The Thrill of the Ride: Bike Racing with Diabetes
By Ezra Ward-Packard
Former Team Novo Nordisk cyclist Ezra Ward-Packard shares how he manages his diabetes while endurance training, everything he’s learned over the last 12 years, and his advice for aspiring endurance athletes.
Disclaimer: The training regimen and diet discussed in this article are specifically tailored for an elite professional athlete. Do not attempt this level of training or the specific diet recommendations without talking to your healthcare team.
My experience as an endurance athlete with type 1 diabetes has been remarkably varied and diverse. I’ve competed in close to 400 cycling races over 12 years, and the correlation is clear: careful diabetes management leads to better training and better race results. But a difficult diabetes day doesn’t necessarily mean a failed day on the bike.
As an endurance athlete with type 1 diabetes, every time I line up for the start of a race, I aim to limit the negative side effects that mismanagement of my glucose levels could potentially have on my athletic performance. Just as I spend months training my body, I also train my diabetes management so that I can perform at my highest possible level on race day.
I’ve finished bike races with blood glucose levels in the 50s and in the 300s. But in the world of competitive endurance athletics, marginal gains are often the difference between winning and losing, and that’s why diabetes management is a central part of my overall training program.
I was diagnosed with type 1 diabetes in 2005, at the age of 11. As a child, I was extremely active and involved in numerous sports, but at the time of my diagnosis, I lived and breathed soccer. When I wasn’t at an organized practice or game, you would find my older brother and me playing hours upon hours of pick-up soccer in our small backyard in Lake Geneva, Wisconsin. My first question after being diagnosed was whether I’d be able to continue playing soccer. When my mom reassured me that I could and everything seemed like it was going to be okay.
In 2008, my passion for endurance athletics began. Long-distance running allowed me to push my body and mind and endurance athletics became a central part of my life and diabetes management.
Managing my type 1 diabetes is something that has never come easy. Adolescence was an especially challenging time in my diabetes management. When I started to participate in endurance athletics, I quickly realized just how important diabetes management was in relation to performance. The better my blood sugars, the better I would perform during training and racing.
Cycling started as a way for me to cross train when I had a running injury, but soon cycling became a separate pursuit. Then I learned about Team Type 1 (now known as Team Novo Nordisk). I always dreamed of one day becoming a professional athlete, but when I was diagnosed with diabetes, I feared it would be impossible. Team Type 1 showed me that I could compete at the highest level, even with type 1 diabetes. In my first bike race I wore a Team Type 1 jersey that my mom had bought me. I finished 3rd place and was hooked.
A few years later, Team Novo Nordisk posted on its Facebook page that it was looking for up and coming cyclists with type 1 diabetes. I submitted a resume with my race results and what I thought was my best cycling action photo, and then carried on with my life, which at the time consisted of a lot of college applications. The day I received the offer is still one of the best and proudest days of my life.
During my three years with Team Novo Nordisk, I mainly competed in two types of races: fast, technical races around a short circuit, called criteriums, which last about 60 minutes, and longer road races that could last up to five hours, depending on the course. In order to be competitive both in criteriums and road races, the team’s training plan balanced short, intense efforts with longer days on the bike. A typical training week usually included two or three intense training days, two or three recovery days, and two days of racing on the weekend. These workouts included strength, speed, and endurance training.
The three years I spent racing with Team Novo Nordisk were memorable. I saw so much of the country and the world from the saddle of my bicycle, but those years were not without struggle. After three years of racing full-time, I was burnt out from the singular pursuit of athletic performance and desired a life with more variety.
So, from 2016 to 2020, I attended Carleton College in Northfield, Minn., where I served as a captain for the Carleton College Cycling Team, and worked as a bike mechanic at Northfield’s local bike shop. I rediscovered my love of racing in the rapidly expanding genres of gravel and bikepack racing (a form of ultra-off-road endurance racing where you are completely self-supported and often have to carry enough food and water to last for hundreds of miles).
Since graduating, bikepack racing has become my predominant focus. Living in a self-converted van in Flagstaff, Arizona, I now work as a full-time bike mechanic for the local REI. This past year has been one of my most successful competitive years on the bike. In May, I placed second at the 302-mile Pinyons and Pines Bikepacking Race, which started and ended in Flagstaff. Then, earlier this month, I won the 530-mile North to South Colorado Bikepacking Race running from Fort Collins to Alamosa.
Training and racing with type 1 diabetes isn’t easy, and it probably never will be. Just like with everyday diabetes management, it requires a lot of dedication, perseverance, and hard work. You're going to have good days and you're going to have bad days. Enjoy the good days, and don’t let the bad days get in the way.
I’m an extremely methodical and data-driven person, both in terms of my training and my diabetes management. I have multiple notebooks and too many Excel documents to count. Want to know how many miles I rode in August of 2015? Give me 30 seconds and I can tell you. (I rode 1,199.26 miles).
My training at the beginning of the season always consists of testing potential workouts. I’m at a point in my cycling career where I generally know what kind of training will best improve my performance, but I am constantly refining these sessions to maximize their effects while also working within other constraints in my life. For example, during my time on Team Novo Nordisk, 20-plus-hour weeks on the bike were standard. Now, working 40 hours a week as a bike mechanic, 20-hour training weeks on the bike only happen a few times throughout the year (and it usually means I have to take time off of work).
My body and my blood glucose levels respond very differently to different sessions or workouts during a season. When I’m riding, I hate stopping to test my blood sugar. I’m working with my new insurance company and medical care to secure a continuous glucose monitor (CGM), but at the moment I’m doing it the old-fashioned way with lancets, test strips, and a blood glucose meter.
