Tag: diabetes

Kris Freeman does not give up easily.

Freeman, an American cross-country skier, has weathered a diagnosis of type one diabetes—which, for the careers of most endurance athletes, would have been a death sentence. He has picked himself up from a snowbank and finished a race at the Olympics after passing out on the side of the trail from hypoglycemia. He has pushed through two surgeries on his lower legs to relieve the debilitating symptoms of exertional compartment syndrome.

On a cool September day in New Hampshire, Freeman is demonstrating this same resiliency. An hour-and-a-half into a 30-kilometer time trial, he is hammering his way up a steep sideroad on rollerskis, and the power he’s displaying is phenomenal. Up until the bottom of this hill, Freeman was skiing at a pace that would have cracked all but a handful of people on the planet—and then he upped it. Only a few hundred meters separated him from the top of climb, which marked the finish line for this test.

Except he didn’t make it. Freeman yelled at his coach Zach Caldwell, who was driving a rental car up ahead.

“I’m done,” he said. “I can finish—my heart rate’s just going to drop. Do you want me to finish?”

“I don’t know. Let’s just take the numbers right now—if you’re pegged, let’s do it,” Caldwell said.

“I’m pegged,” said Freeman.

“Yeah—good. You look pegged,” Caldwell said.

Exhausted, doubled over, Freeman pricked his finger and squeezed out a dark red drop of blood. He touched it to a strip of paper, the other end of which was inserted into a tiny meter.

In just a few seconds, the meter would spit out a two- or three-digit number representing the concentration of glucose in Freeman’s blood. More than anything, that’s what his efforts were dedicated towards today—not training, physical or mental, but these numbers.

That’s why Freeman stopped before the top. And that’s why, after an hour and a half of skiing, he and Caldwell were hunched over the tiny monitor, waiting for a reading.

‘So Many Questions’

The numbers from the monitor will prove important this coming weekend, when Freeman, 30, competes in his first 30 k race of the year in La Clusaz, France, after a strong start to the season. But the day before that September time trial, Freeman was busy recounting the previous year.

Reclining comfortably on an inner tube in his two-car garage, he betrayed no sense of the disappointment and anger that he displayed at the Olympic Games in Vancouver in February, when a decade’s worth of preparation went up in smoke. In the 15 k, Freeman’s best event—and the one to which he had dedicated the most effort towards minimizing complications from his diabetes—his dreams of a medal were crushed by bad skis, and he finished 59^th. Then, five days later, in the 30 k pursuit, Freeman suffered a severe bout of low blood sugar. That left him passed out on the side of the trail, and he limped in in 45^th place, nearly eight minutes behind the winner.

“There were so many questions after the Olympics, and so much doubt,” Caldwell said.

Bad skis had been one of the problems, but the diabetes treatment clearly needed to be re-evaluated, too. In March, his season over, Freeman vowed to take a hard look at his treatment regime, writing on his blog that he was going “back to the drawing board.”

In the spring, Freeman went out and found a new doctor, Matt Corcoran, who specializes in working with diabetic athletes. Armed with new information, Freeman has been working through the summer and fall to develop new strategies for controlling his blood sugar while racing. The 30 k time trial he would be racing the next day was designed to test out an entirely new approach to insulin dosing for the event—one that was, in large part, the opposite of the approach Freeman uses in the 15 k races.

In the garage, as Caldwell worked with a drill and screwdriver to mount bindings on a new pair of rollerskis, Freeman recounted his efforts over the past few years to devise a successful strategy for keeping his blood sugar under control.

Freeman’s body uses glucose as one of its primary fuel sources for his athletic pursuits, from easy running workouts to rollerski time trials to World Cup races in the winter. But as a type one diabetic, Freeman’s body doesn’t produce insulin, the hormone that takes glucose out of the bloodstream and transfers it to the muscles—where it’s actually used. Since 2000, when Freeman was diagnosed with the disease, he has injected himself with a synthetic version of the hormone in order to keep his blood glucose at an acceptable level.

It’s a delicate balance: too much insulin will cause Freeman’s blood glucose levels to plummet and leave him weak and cognitively impaired, even unconscious if he really messes up—a condition known as hypoglycemia. Not enough insulin and Freeman’s blood sugar will climb, leaving him hyperglycemic and at-risk for some of the long-term complications of diabetes, like blindness and kidney damage.

Insulin dosing would be easy if blood glucose levels didn’t fluctuate constantly—but they do. Eating and drinking cause some of the largest changes, but other factors like travel, stress, and—most crucially—exercise can also have a big impact. The basics of the interaction between exercise and blood glucose are simple: The more you train, the less insulin you need to use, because generally, physical activity accelerates the hormone’s effects. But the intense effort of racing can makes things more complicated.

When Freeman was diagnosed with diabetes in 2000, he set about reading, to educate himself about the disease. But what he found, he said, was a minimal amount of research and medical literature on high-level endurance athletes competing with the disease—and certainly no cookie-cutter guidelines for insulin dosing in 10-kilometer, 15-kilometer, and 30-kilometer cross-country ski races. And even if there had been relevant studies conducted, it’s not clear that they would have been much help, since effects of the disease and the drugs used to treat it are different for each individual.

“All diabetes…is very much about that one patient’s experience,” said Katy Tierney, a nurse practitioner at the Joslin Diabetes Center in Connecticut. “We have some general guidelines to go to, and some goals to shoot for, but everybody lives a different life.”

From 2000 to 2006, Freeman was still in what’s called the “honeymoon phase” of the disease—the period in which his body’s natural production of insulin was compromised, but not entirely destroyed. Without injections of synthetic insulin, his blood sugar levels would still have fluctuated, but he needed less of it to keep things under control.

