Olympics 2004: Gary Hall, Jr and Diabetes

August 10, 2004 Los Angeles, before Athens

Our patients often teach us more than we could ever teach them. Gary Hall, Jr, currently an 8 time Olympic medal winner, is one such patient. I was there with him when he won four of those medals, and am heading to Athens to see if he can win more. This is the first in a series of reports as I start on my journey to the birthplace of the modern Olympics and is a recounting of the past 6 years as the physician on the team of an elite athlete.

The Olympics are in Gary’s blood. His father, Gary Hall, Sr, is a three time Olympian and an uncle on his mother’s side was on an Olympic team. All swimmers, built with long lean muscles. But Gary also has some extra-fast twitch muscle mass that makes him a fantastic sprinter. His best race, the 50-meter freestyle sprint, is, as he puts it, the classic race that every kid who leaps into the water with his best friend and challenges ”race you to the other side” is talking about. The event is one lightening fast flash of eight men, springing into graceful action, leaping from the starting blocks, churning through the water, hearts beating, lungs breaking, racing until they hit the wall. The difference between winning and losing is measured in hundredths of a second. Hard to tell who wins from watching; only the electronic scoreboard knows for sure.

Gary, the master at his sport, had won two gold medals and two silver medals in the 1996 Atlanta Olympics. But he had come in second in his two individual events, the 50 and 100 meter freestyle, with Russian swimmer Alexander Popov going home with the golds. Gary was absolutely determined to beat him in 2000. But in 1998, as he’d tapered off training a bit, he developed symptoms of polyuria, polydipsia and blurred vision. His father, an ophthalmologist, found nothing wrong with his eyes but knew the symptoms of diabetes all too well. Gary’s blood sugar was over 500 and at age 24 he was found to have type 1 diabetes.

He went to see his family doctor and then saw several more. All said the same thing: ”you can’t compete at an Olympic level with type 1 diabetes…be realistic and give it up”. Gary, dejected, left for a long vacation in Costa Rica, with his fiance, a glucose meter and a fistful full of rapid acting insulin pens. He learned, on his own, how to adjust his insulin for his exercise and diet—as an athlete he already understood the link between nutrition and performance and was quite in-tune with his body and its metabolic needs.

When he returned his father referred him to come see me, for another opinion. Gary showed up late (his flight had been delayed) with Elizabeth, his fiance. I had to race across town to give a noontime lecture at a local hospital and crammed them (both over 6 feet tall) into my bright red Volkswagen beetle…I interviewed Gary as I drove. I felt a little lost discussing swimming (which I knew nothing about) but what I learned was that Gary really wanted to swim, but even more importantly that he wanted to help other people with diabetes as a role model. I have never had a patient with new onset diabetes who really cared about reaching out to others, even as he was struggling himself. It was this fact, more than anything else I learned from Gary, that made me say, at the end of the day ”I don’t see any reason why you can’t train for the Olympics; let’s see if we can work on this together.”

In hindsight I think the prior physicians said no to Gary because diabetes is a defect in providing normal fuel transport to muscle. It is more than glucose—it involves fat and protein metabolism and it is very, very hard to find the right balance using exogeneous insulin. Sure people with diabetes can swim, and even compete, but at an Olympic level, that’s a different realm entirely. It is where fractions of seconds matter. And how could a physician guarantee that his diabetes could be that well controlled, so as not to interfere? I think I was naive in saying yes; I am very glad that I did.

I flew up to Berkeley where Gary was training. I met with his coach, Mike Bottom, who is an amazing person and incredibly supportive of Gary. I taught Mike about diabetes, and how to watch for low blood sugar reactions (I was worried that during intense training periods Gary might not be able to differentiate between the catecholamine surge of racing and the one that comes from hypoglycemia). I had Gary test his sugars before and after various intervals of training and types of nutritional supplementation. I wrote a list of ideal fuels for Gary to eat while training, and we found them in Platinum Bars (invented by a veterinarian to help race horses heal after surgery). I got to know Gary and he got to know and trust me.

Gary started to do well. Six months after his diagnosis he’d rebuilt enough muscle mass to set a record at the Nationals. He was learning to compete with diabetes. And I went with him to as many of his meets as I could, learning about swimming and the physiology of glucose metabolism and exercise. I went with him to Indianapolis, where the Olympic Trials were held, and (for the first time in my life) found myself screaming support from the stands as Gary blew away the competition and qualified for the Olympics. No-one thought he had it in him to come back, but they didn’t know Gary. What he was doing wasn’t easy, but it was possible.

