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For those on the front lines of Covid-19, life in recent weeks has inevitably been put into overdrive in the worst possible way. For others, the pandemic has forced many of us to slow down and assess the state of work, life, and play. The “stick to sports” media doesn’t really know what to do with itself right now because 99% of the stories that it tells revolve around the play itself. One of my PhD supervisor’s favourite quotes is from C.L.R. James’ Beyond a Boundary: “What do they know of cricket who only cricket know?” That is to say, if all you know is sports, you should probably dig yourself a deeper well from which to draw knowledge. Thus, this moment has presented us with an opportunity to get to know the players away from their athletic achievements and to the tell stories that we supposedly “do not have time for” under non-pandemic circumstances. Sport always has stories to tell but we are often too busy to listen. So, I’m turning the keyboard over to Anissa Gamble to talk about an issue that is near and dear to her heart: Type 1 diabetes. Gamble is a member of the PWHPA, a former member of the Toronto Furies, and a proud Maritimer. Before the global pandemic hit, she was supposed to go to Japan with other PWHPA players in early March for a three-game series against the Japanese National women’s team. She is also a dad joke aficionado. Gamble loves dad jokes so much that has a thread of “Dad Jokes” on her Instagram. And, she likes to end her Instagram videos by head butting the camera. Without further ado, I give you Anissa Gamble.

Give us an overview of your hockey career and what you’re up to now.

I grew up in New Brunswick in a neighborhood full of guys and by nature I started playing hockey because they were too. As I got older playing AAA hockey with body contact, the boys were getting much bigger and it necessitated me to make a big decision to move to girl’s hockey. At that time, there wasn’t a Maritime elite female hockey league so I left home at the age of 15 to go to Appleby College in Ontario. During this time, I also played in the PWHL for the Oakville Hornets and Burlington Barracudas. After, I played NCAA Division 1 at Robert Morris University while completing my Bachelors of Science. Upon graduation, I took a year off of hockey to start my Master of Science in experimental surgery at the University of Alberta in Edmonton, Alberta. After missing competitive hockey, I entered the CWHL draft and was an active roster member of the Calgary Inferno and traveled to China with the team. Afterwards, I moved back to Toronto and played a year for the Toronto Furies before the CWHL shut down. Today, I have the privilege to play in the PWHPA and hope to continue this endeavor.

Explain to readers what Type 1 diabetes is and how it affects you as an athlete.

Type 1 diabetes (T1D) is an autoimmune disorder that affects specific cells within your pancreas to not produce enough insulin. Insulin is a hormone that’s important because it can be portrayed as the key that opens the door to let energy (glucose) to enter parts of the body to be utilized.

For people living with T1D their body can’t produce enough insulin and therefore can’t open the door to let glucose in. This results in excess sugar circulating in the body and causes a term called hyperglycemia (high blood sugar). This is really bad because it impacts your entire body – it’s the leading cause of adult blindness, kidney failure, and possible limb amputation- and without treatment will result in death due to diabetic ketoacidosis (DKA). On the contrary, administrating too much insulin can cause a state called hypoglycemia (low blood sugar) and without treatment of glucose or glucagon can result in death.

To survive, people with T1D like me have to closely monitor our blood sugar levels and closely administer insulin. To do this, there’s a lot of ways you can manage your T1D, like multiple daily injections (I used to use 8-12 needles a day as a kid), or an insulin pump- which is a device you wear that infuses insulin into you 24/7 that you change via a needle like site every 3 days (what I use). To monitor your blood sugars, you can prick your finger to draw blood and check with a glucometer (about 6-12 times a day), or use a continuous glucose monitor (CGM) which is an electronic device that you wear for a period that gives you glucose readings every 5 minutes (I use a Dexcom G6).

To make T1D more complicated, your health is affected by more than blood sugar readings and insulin injections, but is a multidimensional decision-making process that involves up to 42 factors that can influence what your blood glucose levels are. Being an athlete, it presents its’ own unique challenges. For me, the type of physical activity affects me differently. For example, weight lifting increases my BG, conditioning lowers BG, HITT training increases then decreases, and intense games will decease then increase and decrease a few hours later. It’s a complicated ordeal that also takes into account what type of foods I ate, my stress levels, amount of sleep, hormone fluctuations, etc. It’s a dynamic and agile decision process that I go through every day. Throughout my career, I’ve yet to master managing my diabetes as an athlete as I still go low and high. You may see me grab a juice box or leave practice/ training due to my sugars, but it’s an ongoing journey and it’s independent of my work ethic and passion that my teammate next to me also builds and trains.

Are there common myths/assumptions about T1D that need to be debunked/challenged?