“That made the first couple years of having diabetes a lot easier than it would have been otherwise, because I had a little bit of a built-in bailout, something that helped me along,” he said.

During this period, Freeman wasn’t working as closely with Caldwell—instead, he trained under the U.S. Ski Team’s coaches, and developed his insulin dosing regime primarily with the assistance of Larry Gaul, the U.S. Cross-Country Ski Team’s physician. Gaul didn’t have experience working with diabetic athletes, but as a cardiologist, he did have training in internal medicine—which gave him sufficient expertise to advise Freeman. Initially, Gaul said, he put Freeman on a conventional insulin treatment plan, but over the next few years, Freeman learned more about the disease and began coming up with his own schemes.

“He would develop ideas and then test ’em out, oftentimes without any of us knowing,” Gaul said. “He could call when he was in a stuck, or if he was having difficulties with [a] particular process, and so it just sort of evolved.”

Throughout the honeymoon phase, though, Freeman’s dosing strategies were shooting at a moving target, because his body’s natural production of insulin was still dwindling. “Each year, I was dealing with less insulin than the year before—so what I was doing the year before didn’t work,” he said. It took until 2006 for him to finally hit what he calls “ground zero,” when the flow of natural insulin shut off altogether.

2006 was also the year when Caldwell began working with Freeman on a day-to-day basis. Before then, Freeman said, his coaches weren’t particularly involved in discussions about dosing. But Caldwell, who comes from a long line of ski coaches, also has a self-taught background in physiology, thanks to a few years of work alongside experts at the Olympic Training Center in Lake Placid, when he was running camps for the New England Nordic Ski Association. And he was fascinated by the challenge of developing insulin dosing strategies for Freeman.

Working with Caldwell, Freeman said, “was the first time that I was able to discuss dosing with my coach, and its importance.”

“I kind of look at myself as a race car with a broken fuel injector,” he said. “Zach kind of shared that opinion with me, so, basically, we started a dialogue, and we talked about it—what worked, and what didn’t work.”

Caldwell’s paying job is working as a stonegrinder and ski technician at a ski shop in Colorado. But coaching Freeman, and Freeman’s teammate Noah Hoffman, is where his true passion lies.

“The work with Kris, and some of the work with Noah—it’s the only thing that I’m really interested in doing in the sport. I like grinding skis, I like testing stuff, and I like working with the equipment, but I don’t like working with the people very much,” Caldwell said. “It’s incredibly rewarding working with Kris.”

More Insulin, Better Results

Caldwell’s physiological and cross-country skiing expertise was a good complement to Gaul’s medical background, and it was the missing piece for Freeman, who forged ahead developing more complex dosing strategies for his hard efforts. But given that Freeman’s insulin needs had been in flux up until 2006, as his natural production shut down, the pair had some rethinking to do.

Right off the bat, Freeman and Caldwell noticed two basic trends. First, it appeared that Freeman’s best races would come when he was using a lot of insulin. The second thing they noticed was that Freeman would spectacularly flame out at the occasional competition, like in Kuusamo, Finland, in 2006. After a strong race in Sweden the week prior, Freeman completely tanked in Kuusamo, finishing outside of the top 30 and barely making it up the last hill. His lactate at the end of the race—a measure of how hard an athlete has been working—was over 13 millimoles, excruciatingly high. The next summer, Freeman had a similarly bad day on Mt. Sunapee, a hill climb time trial in New Hampshire that he uses as a test of fitness. He was a minute slower than the time he was aiming for, with lactate of over 16 millimoles.

Besides the lactate levels and the poor performances, there was one other constant between those two efforts: Freeman had blood sugar levels of over 300 at the end of both of them, way above the normal range.

Those races got Freeman and Caldwell thinking about the dynamics of blood sugar and lactate. It seemed to them that there was a correlation—when Freeman’s blood sugar got too high, his lactate levels would also rise. And since Freeman tanked whenever his lactate spiked, his sugar would have to be better controlled. That meant he would need to use more insulin, because he needed the hormone to take the sugar out of his bloodstream and push it into his muscles.

On the face of it, using more insulin doesn’t sound too difficult, but in fact, it was easier said than done. For the Kuusamo race and the Sunapee time trial—all the way up until the spring of 2008—Freeman had been injecting his insulin, which meant that the hormone stayed in his system for a full 24 hours after it was administered. That made it hard for Freeman to use large quantities for competitions, because even though he only needed the dose for the brief period of time he was racing, he’d be stuck with it for a full day. Too much insulin floating around in your system is tough on your body, because you have to be continually ingesting food to keep blood glucose levels from dropping too low.

“He was going to be up all night eating to stay alive,” Caldwell said.

But in the spring of 2008—the year after that miserable test at Sunapee— Freeman began using a device called the Omnipod, a pump that administers micro-doses of insulin at five-minute intervals, rather than one large one every 24 hours. The pump allowed him to fine-tune his dose just before races, and lower it as soon as he finished, and consequently, Freeman was able to experiment with higher levels of the hormone. From the get-go, it was clear that more insulin was yielding better results.

In the early part of that training season, Freeman was competing in a team sprint workout in Whistler. With his insulin dose set at .75 units an hour, Freeman gave a miserable showing in the semi-final, Caldwell said. Between rounds, Freeman doubled the dose, then “went out and just destroyed everyone. Just, absolutely skied the legs off ’em,” Caldwell said.

