased insulin sensitivity during cardio and post-run lows. Our bodies often spend glycogen reserves when pushing against “the wall”, causing blood sugars to rise briefly only to see them “tank” once we start to rest.

Weightlifters and HIIT (High Intensity Interval Training) enthusiasts with T1D can tell you about how sometimes, blood sugar goes up during anaerobic activity–typically when they’re pushing hard to met or exceed a previous PR. Adrenalin and cortisol and other hormones kick in when you’re pushing things a bit, and it’s a bit like a “turbo boost” when you hit the gas–you can’t drive your car like that forever, but when you need energy, it’s there.

Also, I’ve written previously about the effects of environmental and long-term stress on BG (blood glucose) due to something called Sympathetic Nervous System Overload. That’s more about the effects of ongoing stress during the daily grind of doing something like a run across a state or continent.

That’s all supposed to go away when you finish, right?

Well, not exactly.

The Absolute Weirdness of Recovery

What happens to your body and your BGs during recovery depends a lot on what you’re recovering from.

Glycogen Replenishment

If it’s a relatively hard but brief effort, it’s probably principally a matter of replenishing depleted glycogen. Laying aside the matters of taking on enough protein to allow for muscle recovery, your body basically is refilling your “backup tank” of energy reserves. At this point, most T1Ds are very insulin sensitive and their reserves of energy are pretty low. That means taking on carbs to replenish those reserves.

Of course, that’s not all there is to it. Rebuilding muscle not only requires protein; it requires an energy source to fuel that all-night rebuilding effort…which can fight for the same resources as you’re using to replenish glycogen.

Think of it as what happens after they close down Disney World for the night. People are scuttering around like crazy refilling freezers and refrigerators, taking out the garbage accumulated from a busy day of tourism, and feverishly repairing rides that broke down from overuse. Costumes have to get cleaned, the people themselves need to sleep, and the whole place needs to look by sunup like no one ever set foot in it until that moment.

That’s a lot of work, and just as with Disney World, your body uses the night to do a lot of work putting things back in order. Glucose and other food sources don’t just get turned into glycogen to refill up your “backup tank”, but power the machinery that stitches proteins and other components of food into muscle. If you don’t have enough onboard glucose to do that, your body will steal glycogen from anywhere it can find it. You may go low during the night, and with insufficient glycogen to power your brain, things will just shut down, and someone will light a blue candle in your memory.

That’s what we all fear. And it’s why getting carbs after a hard workout is important.

So the point is to keep your BG up, then, right?

But what about when it stays high? Should you eat?

Stress

One of the things I learned when I did my first 100-mile run back in June of 2018 was that stress will cause your body to produce adrenalin, cortisol, glucagon and human growth hormone. I suppose the evolutionary reason for stress hormones raising blood sugar by forcing your body to tap energy reserves (principally stored glycogen) is to help you to “escape the cheetah.” It becomes a problem, though, when the stress persists–when the so-called cheetah doesn’t go away for dozens of hours.

We’ve all been told by our doctors that when our blood glucose is high, we should take some insulin and wait for it to come down.

That’s good advice when the reason your blood sugar is high is because you ate too much and didn’t get enough insulin. It’s actually stupid advice when the reason is stress.

My own personal experience on multiple multi-hundred mile runs bears this out: de-stressing (or sleeping) and getting food even when my BG was high were the only things that brought my sugars back in line. I slept well and woke up as refreshed as anyone could be who had been running 50K a day for the last 10 days since a rest period. My blood sugars were typically normal.

If I did not rest or did not eat, my blood sugar would stay high–just when you’d think insulin sensitivity would drive it down.

Welcome to the world of chronic stress.

And Now for Something Completely Different

After I finished my runs across Texas and the USA, I ran into a peculiar cluster of experiences:

• Irregular sleep patterns, often involving 14-hour naps and nights where I couldn’t sleep
• Nightmares that repeated the same theme for at least a week (if not two): being back out on the road, still doing the run, but in the wrong state and going in the wrong direction
• Continuing weight loss despite eating healthy, normal-sized meals
• Extremely high blood sugars that didn’t respond well to insulin and lasted for several days AFTER the stress of running 35-45 miles a day for weeks at a time was gone
• Leg twitchiness so pronounced it woke up my wife nightly
• Foot, ankle, and leg swelling for several days afterwards
• A feeling of ennui and purposelessness
• An inability to summon energy for even the simplest tasks
• Emotional volatility (h/t to Capital to Coast solo runner Rochelle Frisina for cluing me in to this one)

I kept wondering where I’d seen this sort of thing before, then it hit me:

• When I had a horrible case of hives
• When I was stuck for years in a high-stress job in a bad economy, with no serious prospect of escape
• When I’d had pneumonia
• After I had hand surgery

Sebastien’s Experience: Post-Epic Recovery and T1D

I thought I was the only person experiencing those strange post-epic-event symptoms. Then I discovered others had reported similar things:

• Mark Kleanthous reported what he called “post-race blues” after the 150-mile Marathon des Sables run across the Sahara Desert.
• Michael Wilson and other members of the USA Crossers group on Facebook reported “Post-Adventure Depression” after finishing their transcontinental runs
• And finally, Sebastien Sasseville–the rare Type 1 Diabetic ultra endurance athletewith whom I could share and compare experiences shared his thoughts about his post-Race Across America recovery. I’ve invited Seb to blog here at greater length, but for now, I’ll share the highlights AS I UNDERSTAND THEM (pending any corrections from Seb):
  • It took him about a week to start sleeping regularly, and even then he did not sleep well. He hasn’t mentioned nightmares…yet.
  • He lost weight during his ride across the US despite taking in a tremendous amount of calories.
  • Blood sugars were persistently high and he was insulin resistant–not what you’d expect during or after some fairly intense cardio.
  • His insulin needs during recovery were often excessive compared to normal: for at least a week after the race, and slightly elevated for some time after.

I’ve italicized the last two for a reason: they don’t fall into any of the normal categories I’ve previously blogged about, including glycogen depletion/insulin sensitivity (transient lows) or in-the-moment stress (transient highs). They seem not only counterintuitive to the idea that long cardio increases insulin sensitivity, but persistent, don’t go away easily, and they definitely don’t disappear after a good night’s sleep. In fact, many transconners report the symptoms continuing for over a month. Speaking personally, it took me about six weeks to recover fully–and I had lab work done before, throughout, and after my big run. Everything pointed to prolonged stress after all the obvious external causes of stress were removed.

So something else must be going on.

Seb’s and my experiences seem in some ways to resemble the little-studied experiences of T1Ds in post-op recovery.

In other words, it’s less like recovering from cardio and more like recovering from a car accident.

Recovery Stress

There’s actually significant clinical evidence to back up the idea that some of the post-epic-event symptoms are there for a reason. Andra Duncan’s technical paper published in Current Pharmaceutical Design makes the case that in post-operative recovery, hyperglycemia serves a purpose: it provides the body with enough available energy resources to power rebuilding what was damaged during surgery. Weight loss is probably due to the fact that our bodies’ energy needs have been jacked up while our food consumption has not (no wonder we’re hungry and lethargic).

Then there’s super-ultra-endurance.

During events such as The Last Annual Vol State Road Race, a 314-mile ultra run across Tennessee in the heat of summer, or my solo 339-mile run of Relay Iowa in June of 2018, the daily grind can do the same kind of damage to your body that major surgery can. Your body’s inflammatory response can be off the charts. Pain seems magnified. Sleep does not come easily and does not refresh. Your body desperately needs fuel to rebuild itself, and time to get rid of the by-products of repair and cellular clean-up. In the mean time, your legs are swollen from trying to get rid of broken-down myoglobin and you’re hungrier than you’ve ever been, but somehow you seem to be losing weight.

As a non-clinical but intellectually curious person, my hypothesis is that what was going in both Seb’s and my cases was that our bodies were undergoing a resource-intensive, multi-week, almost post-surgical-level of recovery. Meals so large they were difficult to eat in one sitting were still short of the calories needed to “clean up Disney World” in a single night. That multiple days or even weeks would be needed to fix everything; and that until the equivalent of the usual 6 weeks of post-op recovery had passed, nothing was going to feel right and nothing was going to be normal.

You may recall that before, during, and for 10 days after my 851-mile Texas run, I had bloodwork done, including stress biomarkers CRP (C-reactive protein), CK (Creatine Kinase), cortisol, and triglycerides. I can verify that while the biomarkers markers were strong during the middle and latter parts of the run, they were still quite strong 10 days afterwards, and likely until more or less the same time the nightmares and high blood sugars stopped over a month later. Not when the stress was removed–not even for weeks after that–but instead, when recovery was complete.

It’s my personal opinion that the unique experiences of Type 1 Diabetic ultra endurance athletes like Sebastien have a lot to teach us about stress, recovery, and BG; and that those lessons can specifically provide insight to professionals to help develop appropriate protocols and guidance for dealing with the challenges of stress during recovery, not just before it.

A Final Word

It’s my fervent hope that the rarity of such data as Seb’s and mine will become a thing of the past as more is learned about major stress, Type 1, and their relation to recovery. That as more and more Type 1s discover safer ways to maintain physically active lives and challenge themselves to Do The Hard Things, we’ll learn more, know more, and do better.

But for now, I’m grateful there are a few of us out there discovering. Like Sebastien. Seb, we are all looking over our shoulder and trying to cheat off your test. 🙂

Sebastien’s story is inspiring, confidence-building, and gives hope to the rest of us T1Ds that we, too, can do great things if we pay enough attention to the details and act with our own safety in mind. And if you’re ever in the Dallas-Ft. Worth area, Seb, I’d be honored to treat you to the recovery meal of your dreams.