By Stanley Kay
January 20, 2014

Kris Freeman was approaching the 12th kilometer of the 30 km pursuit at the 2010 Vancouver Olympics when he noticed the first sign: An uphill climb seemed strangely difficult. He had been skiing well to that point, and had moved into a top 20 position. Then his body started shaking and wobbling. Freeman knew that roughly a kilometer ahead he had a coach waiting for him with a sports drink. But before he could make it, he collapsed in the snow.

Freeman, an American cross-country skier, was experiencing hypoglycemia, otherwise known as low blood sugar, a condition to which he is susceptible because he is a Type 1 diabetic, a rarity among professional and Olympic athletes.

After collapsing, Freeman received aid from the crowd, managing to acquire a sports drink and a GU packet from a spectator and finish the race. But the delay was costly: He fell far behind the pack and finished 45th. At the next race, the 50 km, Freeman did not finish. His Olympics ended in utter disappointment.

"I hadn't been able to do what I came to do at the Olympics, and that wasn't easy," Freeman said. "I try not to get mad at myself for making mistakes with diabetes because it is really difficult. It took me six weeks to accept what happened and feel better."

Following the Games, he had one of his best seasons ever. In the 2010-11 World Cup standings, Freeman bested Johan Olsson, a four-time Olympic medalist including a bronze from the race in which Freeman collapsed. Freeman decided then that he was going to try to compete in 2014, even though he would be 33 at the time.

[UPDATE Jan. 22, 3:45 p.m.: Four years after a difficult Olympics in Vancouver, Freeman has officially been nominated to represent Team USA in Sochi. The 2014 Games will be Freeman's fourth Olympics.]

The journey to Sochi, and all of Freeman's past Olympics, hasn't been easy. A native of rural New Hampshire, Freeman was a teenage skiing prodigy. But that all seemed lost in August 2000, as he was training with the U.S. Ski Team in Park City, Utah, for the 2002 Olympics.

Around the time he arrived in Park City, he started noticing some unusual symptoms in his body, such as blurry vision and the need to urinate often. What he originally rationalized as effects of the altitude were actually classic traits of undiagnosed diabetes. At a regular team-conducted blood screening, he notched a blood sugar reading of 240 milligrams per deciliter. Freeman, then 19, was diagnosed with Type 1 diabetes.

At the time, Freeman had no idea what the number 240 meant. He didn't really know anything about diabetes and what it entailed. He didn't know a normal blood sugar level -- 70 to 100 milligrams per deciliter -- from an abnormal level. He didn't know about the long-term dangers of hyperglycemia (high blood sugar), which can include vision loss and potentially amputation; hypoglycemia was also a foreign concept. He didn't know much about insulin -- which diabetics have to take -- and how diabetes occurs when the pancreas stops producing insulin, which carries glucose to blood cells. What Freeman knew at the time was that doctors were telling him his skiing career was over.

Freeman's dreams had seemingly come crashing down. The afternoon after his diagnosis, he participated in a kayaking workout with the ski team. While his teammates were joking around and splashing one another, Freeman was in tears. "I was terrified," he recalled. "I didn't know anything about the disease."

He immediately started taking insulin and testing his blood sugar. He knew that he had to alter his lifestyle but refused to believe his career was over. Freeman read everything he could about diabetes in his spare time, setting out to tame the disease similar to the way he dominated mountains. He gained control over his body and lifestyle, adhering to a strict diet and carefully managing his health. Even though there was no track record to follow in terms of diabetes management for workouts and endurance competitions, he was determined to continue his career.

Roughly 13 years as a professional and soon-to-be four Olympics later, Freeman has silenced questions about whether a diabetic can compete at such a high level in an grueling endurance sport like cross-country skiing.

Managing blood sugar levels is a difficult but necessary task for any Type 1 diabetic. Maintaining stable blood sugars that ideally hover somewhere between 70 and 120 is integral to long-term health and short-term safety. A reading under 70 is considered low, while high blood sugar includes a much larger range, starting at around 180 and continuing upward. Regulating blood sugar requires carbohydrate counting and insulin dosage based on how the body responds to those carbohydrates.

For Freeman, diabetes management involves determining how his body responds to the high-intensity physical strain placed upon it by cross-country skiing. "Learning how the body reacts to different situations has been the biggest challenge for me," Freeman said. "And I'm still learning it."