The pair wanted more data, so they booked time for treadmill testing with the U.S. Ski and Snowboard Association’s sports science department in Park City. That testing only confirmed their suspicions that there was a correlation: lactate levels seemed to be closely tied to Freeman’s blood sugar. So they kept pushing Freeman’s insulin dose up, because he needed the hormone to keep his blood sugar from getting too high. For the next few field tests, Caldwell said, the pair left caution aside—even though too much insulin can result in severe hypoglycemia. Both Caldwell and Freeman have a morbid sense of humor when it comes to diabetes, and Caldwell in particular seemed to relish one story from an uphill running test in Whistler.

“Kris was like, ‘if I don’t show up within this amount of time, start running back down the trail. And if you find me passed out in a ditch, rip the pod off the back of my arm!’” Caldwell said. “I’m like…‘okay…’”

By the beginning of last season, the Olympic year, the pair had finally settled on a dosing strategy for the 15 k races, which was where Caldwell and Freeman had been focusing their efforts. What they had discovered was this: As long as Freeman stayed at a sustainable pace—at or below his anaerobic threshold—his blood sugar would drop, and he would need minimal insulin. But as soon as Freeman crossed over that line into the anaerobic zone—the hard pace at which he raced the 15 k events—his body would start dumping massive quantities of sugar into his system, meaning that he needed massive amounts of insulin to deal with it.

According to Caldwell, Freeman’s normal insulin needs are relative to any number of factors: his fatigue level, state of recovery, and even environmental conditions.

“But at a certain point, once he hits that anaerobic work level, it feels to us like it’s just sort of absolute. This isn’t relative to stress load—it’s just, ‘you need this much to move this much sugar,’” Caldwell said.

The amount of insulin Freeman settled on for anaerobic efforts was a huge dose: between six and seven units an hour. That’s up to ten times as much as an average diabetic uses during training, but it was what Freeman needed. And by the end of the 2008-2009 season, it seemed to be working. Despite suffering a relapse of compartment syndrome at the end of the year, he still managed to place fourth in the 15 k classic at World Championships—what he called a career result, just 1.3 seconds from a medal. While the compartment syndrome had hurt him, there had been few diabetes-related complications that season. And for that reason, Freeman said he saw little need to make any changes to his treatment regimen leading into the Olympic year.

Freeman’s early-season results only reaffirmed that his approach was working. Over the first five weeks of the 2009-2010 season, he raced a total of ten times. And using the high insulin dose, Freeman was consistently skiing to some of his best results ever. His first World Cup race was in November in Beitostolen, Norway, where Freeman raced with a dose of six units an hour to a 22^nd place finish. The weekend after Beitostolen, in Kuusamo, Finland, he upped the dose to seven units an hour, and was fourth in the 15 k classic. Two weeks later, in Davos, Switzerland, he used the same amount, and was seventh. Those were some of Freeman’s best-ever World Cup results, and they came while racing a packed schedule.

“The guy is phenomenally resilient, and over the course of that, his fitness got better and better,” Caldwell said.

After the World Cup in Davos, the circuit moved on to Rogla, Slovenia, for two classic races: a sprint, and a 30 k. The events were Freeman’s last ones before heading home to New Hampshire for Christmas, and after the fall’s strong performances, he and Caldwell were hopeful, since his fitness still seemed to be on the rise. For all of his national championships, and for all of his strong international results, Freeman had yet to be on the podium at a World Cup. The way he had been skiing, both he and Caldwell felt that there was a chance that Rogla could be the first.

‘A Real Bitch’

Except for one problem: The race where he’d have his best shot to do it was a 30 k, not a 15 k. The distance was a good one for Freeman—he won the world U-23 championship 30 k in 2003, and his first national championship came in the 30 k in 2000. But since 2008, when Freeman had gotten his Omnipod pump—which required an overhaul of his insulin strategy—he had only raced the distance twice, giving him few opportunities to experiment with different doses. And in his off-season testing, Freeman’s emphasis had been on the 15 k competitions—racing a 30 k time trial in the middle of the summer isn’t the best way to get fit, he said.

Physiologically, a 30 k race is very different from a 15 k. Since the distance is longer—and because the format is a mass-start, not an individual-start—the race would often go out slower, closer to an aerobic pace than an anaerobic pace. And because Freeman needs minimal insulin at an aerobic pace, he and Caldwell knew that the proper dose would be lower. The problem was that it couldn’t be too much lower, because to win the race, Freeman would have to ratchet his pace up to an anaerobic level at the end. That would trigger the big sugar dump, and to compensate for it, Freeman would still need a whole lot of insulin in his system.

“Our thinking is this…we know for a fact that Kris doesn’t need seven units an hour to go out and ski at threshold,” Caldwell said. “The problem is, to win one of those races, during the last 10 k, he’s got to be maxed out at times. And for the last five k, he’s got to be, just, hammering.”

That made dosing for the Rogla 30 k “a real bitch,” Caldwell said. While he and Freeman knew that the right dose would be less insulin than for the 15 k’s, they didn’t know how much less. Too little insulin, and Freeman would end up full of lactate and off the back of the pack. Too much, and he’d end up with plummeting blood sugar, and the crippling effects of hypoglycemia.

Ultimately, they decided on six units an hour—only slightly less than Freeman had been using for the 15 k races. There was a chance that the dose could be too high, but the two figured that if Freeman went hypoglycemic, he could just drop out, drink some Gatorade, and be back to normal.

“We had decided, ‘okay, it’s a risk, but we’re going to try this,’” Caldwell said. “He’s fit enough to win. So let’s put him at a winning dose.”