Next was Sydney and although I had just changed jobs and was busy trying to start two diabetes centers, I agreed to travel with him. I brought my 9 year old son, Max. But before anyone starts looking to become a doctor for an Olympic athlete, realize that everything I did I paid for myself. All of the trips—Berkeley, Indianapolis, Sydney—the time away from work, all of that was time I donated to Gary because I believed that he would help others live their dreams. It was my own, odd contribution to help people with diabetes. And I’ve never regretted it; Gary has helped hundreds of children with diabetes believe in themselves and in their futures. He has given it back a hundred times over.

Sydney was tough. Gary got sick from the flight and couldn’t get his blood sugars below 400 in the days before the first race. He needed three days with normal blood sugar levels to store enough muscle glycogen to be in peak competitive form. It was only 12 hours before his first event, the 4 x 100 freestyle relay, that his diabetes became manageable. Unfortunately this first race had alot of media attention. It was pitting the home team, the Aussies, with super star Ian Thorpe, against the US men. In recent times the US team has nearly always won this race. Gary swam last, the final leg. The first three swimmers had let him down; he dove into the pool with Ian Thorpe leading. Gary, with his amazing strength, pulled ahead of Ian in the first half of the race. He was ahead after the turn and looked like he was going to win it for team USA. But suddenly, in the last 25 meters, he began to slow, he looked like he had run out of gas. He struggled, galantly, to maintain his speed, but Ian Thorpe pulled passed him and won the race. I was crestfallen. It looked to me that his diabetes had gotten the best of him. The days of insulin resistance and hyperglycemia had made it impossible to prepare him adequately for Olympic competition. The other doctors had been right, afterall…I felt awful.

Gary never once used his diabetes as an excuse. He accepted his silver medal graciously. And then, in true Gary form, he went on to win the bronze medal in the 100 meter freestyle event (an event in which no-one thought he had a chance of winning a medal at all). And he achieved his dream of winning the gold in the 50 meter freestyle race. I have never cheered so loudly or cried so much at an athletic event. It was absolutely fantastic to be there with him.

So here I am again. Gary made it into his third Olympics. At 29 he is the oldest swimmer in decades to be competing and he and his father and the only father/son pair to each compete in three Olympics. Gary is, in many ways, stronger than ever. His diabetes is also tougher to manage than ever. But I was there with him at his last meet; at the Olympic trials and now on to Athens. I will be reporting back from the Olympics as I, as part of team-Gary, help work with him to bear the torch of hope for the millions of people with diabetes who need to know that with a little work they live their dreams.

Sunday August 15, 2004 Athens

The experience of Athens for the Olympics is like being in an evacuated zone, waiting for a bomb or a hurricane to strike. The town is all but deserted—the locals have fled to make room for the hords of Olympic fans who failed to materialize. Unfinished construction is everywhere, clouds of dust from unsodded fields of dirt surrounding Olympic venues blows through the roofless swimming stadium, carried by the ceaseless wind. The sun beats relentlessly down on the spectators who only half fill the seats. Security is omnipresent; menacing white blimps with mysterious lettering and helicopters hover overhead. Police are everywhere; roads are randomly closed and reopened, making efficient transportation virtually impossible. Triple security check points must be passed to make it into some of the fancier corporate parties. This is one Olympics to watch from home, no matter how hard Greece has tried to ready their aging city for the modern version of their ancient games.

I watched Gary swim this morning on the men’s 4 x 100 freestyle relay; I saw him swim a good race, unhampered by his disease. I also watched him come in second, which meant he was bumped from the final relay by swimmer Michael Phelps, who is being put into an event for which he hasn’t previously raced in order to increase his odds at winning a record number of Olympic gold medals. As a physician I know I have done my job—helped render his disease controlled, so he can pursue his dreams. As a friend I am disappointed for him and wished he could be swimming in the relay finals, a position he earned fairly, but lost to a younger, more lauded swimmer. But these are all an amazing group of men and women, with gifts that medical science can’t fully explain.

Before I knew Gary Hall, I didn’t understand how different these high performance individuals are than the rest of us, or at least from me. I, like everyone who has been through medical school, knows about hard work and dedication. If I were told that I had to swim five miles in a pool everyday in order to become a doctor, I could probably do it (providing I wasn’t being timed). But that wouldn’t make me an athlete; not in the way that the elite swimmers I know are athletes. Their bodies possess some different composition of muscle fibers; an attachment of bones to muscles, tendons and ligaments that makes for fluid, exact movement. Something my knock-kneed, gangly and uncoordinated self could never emulate. Training is of critical importance, as well, to refine what nature and perserverance have molded, but as a physician who has seen many human bodies, I know these are intrinsically different.