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His race routine in terms of diabetes management is rather complex and depends on the type of race, including its distance and importance. (He has learned that nervousness before a big race, such as the Olympics, raises his blood sugar.) For a 15 km race at the Olympics, for example, he tests his blood sugar immediately after waking up and eats a meal three hours before the start of the race. He tries to eat the same breakfast at least three days in advance of an event, so that he has an idea of how much insulin to take -- particularly because he races all over the world and might not be familiar with all culinary traditions. After breakfast, he tests his blood sugar three or four times before warming up at the race venue approximately two hours before the start time. Using his continuous glucose monitor -- a device that gives real-time updates of blood sugar levels -- Freeman studies his blood sugar trends. If he is trending high, he takes small doses of insulin to get his blood sugar down; if he's trending a bit low, he'll consume energy drinks to raise his blood sugar.

An hour and a half prior to the start, he increases his basal rate, which is the amount of insulin his insulin pump gives him each hour, by 20 percent. He also tests his blood sugar several times, including one final time as little as five minutes before the start of a race. On a standard race day, Freeman tests his blood sugar no less than 20 times, a number far greater than required of the average diabetic. Ten minutes before he explodes off the line, Freeman gives himself a one-unit dose of insulin to help mitigate the effect of the initial adrenaline surge. His goal is to start the race with a blood sugar level around 140.

All of this analysis and preparation is necessary because intense exercise poses major challenges to diabetes management. Aerobic exercise lowers the blood sugar, but adrenaline raises it. Freeman adjusts his pre-race insulin dose regularly in an effort to strike a balance between the dual dangers of low and high blood sugar. When his blood sugar isn't cooperative, his performance suffers.

"If my blood sugar isn't in the right range, I'm not going to perform at a world-class level," he said. "I can feel the difference of racing at 250 and 140. That's a clear message to me that my body is not designed to function with a blood sugar that high."

Before the 30 km race at the Vancouver Olympics, Freeman, like most athletes competing on the world's biggest stage, was nervous. He had years of experience and practice as a diabetic skier and had competed in the Olympics on multiple occasions in the past. But his nerves that day caused his blood sugar to rise, which led Freeman to respond with an insulin dose to lower it, taking into account the adrenaline he would experience at the start of the race. But as Freeman started the race and the nerves subsided, the insulin overwhelmed his body, causing his blood sugar to drop too low.

Four years later, Freeman continues to adjust his diabetes management in a quest to master his body and avoid the diabetes-induced disappointment of 2010. The difficulty is that regulating blood sugar is a bit like trying to kick a football through moving goalposts; the body constantly evolves, as do external circumstances, such as food differences around the world and varying air pressures. What works one day might generate poor results due to different conditions on another day.

Freeman's coach, Zach Caldwell, has been involved in his skiing career since the Olympian was a teenager. In his many years watching Freeman, Caldwell -- who also coaches Noah Hoffman, currently the top-ranked American distance skier -- has become a sort of human glucose monitor for Freeman. Caldwell sounds more like a doctor than a ski coach at times. He has a keen eye for recognizing when Freeman's blood sugar might be too high or too low, and he can rattle off medical terms like an endocrinologist, a doctor who treats diabetic patients. Freeman trusts his judgment deeply. One tremendous challenge for his pupil, Caldwell said, is that Freeman wants to be viewed as a normal skier and not a diabetic skier. Yet he has to prepare intently with diabetes in mind.

"Sometimes if he has a bad race, I feel it should be about the blood sugar, and he doesn't," Caldwell says. "The last thing he wants is to be defined by diabetes."

Freeman has taken several measures to master his blood sugar control ahead of the 2014 Olympics. He started using the continuous glucose monitor. He tested himself more often on the treadmill to fine-tune his insulin doses, trying to understand the patterns of his blood sugar and how his body responds to certain strains. Freeman has also placed greater emphasis on remaining calm before a race; to combat nerves and thus reduce the frequency of pre-race high blood sugar levels, he has experimented with yoga and meditation.

At age 33, Freeman's hopes of medaling in Sochi are slim. But the ability to represent the United States as well as the diabetic community in the Olympics for the fourth time is a testament to the diligence and intensity that has characterized his training and diabetes management since his diagnosis and particularly in the last four years.

Caldwell said Freeman was initially concerned that he had failed the entire diabetes community after his low blood sugar episode in Vancouver. "For him to fail so abjectly to manage the sugar in the target event of his career was devastating for him," Caldwell recalled. "But it really humanized the struggle. It took him from being an untouchable Olympian to being extremely human."

Though Freeman will likely never see an Olympic podium, his career, which includes 16 U.S. titles, still makes a strong statement about the possibilities of a diabetic athlete. He demonstrates that it's possible to excel athletically at the highest level while also maintaining good blood sugar control, the latter of which is important not just for Freeman's skiing career but also for his long-term health.

"I don't want anyone with diabetes to feel like it's a limitation and that you have to set your sights lower," Freeman said. "It certainly makes some things more difficult, but I don't believe the disease has to stop anyone from reaching their dreams."

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