Last December was the first time Rogla had ever held a World Cup, and the conditions were raw. The first race, the sprint, was held in a snowstorm. The day of the 30 k, it was windy and frigid, and there was nowhere indoors for Freeman to fine-tune his insulin dosing just before the start, like he usually does. His monitors aren’t reliable below 40 degrees, although with a handwarmer, they’ll work down to about 10. At Rogla, it was seven degrees. With just a few minutes before the gun, Freeman’s glucose monitor was telling him that his blood sugar was perilously low—and while he didn’t trust it in the cold, he still decided to wolf down about 45 grams worth of carbohydrates, just to be sure.

When the race started, Freeman looked great. 20 minutes in, he was comfortably in the pack, or more accurately, at the front of it. At the time check at 7.5 kilometers, a quarter of the way through the race, he was sitting in fifth, ten seconds behind the leader. And according to Caldwell, he looked “fantastic,” moving easily and skiing comfortably at the front of the race. It appeared that the dose was bang on, and that Freeman would finally have his shot at the podium—until he suddenly lost two minutes on an uphill.

Just like that, Freeman had gone hypoglycemic, and the race went down the drain. At first, he was so disoriented that thought that his blood sugar was too high, not too low, and he was skipping the sports drink handouts that he normally took from coaches to keep his glucose levels up.

“It was bad. I couldn’t figure out what was going on,” Freeman said. “When I got to 20 k, I…felt like crap, and just went, ‘screw it, I’m going to pull over.” When he tested his blood sugar, it was 49—very low. Freeman shut off the Omnipod that was still pumping insulin into his system, then spent the next five hours chugging sports drink, to try to keep from going too low again.

“No matter how much I ate, [my blood sugar] continually fell to 50. Continually, just fell,” he said. “I was sitting in a car next to [teammate Andy] Newell, pounding Gatorade. I would test my blood sugar, and I would be down to 50 again. I’d drink a quart of it, and it would go up to 65, and then it would go down to 50.”

Freeman said he didn’t feel too bad after the race—like he had just finished a hard effort, but not horrible—and a day later, on December 21, he was already back home in New Hampshire. But by Christmas evening, he started to feel nauseous, and that night, he came down with a vomiting flu, which knocked him completely out of commission for two days and threatened his trip to the U.S. National Championships in Alaska. By December 31, Freeman was finally feeling better, though, and he left for Anchorage the next day.

Little did Freeman know at the time, but his season had begun to unravel. The hypoglycemic episode in the 30 k—and the high insulin doses he had been using at other races—had exacted a huge toll on his body, though he wasn’t aware of it. Until the race in Rogla, there were few indications that Freeman was doing anything wrong with his dosing. In fact, the strong results in the early-season had only reaffirmed his belief that he was doing the right thing.

‘My Worst Nightmare’

After recovering from his illness, Freeman’s first event of the championships was the 15 k, which went fine: he won the race by nearly 30 seconds over his closest challenger, 21-year-old Tad Elliott. But his next race was another 30 k, which again presented Freeman with a dosing dilemma. After the debacle in Rogla, where he had used six units of insulin an hour and gone way too low, two units seemed like a reasonable dose. But to confirm that that dose was working, Freeman decided to do something he’d never done before: stop in the middle of a race to test his blood sugar. His rationale was that the data was crucial—especially with the 30 k at the Olympics less than two months off—and, given the way he had been skiing on the World Cup, Freeman felt he could still do it and win.

But it didn’t happen. Freeman had horrible skis that day, couldn’t shake James Southam, got dropped when he stopped to test his sugar, and then buried himself trying to catch up. He limped in in second place—and to make matters worse, the glucose test was a failure.

“I don’t like losing. And to make matters worse, we didn’t even get the data point. It wasn’t reliable,” he said. “The whole day was ruined.”

The good news? Freeman didn’t go low. His blood sugar was 108 at the finish, right on target, which he and Caldwell took as a sign that they’d finally nailed down the 30 k dose. Two units was what he had used that day—the last 30 k he would race before the Olympics—and two units was the dose Freeman ultimately decided to use for Vancouver.

Nationals was Freeman’s final event before the pre-Olympic World Cup races in early February in Canmore, Alberta, where he placed 20^th in the 15 k freestyle and 40^th in the sprint. Those results weren’t quite what Freeman wanted, but on the heels of a solid training block at home after Anchorage, he knew that it would take a few hard efforts to climb back to the level where he’d been in the early season.

“I did not go into the Olympics thinking I was in bad shape,” he said.

Freeman had been looking towards Vancouver for nearly his entire career—and for once, it seemed like the whole country really was watching. In the lead-up to the Games, he was a media darling, making the cover of Outside Magazine and appearing on the Today Show. But beginning with Freeman’s first race on February 15, his two weeks at the Olympics were an unqualified disaster.

That first race was the 15 k—Freeman’s best chance at a medal, and an event he’d been targeting for years. It was the first cross-country ski event of the Games, taking place just three days after the opening ceremonies, and on a warm day at Whistler Olympic Park, Freeman had a brutal race, finishing 59^th, over three minutes behind the winner, Switzerland’s Dario Cologna. He wasn’t even the first American—that honor went to Alaska’s James Southam, in 48^th place. The reason for Freeman’s implosion was the topic of much debate at the time, generating a firestorm of criticism and comments. But seven months out, Caldwell made it clear: Freeman had “atrocious” skis.

While Freeman’s confidence was shaken, he and Caldwell still knew that his fitness wasn’t bad. Caldwell took video of a workout three days before the 15 k, and he said that it was the best Freeman had looked since December, when he was tearing it up on the World Cup. So when Freeman stepped to the line for the 30 k pursuit on February 20, no one knew exactly what to expect. Like in Anchorage, Freeman was using two units of insulin an hour—much less than the dose he had settled on for the 15 k’s.

