Chris Pannell (Worcester Warriors)
From the age of nine I became very passionate about Rugby Union. My first taste of the game came on a cold Sunday morning when friends invited me to have a go at my local club. Being a hugely energetic, pain in the backside nine year old, both my mother and I thought this to be an opportunity not to be missed. Since that morning, I knew no other sport would compete and I feel extremely privileged to be in a position where Rugby is my profession and livelihood. Now aged 24 I currently captain The Worcester Warriors in the Aviva Premiership after earning promotion in the 2010/2011 season.
I was diagnosed with Type 1 Diabetes aged 19 following a routine blood test at the rugby club. There is no history of diabetes in my family so it came as a bit of a shock. That is until my research began and then the symptoms slotted into place. I feel extremely lucky to have found out before any serious damage was caused. From here, my learning of how to manage my condition began.
Following my diagnosis I was fortunate enough to see Ian Gallen to learn about the impact my diabetes would have on my profession. With his help my understanding grew and the next few months were a huge learning curve.
The trial and error phase then commenced where I started to take ‘small’ amounts of insulin. I am on a 24-hour background insulin taken once a day at 8pm. The background dosage changes according to the following days activities and my current state of fitness. I also take fast acting insulin around any intake of carbohydrate. Again, the dosage changes quite significantly depending on a few factors I will explain later. My observation of trends began thanks to numerous blood glucose tests throughout the day. My coaches at the time were very understanding in giving me a chance to test when I needed, something I am very appreciative of. I quickly learned I was quite insulin sensitive and I began to adjust my dosage accordingly as my blood glucose levels were dropping off very suddenly during training. Regular blood glucose testing is still absolutely essential in keeping my control and recognizing any abnormalities early.
In my career I have been very unlucky with injuries. To this day I have had 7 major operations through injuries sustained whilst playing professional rugby. Now although unlucky, the time I spent on the sidelines was invaluable in my understanding of not just my diabetes, but also my body and how it operates. I can effectively breakdown my insulin treatment into three categories. I have the ability to efficiently slide between the three as and when required.
- Fully fit. During this time, my insulin dependency is quite low. My metabolism is fast as I am active most days and competing in my sport on weekends. I am fit. During this time, my background dosage drops to 8-10 units. My fast acting insulin dosage will change depending on the format of my training day. I will only need 1-2 units with a large bowl of porridge along with sipping sports drinks during my morning training. My Blood glucose levels will stay consistently between 5-8mmol/L during this training period. Depending on the intensity of the afternoon session, I may not take any fast acting insulin with my meal despite eating a small portion of carbohydrate. These sessions tend to commence 1-½ hours after eating. In this afternoon session I can regulate my blood glucose by sipping sports drinks over the training period in accordance with the type of training session and its intensity. If I have no training, I will take 1 unit per 30grammes of carbohydrate and continue this dosage for any further food until dinner. At 8pm I will take my background insulin. I have found that this increases my sensitivity to the fast acting insulin and so I drop to 1 unit per 45grammes of carbohydrate with my evening meal. I like to go to bed at a level between 6-7mmol/L and tend to wake up between 4.5-6mmol/L. During this fully fit period, my control is very good. Regular blood testing allows me to spot if I need any extra carbohydrate during training sessions. Glucose tablets work very well in pushing my levels up during more demanding sessions.
- Injured. Being injured presents a huge challenge as a diabetic especially when there is a sudden change from being fully fit to bed ridden. During this time, unsurprisingly my insulin requirements shoot up. I very quickly adjust my background dosage to 16-20 units (a 100% increase from fully fit). My fast acting dosage goes up to 1 unit per 15grammes of carbohydrate (again, a 100% increase from fully fit). This change seems drastic, however I have found this adjustment is necessary just days after being injured and usually encouraged after a general anesthetic. Again, regular testing allows small amendments to be made and prevents any serious hypoglycemic or hyperglycemic episodes. For me, there is often very little transition between the two categories. I have found however that during the return to fitness, I need to apply a slightly different tactic.