Gary is more different than most, because he is slightly imperfect. His beta-cells no longer secrete insulin. Watching his blood sugar levels rise and fall with training and racing provides a window into his physiologic needs for fuel, and an understanding of the intense stress athletes face when they compete. Working with Gary has taught me how to treat all of my patients who exercise, whether it is by walking around the block in the evenings or training for and competing in triathalons. The same rules apply.

The most important principle I learned is that every rule can be wrong in a given individual. I thought I knew about exercise, that training would make muscles more sensitive to glucose and lower insulin requirements. It made sense. But in Gary’s case, that rule doesn’t always apply. When he trains intensely he needs more insulin, largely because his carbohydrate intake is so high—4,000 to 5,000 calories per day, with 60% or so of his calories coming from carbohydrate. When he’s training less hard, his caloric intake and percentage carbohydrate ingestion is markedly reduced. So his insulin requirements are less. Another reason his insulin requirements are higher during his intense training sessions is because of the catecholamine response to such heavy training. As a sprinter he doesn’t do lots of slow long distance swimming; he does more intense episodes of training, which may be more physiologically stressful.

Gary’s insulin requirements change if he is training once a day or twice a day or three times a day. They differ if he is doing more weight training than cardio or the other way around. Time spent training in the pool is different than time spent training on land. Calculating doses wrong and he’s too low at night, a delayed effect of training, but giving too little insulin overnight results in fasting hyperglycemia and a bad workout the next day. An insulin pump might offer the fine tuning of basal rates that would better match his physiologic needs, but as a swimmer Gary can’t stand the drag of the tape and infusion site on his skin against the water. So he has become a master at adjusting his insulin doses, using a multiple daily insulin injection regimen that is more complex and varied than almost any other patient I treat.

Most of the time this approach works; the frequent insulin dosing and the 10 or more times he tests his blood sugar levels each day keep his sugars under control and his A1C level less than 7%. Sometimes, as with all patients, it doesn’t work as well and hopefully that doesn’t coincide with race days. I wish it were easier to manage our patients with type 1 diabetes, but it isn’t, not yet. Gary, like all my patients with diabetes, dreams of the day this disease is cured. I dream along with them—I’d like to be out of a job, at least a job of treating blood sugar levels.

Today Gary gets another bronze medal, for being part of the 4 x 100 relay team, even though he didn’t swim in the finals. He deserves that medal as much, if not more so, than anyone else who swam tonight. He received the medal as part of a team, a medal that he should be as proud of as any other. I certainly am proud of him. And, in a way, we are all part of the same team—the team who routs for our patients to live their lives to the fullest, to overcome obstacles and to be who they want to be in life. That is Gary’s message and he is always a champion to me.

Prelims August 19, 2004

The fifty meter freestyle sprint…the swimming equivalent of the 100 yard dash; once across the pool and you’re done…swimmers from all over the world turn out to try their luck…11 preliminary heats, starting with the slowest qualifying times…fans cheering for athletes from all over the world: Maldives, Trinidad, Croatia, Korea, Malawi. The most international event I’ve seen yet. And the winner of each heat of 8 swimmers waved and smiled as though they’d won the gold—although most didn’t qualify for the semifinals, the joy was about swimming in the Olympics, proudly, for the country each represents…this was the true Olympic spirit, separate from politics and terror-threats. The real thing.

Gary’s heat was number 11, the last. Heats go by quickly; no introductions, just ”swimmers take your mark”, get set, go…one splash and the swimmers are at the other side is 22 seconds, give or take a few hundreths…less than half a minute…and Gary’s hopes as a swimmer, and to some degree his future, hang on getting it right…By heat 9 I feel the adrenaline, the jitteryness, like I’m about to give the biggest lecture of my life…then Gary appears, strong, determined, no joking around…he needs to come back from the negativity of being passed over for the relay team (and given the results, a particularly bad decision on the coach’s part).

The buzzer sounds, the starter speaks, Gary leaps into the water like a coiled spring coming undone…I am beside myself…screaming ”Go Gary” from the second I see him on the pool deck…it feels good to scream…I try to give him energy…I pray to the Gods of diabetes to give all the people with abnormal glucose metabolism who look up to this man another victory…he streaks to the other side, fast twitch muscle propelling him seamlessly through the water…he makes no errors; there was no hestitation here…and he wins…he wins the prelims…he beats the South Africans and the Dutch and the Russians and everyone else who was supposed to beat him…he shows the world he is still Gary Hall, one of the greatest sprinters of all time. Undaunted by diabetes and age and being out of favor with the swimming coaches…he still can swim with the best of them.