In the early part of the race, Freeman looked fine. He wasn’t doing anything special—he was in the pack, but the pack wasn’t doing a whole lot. Then, on the second lap, Czech strongman Lukas Bauer put in a series of attacks to try to break the race open, which dropped a handful of skiers, but wasn’t enough to shell any big guns. Meanwhile, Freeman was skiing well, moving up in the pack.

“During that lap, Kris skied from 45^th place to 16^th, through traffic, without any effort. Like, take a double pole, pass three guys. Easy,” Caldwell said. “And we all started to get excited. I was watching on the monitor, and [the staff was] running out to the side of the trail.”

That excitement lasted up until Bauer gave up his breakaway attempt and slowed down. But even though the pace had gotten far easier, Freeman, inexplicably, couldn’t handle it, and he was dropped from the lead pack. A few minutes later, he was passed out on the side of the trail from hypoglycemia, and it took a packet of gel from a German coach to get him out from a snowbank and across the line—nearly eight minutes behind winner Marcus Hellner of Sweden. The effort of finishing took a huge toll: Freeman’s back seized up as soon as he was done skiing. Caldwell drove him back to the Olympic village, where he said Freeman was “basically incapable of moving.”

“I couldn’t get out of the car,” Freeman said.

To make matters worse, Freeman had no idea what had caused the hypoglycemic episode—since the same dose had worked fine at the national championship 30 k less than two months earlier.

“I ran the same basal rate as in Anchorage, and in Anchorage it worked,” he told FasterSkier at the time. “I’m crushed. I don’t know what’s happened.  I’ve been working towards this for four years, and it’s my worst nightmare.”

The 30 k was the last race Freeman would finish that season. He entered the 50 k on the last day of the Games, but struggled early and dropped out less than halfway through the race, to avoid a repeat of another hypoglycemic incident. Rather than heading to Europe for the last World Cups of the season, Freeman went home to recover and train for the U.S.’s final domestic races. Instead, he ended up with a fever, another vomiting attack, and a sinus infection.

‘Nowhere to Go’

After the struggles with his blood sugar through the winter and at the Olympics, Freeman resolved to revamp his diabetes management strategy in the spring. First, he got fitted for something called a continuous glucose monitor—a device attached to his body that gives him a blood sugar reading every five minutes, courtesy of tiny needle inserted below his skin. He also began working with Matt Corcoran, an endocrinologist and an expert on diabetes and exercise. (Endocrinologists are specialists on hormones and glands.)

In the past, Freeman had never worked closely with an endocrinologist. The two key members of his team were Caldwell and Gaul, the cardiologist and U.S. Ski Team doctor. Prior to this spring, Freeman had never found anyone else with any insights to offer, and who was willing to build on his existing knowledge. Most endocrinologists, he said, worked with patients at an entirely different athletic level.

“If you look at the average road-running race,” he said, “there’d be 5,000 people running in the race, and there would be about 70 of them actually racing. And so, there’s all kinds of doctors and endocrinologists trying to figure out how to help diabetics complete a race. But they’re not talking about working at maximal exertion—most people don’t even know what maximal exertion is.”

There are a small number of diabetic athletes who have raced at the Olympic level, including swimmer Gary Hall, Jr., and rower Steve Redgrave, but both of those men competed in events much shorter than Freeman’s.

“No one has ever attempted to be an Olympic athlete with type one before, in an endurance race,” Freeman said. “So there’s just nowhere to go.”

The mindset of many people with medical backgrounds, Caldwell added, didn’t help either.

“He’s never talked to a doctor who could even begin to relate. The most arrogant of them want to come in and start from scratch. And Kris is like, ‘you know, I’m not at scratch–I’m way beyond that,’” Caldwell said.

According to Gaul, Freeman has become his own expert—“the biggest expert there is on himself, and on diabetes and endurance sports, probably.”

But despite the results Freeman achieved with the insulin program he’d designed with Caldwell and Gaul—without an endocrinologist—Corcoran said that he could have added something to the picture, and perhaps helped Freeman avoid some of the hypoglycemic episodes that plagued him last year.

“I do think some athletes who operate at a higher level sometimes isolate themselves off a bit—and maybe they should,” Corcoran said. “Oftentimes, [they] sort of work under the perception that they’re the only ones out there, if that makes sense.

“But there have been a lot of elite athletes who have diabetes. I mean, if you look at the list of athletes who have competed, in the U.S. and in the world, with type one diabetes, it’s pretty phenomenal what level they’ve taken it to,” he added. “I do think there’s a body of knowledge out there, and understanding.”

In retrospect, Freeman acknowledged that his reluctance to reach out to an expert might have hurt him over the past season. But heading into that year, Freeman had just netted a career result at World Championships, which he had attributed to solid insulin dosing.

“At the time I thought my energy would be better served training than seeking out new medical advice,” Freeman wrote in a follow-up e-mail. “I was wrong and I learned the hard way.”

Looking for a Spike

Freeman has not been working especially closely with Corcoran, but through their interactions, combined with new information from his continuous glucose monitor, he was able to obtain some crucial insights into his treatment.

In the past, Freeman had always operated under the assumption that his insulin was taking about 15 minutes to kick in—“reach peak,” in medical parlance—because he had a fast metabolism.

“From the limited amount of glucose testing I could do, that was the closest I could figure out. And it was what I was led to believe,” Freeman said.