- Transition. This is the period of time between beginning to exercise after injury and returning to full fitness. During this period I have found a steady change in my insulin dependency in direct correlation to my activeness during training. In the early stages of recovery where training intensity remains fairly low, my insulin requirement stays high. Through the natural progression of returning to fitness, my insulin requirements drop accordingly. All of my injuries to date have been lower limb with running being restricted. Once running resumes, my dependency quickly shifts back nearer the ‘fully fit’ levels. During this time I test very regularly and make small adjustments over the weeks until I return to full fitness. With an upper limb injury, this transition will be much sooner as running is only restricted for short periods.
I understand that there will be huge variation between patients however as a general rule, this method has allowed me to control my blood glucose levels whilst coping with a different variety of training intensities and periods.
Despite my general rules around my insulin I have become acute to the different requirements of different training sessions. It is well documented about the difference between the effects of aerobic and anaerobic exercise. I have learned to adjust the amount of glucose I intake through sports drinks depending on the type of training and its intensity.
The nature of my sport and position means I must have the ability to perform in both an aerobic and anaerobic capacity to a very high level. In a fully fit state, I am able to adjust my glucose intake without changing my insulin requirements. During aerobic training, my glucose requirement goes up and additional supplementation is sometimes needed on top of the sports drinks to avoid hypoglycemia. This is often in the form of glucose tablets. During Anaerobic training I have found very little if any need to top up my glucose levels due to the hormone response from the body. I have however found need to monitor my blood glucose levels after very intense anaerobic training, something I only really experience during preseason.
Match day is another time when things change slightly for me. In the early stages I would go into matches having done everything the same as a training day. I would go into a game with my blood glucose level between 6-8mmol/L and sip glucose drinks during stoppages. It took me a good few games before I realised why my blood glucose readings were very high both at half time and full time. I stopped drinking the sports drinks and stuck to water. This had very little effect. I then took the leap and injected 1 unit 5 minutes before kick-off and 1 again at half time. Because of my sensitivity to insulin I was worried that I would simply induce hypoglycemia, however, this had the desired result and I would finish games between 6-9mmol/L. My body’s response to playing in big matches in front of big crowds of course made my glucose levels shoot up. I will constantly be on guard, as I become more of a seasoned campaigner, for any changes in my nerves! The only other event to have had an effect like this is on my levels is flying. Apparently it appears I may suffer slightly from aerophobia! Again, as I do before a game, I will take a small extra dosage of fast acting to keep my blood glucose levels steady.
The control of my diabetes is something I take extremely seriously and like everything I try, I want to be as good as I can be. Over the last 5 years my HbA1c results have come down from 7.0 to the most recent being 5.4, a normal reading for a non-diabetic. I largely put this down to keeping active, a luxury my profession requires but also sticking to a strict diet.
My diet over the last 5 years hasn’t changed dramatically as I have always enjoyed eating healthily and staying in shape. The main changes have been around the choices of carbohydrates I eat and the balance of food on my plate. As a basic rule for meals, I have an even measure of protein, fibrous carbohydrate and starchy carbohydrate. This balance of food provides me with all the nutrients and fuel I need to maintain a regular body fat percentage and weight. The main change has occurred in my choice of starchy carbohydrate. Instead of eating white pasta, white rice, white potato and white bread, I have swapped for whole meal pasta, rice and bread. My favorite source of carbohydrate comes in the form of sweet potato. I believe this small change in choice has been the reason my HbA1c has come down to those of a non-diabetic. The steady drip of glucose into my blood stream forms a smooth blood glucose curve throughout the day.
Being a type 1 diabetic of course has its challenges in the arena of sport. It does however give an athlete a better understanding of their body and how it works. I will not let type 1 diabetes limit me reaching my potential in rugby.