Winning the prelims is by no means winning a medal. He still has the semifinals and the finals to go. But regardless of how he does in those events, he has shown that he is still in the game. He had valid cause for showing up at these Olympics, and who knows, he might win an individual medal afterall.

Athens Airport, 5:00 AM, Saturday, August 21, 2004

Gary won the gold. Unbelievable. He did it. He did it for himself, his family and friends, and for all people with diabetes. He says he’ll give his gold medal to the person who finds the cure. I hope he has to give it away soon. But for now he inspires; he inspires me and all of the people in the world who live everyday with the disease that is diabetes.

The race was 21.93 seconds of pure speed through water. All day I’d tried to calm myself, rationalizing that win or lose he was the same Gary to me. I said I didn’t care about competition (a comment Gary’s sweet siblings teased me with later, as I staggered up the stands to them, after Gary won, so overcome with joy and emotion that I could barely walk). As the race grew close I sat alone in the stands, surrounded by a sea of orange clad fans from the Netherlands. In front of me was a family from Australia, wearing teeshirts that said in turn ”Chelle’s Mum”, ”Chelle’s Sis” and ”Chelle’s Dad”.

The sun was setting behind the stadium, descending below the hills of Athens. The crowd was cast in the lengthening shadows of evening fading into night. An agonizing number of races preceded Gary’s. The women’s 200 meter backstroke won by Kristy Coventry of Zimbabwe; the men’s 100 meter butterfly, giving Michael Phelps his fifth gold medal, the endless women’s 800 meter freestyle race, won by Japanese swimmer Ai Shibata, whose mother sitting near me sobbed uncontrollably after the race was done. Finally the awards ceremonies for the first two events. Then, suddenly, it was time.

Gary emerged, covering his USA Swimming-issue warm-up suit with a red, white, and blue silk boxer’s robe and shorts…even in lane two, a less than desirable position, he showed some of his characteristic bravado. It took longer to announce the swimmers than for the race to be swum. I was on my feet from the start. The eight men tore across the pool, so close together it was impossible to tell who won until a ”1” flashed on the scoreboard next to Gary’s name. HE WON I shrieked, GARY WON. I started shaking uncontrollably. I could barely breathe. I didn’t know what to do except to leap in the air for joy. The guys sitting next to me asked if I was okay. More than okay I said, definitely more than okay. All those long days of sweltering Athens heat, the waiting, the anticipation, it was over. And resolved in the best possible way, at least for me.

Gary won by 0.01 of a second. Duje Draganja, his friend from Croatia had a time of 21.74. In distance this translates to about one fingertip, one distal phalynx, difference between the two. Watching the replay of the race, in the NBC Athens headquarters, I saw Gary’s long hand reach out and touch the wall first. It made me think of how many times a day Gary pokes those fingertips with a lancet to check his blood sugar levels. And how hard he has worked to get where he is today—so much harder than most. His fingertips help keep him alive by providing the data he needs to balance his blood sugar levels; his fingertips help win him Olympic gold medals.

I celebrated for most of the night with Gary’s large family and other assorted members of his support team. We sat on an outside patio in a traditional Greek restaurant and were treated like royalty by the staff, who stayed open long past closing time. At 1:45 AM Gary showed up; exhausted but happy. Hugs, tears, and a sharing of the joy we all felt. When Gary handed me his medal to hold and examine I thought of the remarkable path he’s taken. In 1996, before he had diabetes, he won a silver medal in the 50-meter freestyle; in 1998 he was told his swimming career was over because he had type 1 diabetes. Just 2 years later he was back, and tied for gold in the 2000 Olympics. Now, four years later, with diabetes that is harder to treat than ever because he has lost much of his residual beta-cell function, he has won a gold medal in his event all for himself. He has only gotten better with diabetes and age. When asked why he does this, why he pushes himself so hard, he says, simply ”I just love to race.” And he doesn’t let much get in his way.

Gary has taught me what is possible with diabetes. And although I understand that diabetes is tough, it is controllable. And along the way people can lead the lives they aspire to, with role models like Gary to light the way. So as I head back to Los Angeles, where busy days of clinic await me, Gary is having a well-deserved vacation in Athens where he is dreaming of Bejing in 2008.