But in fact, he learned in the spring, the effects of the insulin weren’t actually coming to peak for roughly 45 minutes. So when Freeman would crank his dose up to six or seven units an hour, just prior to one of his 15 k races, he would only be using a small proportion of the hormone before the finish line. Afterwards, the large quantity of insulin still floating around in his body would cause his blood sugar to drop to hypoglycemic levels. While Caldwell and Freeman had recognized that he would often be ending races with low blood sugar, they had assumed that Freeman could easily push it back up with sports drink or food, without suffering any lingering effects.

“That was something that was okay,” Caldwell said. “It was like, ‘yeah, you just feed it.’ Big deal. You finish the race, it’s over, it’s done. Now you’ve just got to manage the sugar however you can.”

But in his conversations with Corcoran, Freeman learned that the minor low blood sugar episodes at the end of each race were having cumulative effects—and that the two major crashes last year, in Rogla and Vancouver, were probably what destroyed Freeman’s whole season.

Last year, Freeman now believes, each time he raced, his body was relying on adrenaline, a backup hormone, to try to boost his blood sugar back to normal levels during his recovery. That became tougher and tougher on his immune system as the year went on—and eventually overwhelmed him after the severe hypoglycemic episodes in Rogla and Vancouver, draining his energy reserves and causing the illnesses that disrupted his season.

“I’m racing twice a week on the World Cup. I’m skiing well. But to compound recovery from one race to the next, I’m also dropping to [a blood sugar level of] 40 in my cooldown,” he said. “It’s uncomfortable, you feel crappy, but you drink some Gatorade and eat a Powerbar and you feel fine again. I didn’t really realize the long-term implications of the fatigue I was putting myself under. Who knows how much adrenaline I was wasting doing that?”

The insights that Freeman gleaned from Corcoran, and the data from the continuous glucose monitor, led him to make some major changes in his insulin regime. Rather than upping his dose 15 minutes before races, like he did last year, Freeman has been making his adjustments roughly half an hour prior to the start, to make sure that the hormone is coming to peak just as the race begins—not just as it’s finishing. That strategy was successful in a number of hard efforts in the summer, including running races in New Hampshire, up Mt. Washington and Mt. Moosilauke.

Those races were both hill climbs—anaerobic efforts similar to the 15 k ski races Freeman does in the winter. But while the adaptations for those shorter races were fairly straightforward, he still had a problem: the 30 k’s. He had only started three of them last year, two of which had ended disastrously, and after the nightmare at the Olympics, Freeman still didn’t know how much insulin he would need.

The event was a potential strong point for Freeman, though. So beginning with the U.S. Ski Team’s first camp of the season, in Bend, Oregon, and continuing in New Zealand and later in New Hampshire, in September, Freeman and Caldwell conducted a series of 30 k time trials to try to get a better idea of the just how much insulin Freeman would need. While there was “very questionable training benefit” to doing long time trials in the off-season, Freeman said, he desperately needed the data.

In the past, the pair had always operated under the assumption that Freeman would need a healthy amount of insulin for these races. While the first portion of the 30 k’s on the World Cup was usually fairly tame—putting Freeman at an aerobic pace, and burning up the sugar in his bloodstream more quickly—the race would always ratchet up to a far more challenging speed by the end. The strenuous, anaerobic effort necessary to keep up would precipitate the same blood sugar spike that Freeman experienced in his 15 k races, and in order to combat it and keep his levels acceptable, he would need to have plenty of insulin around—or so he and Caldwell suspected.

However, the available evidence was inconclusive. Clearly, the dose of seven units an hour for the 30 k at Rogla had been too much. So was two units an hour at the Olympics. Freeman had also used two units an hour with moderate success at the 30 k in Anchorage, but that event was a special case—he had had terrible skis, and was at an anaerobic pace for almost the entire race trying to drop and then catch up to James Southam—which likely led to a prolonged blood sugar spike that offset the large insulin dose.

Since Freeman had gotten the insulin pump, he and Caldwell had always assumed that his body would behave the same way when he went hard at the end of a 30 k as it did when he went hard at the beginning of a 15 k—with the spike in blood sugar. But what if they were wrong? What if, by the end of the 30 k, that spike didn’t come? Caldwell surmised that after nearly an hour and a half of racing, Freeman might have already burned up all the available glucose stored in his body—“defusing the bomb,” so to speak.

“We had assumed that that spike was going to happen under any circumstances… But understand that it is different to try to go really hard after an hour of going pretty hard, than it is just to go really hard right from the gun,” Caldwell said, outlining the difference between the 15 and 30 k races. “After an hour of operating at threshold and burning a lot of sugar, is there enough glycogen [glucose stored in the liver] to cause the same spike? I assumed that the answer would be yes, which is why we were trying to jack the dose up.”

But by the time Freeman began with his 30 k time trials in the spring, he and Caldwell were no longer sure. So to start, the pair decided to run Freeman at a much lower level of insulin than he had used in the past—on the off chance that it might be enough. For the first 30 k, in Bend, Freeman raced at his basal insulin rate—the same level he was using to lie on the couch in the middle of the day. That was .5 units an hour, or roughly one quarter of what he had used in Anchorage and at the Olympics—just 10 percent of the Rogla dose.

Freeman conducted the Bend test on a series of loops—three seven-kilometer circuits to start out, then four three-kilometer loops to finish. At the end of each loop, he would stop to test his blood sugar and lactate levels, as well as to refuel with some Gatorade. He and Caldwell expected to see some kind of blood sugar spike as Freeman ratcheted up his pace at the end of the test, but to their surprise, they didn’t. His glucose levels remained constant throughout the entire workout—despite the fact that Freeman went all out for the final half hour.

“I went absolutely maximum for the last 10 k, and didn’t get a rise in blood sugar,” he said. “I did this time trial with about the best blood control I’ve ever seen.”