During my initial workouts, I stop at the end of every interval to test my blood sugar. To measure consistently, I try to complete these workouts at the same time of day, after having eaten the same pre-workout meal, while consuming the same number of carbohydrates during my workout. I have found that these three factors (time of day, my pre-workout meal, and carbohydrate intake) have the greatest effect on my blood glucose while training.
When I’m completing my initial phase of intense blood glucose testing, I work out during the same time of the day, either before or after work. I prefer to do high intensity workouts after work since I’m usually exhausted and worthless for a few hours after these challenging workouts, and my boss doesn’t like it when I fall asleep while working on a customer's bike.
There are an unlimited number of potential pre-workout meals, but for me there is nothing better than sweet potatoes, eggs, spinach, a pinch of shredded cheese, and an aggressive amount of salsa. If I do have a bit more time before my workout, whole wheat pancakes with 100% real maple syrup are another go-to meal.
Both of these meals are very carbohydrate-centric and usually end up being a majority of my carbohydrate intake for the day. At this point, my body knows that if I am eating either of these meals, it’s time to get ready to put in the work.
My carbohydrate consumption on the bike also varies with the type of workout. During “endurance” rides (lasting longer than three hours), I aim to consume about 100 grams of carbohydrates each hour from a combination of solid foods (like bars, rice cakes, and mini sandwiches) and liquids (sports hydration mixtures and, yes, the occasional gas station Coca-Cola during those really long days on the bike).
Shorter rides are more intense, but I still aim to consume about 100 grams of carbohydrate per hour. Getting food down while exercising at higher intensities is harder. I use a lot more fast-acting and concentrated carbohydrates such as energy gels, energy blocks, and higher concentrations of sports hydration mixtures.
During recovery rides (shorter, low-intensity rides lasting less than two hours), I often don’t consume any carbohydrates, unless it’s extremely hot – in which case I’ll sip on a low-concentrated sports hydration drink.
By completing initial workout tests, you can create a set of guidelines for your diabetes management. Every person with diabetes who is on a basal-bolus insulin regimen has an insulin-to-carb ratio and a correction factor, but these equations aren’t always perfect. I know that when I’m going to be eating pizza, I’ll need to take more insulin. The same is true when training.
Short, intense intervals almost always cause my blood sugar to increase. This has been true ever since I was a high school long-distance runner. Longer, lower intensity efforts have the opposite effect on my blood sugar. On rides that last longer than three hours, I’m able to eat pretty much anything and stay in my desired glucose range.
I also experience a compounding effect. In college, I led summer bike touring trips for teenagers. In 2018 and 2019, I led “America Coast to Coast,” which ran about 2,700 miles from Charleston, S.C., to San Diego, Calif. At the end of this trip, after averaging 80 miles a day, my basal insulin would decrease by half of what I would take during the school year. The same is now true for me with bikepacking races.
This past spring, when I completed the Pinyons and Pines Bikepacking Race through the mountains of northern Arizona, I started the 302-mile race at 80% of my usual basal rate and ended up at half on the second day. In terms of bolus insulin, my insulin-to-carb ratio went from one unit to ten grams to one unit to about 15 grams. My blood sugars were remarkably consistent – until the second night of riding, when I started to hallucinate as a result of only napping for 10 minutes.
This was my first time pushing my body to this extreme level, and my intense focus on staying awake (and staying upright) meant I neglected to adequately test my blood sugar levels. After leading for the first 200 miles of the race, I ultimately finished in second place with a time of 48 hours, 25 minutes. The hallucinations continued on past the finish line, and only subsided after a long nap and a few thousand calories (which I dosed for using around 75% of my normal bolus ratio).
I always carry my testing supplies, insulin, and extra carbohydrates on bike rides. Over the past twelve years, I’ve developed a good sense of where my blood sugars are while cycling. Usually, if my legs feel good, my blood glucose levels are within my desired range.
If you are an inexperienced endurance athlete, developing this sense for your own blood glucose levels is key. Test your blood sugar before you train, start the training session, guess what your blood sugar is whenever you test during training, confirm with a quick blood glucose check, and see how accurate you are. This is a useful skill to have during crunch time in the middle of a race, but proceed with caution. If you feel like you need to test or check your CGM, always do so.
As you become stronger, more efficient, and capable of training harder for a longer period of time, your diabetes management is also going to change. I’m now confident in my abilities to make the necessary changes, but this is only after years of trial and error and working closely with my endocrinologist.
For years, racing was stressful for me, in large part due to managing my type 1 diabetes. I’d struggle to sleep the night before, fret over every single detail, and start every race with my heart pounding out of my chest. My approach now is much more controlled. I view racing as an opportunity to show off all the preparation and training I have completed. I’m always nervous to get started, but these nerves are now positive.
Your workouts should reflect what the race will be like. For my bikepacking races, the workout consisted of completing hard intervals at the start of my ride in order to fatigue my legs to simulate what it would feel like once I rode longer than six hours. Then, I would complete as many hours as I could at endurance pace. Bikepack racing isn’t just about riding your bike, it’s also about your ability to eat while riding for extended periods of time; so during these training rides I would also attempt to eat as many carbohydrates as I could (aiming for 100 grams per hour).
On race day, there are many factors that can come in the way of you achieving your goal. For athletes with diabetes, managing your diabetes is one of the toughest. Despite this, athletes with type 1 have completed and succeeded at the highest levels of athletics for years now.
In the North to South Colorado Bikepacking Race earlier this month, over the 76 hours, 530-mile journey from Fort Collins to Alamosa, I faced constant challenges, both diabetes-related and non-diabetes-related, including multiple broken spokes, dehydration, and extreme hyperglycemia. There was a time in my career where I would have called it quits. But over the past dozen years I have developed the skills and mindset to overcome such challenges, and in Colorado I won the race by a margin of more than five hours.
I’ve never let diabetes slow me down, and hope you won’t either.