In New Zealand, at the U.S. Ski Team’s summer camp, Freeman conducted a second time trial, where again, he raced with a dose close to his basal insulin level. Again, there was no spike. That was despite the fact that in both time trials, Freeman was drinking a huge quantity of Gatorade—in Bend, he’d had 57 ounces, nearly half a gallon—which should have helped prop up his blood sugar. The evidence was mounting that any blood sugar spike at the end of the 30 k races was extremely small—if there was one at all.

‘We’ll See If We Can Kill Him’

After the two tests in Bend and New Zealand, Freeman and Caldwell scheduled their third 30 k time trial in New Hampshire in September. This time, they decided to try something unprecedented: have Freeman race the entire 30 k distance without any insulin. Just before starting the race, Freeman would turn his pump off, and leave it off.

“We need to come at the solution from both sides,” Caldwell said. “He’s low enough at this point that basically, we’ve got to say, ‘what if we just shut it off?’”

Clearly, this strategy was a sharp departure—essentially a reversal—from the one that they had been following the previous winter, when Freeman had raced the 30 k at Rogla with a dose of six units of insulin. In nine months time, their approach to the long races had taken almost a complete about-face. In the previous season, Freeman and Caldwell had been operating under the assumption that the dosing for the 15 k and the 30 k races would be similar. It had slowly become clear that they were closer to opposites.

“Every test we’ve run, so far, has indicated that the 15 k and the 30 k are totally different events that need to be fueled differently, and medicated differently,” Caldwell said.

Caldwell lives in Boulder, Colorado, but the U.S. Ski Team had paid for him to fly back east to oversee the testing. The day before the time trial, Caldwell drove up to Freeman’s condo in Thornton, New Hampshire, at the southern edge of the White Mountains. The next morning, just after 10 a.m., the pair set out—Freeman on his classic rollerskis, Caldwell rolling along just behind in his rental car.

After navigating some construction and getting a guarantee of safe passage from one of the flaggers, Freeman made his way up a long rise. At the top, he turned right onto a road that looked like a driveway, but instead wound precipitously upwards for about a mile. Freeman didn’t usually test himself on this particular climb, since he has no way of descending safely when training alone. But with Caldwell driving, he could use it as a challenging finish to his time trial, then catch a ride down. The idea, Caldwell said, was for the last part of the test to be “fucking hard,” to make sure that Freeman could hurt himself badly enough to get into an anaerobic state, and potentially precipitate a blood sugar spike.

For now, though, Freeman was still in the middle of his warm-up. At the top of the climb, he hopped in the car with Caldwell, and as the pair drove down, Freeman pricked his finger to get a blood sugar reading. While he was still wearing the continuous glucose monitor, the readings it takes are about ten minutes behind—which means that a blood test is the only way to get a current reading.

“So, I’m dropping quickly… I’m going to take some sugar before we start,” Freeman said, taking a swig of Gatorade. “As long as I don’t die in the [construction], this should be good.”

At the bottom, Freeman got out and skied another few kilometers before stepping off the road under some pine trees next to a stone wall. Caldwell pulled off behind him: This was the start. Freeman would ski four loops of about seven kilometers, and at the end of each lap, he would stop here to test blood sugar and lactate levels. He’d finish by hammering as hard as he could to the top of the steep section. “We’ll see if we can kill him,” Caldwell said.

Freeman began the effort unceremoniously—there were no starters, no motorbikers to lead him along, no teammates. Even at threshold, Freeman’s power was something to behold, propelling himself with huge, sharp double pole strokes up long climbs, with no fumbles or signs of fatigue. After 22 minutes, he made his way back to the stone wall where he started, and hopped off the road for a blood sugar and lactate test. He was breathing hard, but didn’t seem to be in a whole lot of pain.

“You’re looking great—that’s gotta be pretty fuckin’ hard,” Caldwell said.

“Let’s see what we’ve got,” Freeman said, looking at his watch. “Average heart rate 147, max 167. I backed off when I saw the 167.”

Freeman pricked his finger, squeezed out a drop of blood, and touched it to a strip of paper connected to his glucose monitor. A second drop of blood went into the lactate analyzer Caldwell was holding. It beeped.

“Did it get it?” Caldwell asked.

“I think so,” Freeman said. “134.”

That was well within the acceptable range for blood sugar for Freeman. “Sounds perfect,” Caldwell said. “Cool. On the road whenever you like.”

On his second lap, Freeman didn’t look like he had lost any of the pep that he had when he started. He was still eating his way up the climbs on the course, moving with a relentless intensity.

“It’s phenomenally impressive to watch him do one of these 30 k’s,” Caldwell said. “You’re just like, ‘we’ve been out here an hour and a quarter, and he’s still doing that.’”

After 47 minutes, Freeman had completed his second lap, and he turned off again at the stone wall to squeeze out another couple of drops of blood. After a quick switch to skate rollerskis to simulate the transition in the pursuit races run on the World Cup, Freeman continued on. His blood sugar was on target, at 116, and his lactate was still in the right range as well.

“So far, so good. We already know that if it comes to just supporting a threshold-type effort—something in the four to six millimole range, which is where he’s been every time we test him here—then he can be in the pack in a mass start 30 k….This has never been the issue,” Caldwell said. But, he added, Freeman has no chance of winning a race “unless he can lay out 15 minutes of astonishing work on top of this. And that’s just what we want to test.”

After a third lap of skiing at threshold, Freeman was still moving at the same impressive pace, but he returned to the stone wall looking a little more spent—he had been working for nearly an hour and ten minutes.

“Do you want me to jam it from here?” he asked Caldwell.

“Yeah—I want to see if there’s a spike,” Caldwell said.

Freeman headed off for his final lap, and the numbers came back: blood sugar at 116, lactate of 4.8. The blood sugar was still right where it should be, but the question was whether it would stay that way when Freeman really began digging deep. As Caldwell followed on the final lap, Freeman was starting to attack the uphills using an energy-intensive hop-skate technique.

“Look at him accelerate!” Caldwell said, pulling up alongside Freeman. “That looks fantastic, Kris! Really nice skiing!”

As he turned up the sideroad that he and Caldwell had scouted on the warm-up, Freeman was suffering, head down, burying himself. If he wanted to see a blood sugar spike, he was going to have to create it, pushing himself into that painful anaerobic zone, where his liver would release its stores of sugar. The first hour and 20 minutes of Freeman’s test were necessary, but the data wasn’t particularly useful—what he and Caldwell really wanted to know was what would happen over the last few kilometers.

The hill was a brutal grade, but Freeman was grinding his way up impressively—especially considering his pace for the past hour and a half. Finally, as he approached a steep righthand corner, he signaled to Caldwell: He was done, a few hundred meters short of the top.

Hanging from his pole straps, gasping, Freeman pricked his finger one last time and explained to Caldwell why he had stopped—he had already maxed himself out.

“I totally understand—the whole premise of this thing is the possibility of not making it to the finish,” Caldwell said. “This is not a race—this is an exercise in hurting yourself.”

“It went from being pretty darn fun to hurting real bad real quick,” Freeman said.

He touched his finger to the glucose monitor, and the drop of blood jumped to the strip of paper. He and Caldwell both gazed at it until the number flashed on the screen: 112. Right on the money.

“That was it, Zach—that was all I had,” Freeman said.

“That was all you had…There’s no spike. There’s no fuckin’ spike,” Caldwell said, sounding a little flummoxed. “That makes it easy…couldn’t have hoped for a better outcome.”

Freeman pulled his continuous monitor out of his pocket and looked at its screen, which showed a graph of his glucose levels for the hour prior. It was a straight, flat line, showing that his readings had barely budged over the past 60 minutes, despite sustaining a huge effort and power output.

“Absolutely dead-on perfect blood sugar for any time of day, let alone at the end of a maximal effort,” Caldwell said.

Freeman had given everything he had on the final climb, gone deep into the pain cave, but there had still been no spike in blood sugar—like he normally experienced when he put the hammer down in 15 k races. Caldwell wasn’t sure why, but he suspected it was because Freeman had already used up most of the sugar stored in his muscles.

“The only way I have to interpret this is that…when that signal comes for that sugar dump, there’s not much left to dump. That’s all I can come up with as an explanation,” Caldwell said. Besides, he added, “it doesn’t really matter whether I state that or not—we just operate off what we can measure.”

Before this season, the pair had always assumed that the spike would come if Freeman went hard enough, no matter how long he had been racing. But the fact that it hadn’t showed up was an unexpected boon, because dosing for a race where Freeman’s blood sugar levels were shooting up at the very end would have been challenging. If he only needed a high dose for the finish, when the pace got fierce, how would he administer it? Freeman and Caldwell had discussed programming the pump to send the insulin halfway through the race, or even having a coach run alongside him with a remote, to jack up the dose when things got wild. But with the insulin’s effects peaking 45 minutes later, such a strategy would have been difficult to coordinate.

With the 30 k dosing presenting such a challenge, Freeman said, a number of people had floated the idea that he should just drop the event entirely. But 30 k’s, he said, are “half the sport—and that’s not the way I want to do this sport.”

Given the indication that the sugar spike didn’t show up at the end of an extended effort, though, it meant that Freeman wouldn’t have to dose for it.

“Our expectation being wrong was obviously a good thing,” he said.

‘Something You’ve Got to Live With’

Freeman’s first 30 k of the year is this coming weekend, in La Clusaz, France. He’s obviously on track, after a series of top-15 results in the early season. But while the time trial in September answered a lot of the questions about 30 k dosing for Freeman and Caldwell, it didn’t answer all of them. Clearly, he wouldn’t need anywhere near the amount of insulin he had used last season: six units an hour in Rogla, and two in Anchorage and at the Olympics. The pair had began pondering the day of the test.

“It just leaves us in a little nervy situation, where it’s like, ‘well, do you actually race a World Cup with no insulin?” Caldwell said.

The answer is no—at least not this weekend. While rollerski time trials in New Hampshire in September are no big deal, Freeman gets nervous before World Cup races—causing him to secrete adrenaline, which in turn boosts his blood sugar. For La Clusaz, Freeman said that he would still have to use some insulin—just not very much. In an interview from Davos last weekend, where he was racing, he said that he’d be using between .3 and .5 units per hour.

From La Clusaz, Freeman will return to Davos for Christmas break, before tackling an entirely new challenge: the 2011 edition of the Tour de Ski, an eight-day stage race. Outside of the Olympics and World Championships, it’s the most prestigious event on the circuit, but to compete, Freeman said that he’ll have to be able to keep his health together. The 30 k in La Clusaz, he said, would tell him a lot about how he’ll hold up in the tour.

In an interview in November, before heading over to Europe for the season, Freeman said that he didn’t anticipate the same kind of complications from diabetes that he dealt with at the Olympics—but he also recognized that there’s no way of knowing if there are still holes in his knowledge.

“I don’t foresee a huge falling out like there was last season. But it could happen again, and it’s just something you’ve got to live with,” he said. “I haven’t been doing this for ten years by being scared to try.”