There’s a lot of misconceptions that I hope people will learn and apply. The first being how different physiology and management styles of type 1 and type 2 diabetes. Both types are challenging, but some key differences that I hope people will understand:

1.  T1D is due to autoimmune-related events. It is not caused by diet or lifestyle choices – aka too much sugar or a sedentary lifestyle, with which T2D prognoses are often associated.
2. You are not necessarily born with T1D. In fact, there’s more evidence that shows T2D to have a higher genetic prevalence than T1D. Also, anyone at any age (not just children) can be diagnosed with T1D!
3. Managing T1D can be much more rigorous and tedious than T2D. As a person living with T1D, you are making over 600 diabetes decisions a day and all of these decisions can have serious consequences.
4. There’s a lot of psychological aspects of living with T1D or any chronic disorder. For T1D, diabetes distress refers to an emotional state where people experience feelings such as stress, guilt, or denial that arise from living with diabetes and the burden of self-management. Factors like relationships, financial burden, glycemic control, social stigma, etc. can affect their diabetes, and sometimes questions or actions people may not realize can affect people living with T1D.

You’ve mentioned on your Instagram that your insulin pump and CGM (what does this refer to?) are considered luxuries under Canadian health care. Explain this ridiculous logic to us.

Managing T1D is expensive! I mentioned above how’s there are different ways to manage your T1D. For me, I use an insulin pump and a Dexcom CGM system that can cost up to $15,000 per year that’s out of pocket. Luckily, I’m living in Ontario, which has an assistant device program that helps with insulin pump coverage, but it doesn’t cover everything and not every province has this. I’ll continue my rant in the question below regarding insulin inflation, but it’s a very expensive disease and minimal essentials are covered by government or insurance. Check out this link on an estimate on how much per year T1D could cost someone out of pocket (Ontario based atm https://www.connectedinmotion.ca/ontario-diabetes-cost-calculator/ )

What accounts for the rise in insulin prices that you also noted in your Instagram post?

The inflation of insulin prices is American specific! Like other medications, the American healthcare system has the ability to change medication prices. For insulin, there has been a significant increase in its price within the past few years! The 1920’s drug patent (proudly discovered in Canada) was sold for $1 to ensure everyone would have access to this life saving medication. Over time, three main pharmaceutical companies monopolized the market — Eli Lilly, Novo Nordisk, and Sanofi dominate the insulin market and simultaneously increased American prices. So much so, that since the 1990s, the cost of insulin has increased over 1,200%. Specifically, from 2001 to 2015 the price of Humalog insulin increased 585%! Luckily in Canada, there’s regulation to price cap medications like insulin, where I can buy a vial for approximately $40 that will last me roughly two weeks; however, I will emphasize insulin is not covered by Canadian healthcare! When I posted that Instagram post playing in the CWHL, I was being extremely careful as I didn’t have insurance and was asking people in my diabetes community for insulin because I couldn’t afford it. It’s a crazy reality issue.

For more information check out T1International https://www.t1international.com/usainsulin4allaction/ or this article https://www.vox.com/2019/4/3/18293950/why-is-insulin-so-expensive

What should coaches, parents, and players know about supporting athletes competing with T1D?

I hope coaches, players, parents do not treat or view a person living with T1D differently. A player is an athlete despite their diabetes or any life factor that may present. People living with T1D may need some extra help, time, or resources, but they are still human and their level of competition or passion is no different than the athlete beside them.

If you as a player, coach, or parent feel uncomfortable, I encourage you to do some research to educate yourself and ask A LOT of questions. As emphasized, T1D is complicated and is a teamwork effort. Communication, education, understanding, and teamwork is so important for not just someone’s diabetes but life.

What is Connected in Motion and how are you involved?

Connected in Motion (CIM) is a not-for-profit organization that encourages peer-based education through experimental learning. CIM does a variety of events from multiday adventure hikes, weekend canoe trips, weekend camps, to social gatherings. Regardless of the activity, the focus is on connecting people with diabetes and allowing a safe space to share diabetes management and experiences. I’ve been involved with CIM for a few years, first as a fundraiser hiking the North Coast Trail with other T1D’s, as a wilderness guide for canoe and hiking trips, and as a volunteer for slipstream weekends doing whatever I can to help. It’s a great organization and I strongly recommend it for all people living with diabetes to seek programs like CIM, DSkate, IChallenge Diabetes, Diabetes Canada Camps to connect with others.

How does Covid-19 further complicate life for someone with T1D?

Living with T1D may increase your risk of infection and will increase your severity. There are several reasons for this: 1) hyperglycemic states (high blood sugars) can increase viral replication (more glucose in your system), so it’s important to maintain good glucose control. However, infections – like Covid-19 – will initiate your immune response that decreases insulin sensitivity, increasing blood glucose levels. Additionally, T1D is an autoimmune disease, so you have a weaker immune system than a normal person. For me, I have four auto-immune disorders so this significantly impacts my health if I contract Covid-19. Overall, don’t get Covid-19 if you have diabetes, and if you do keep a close eye on your levels (increased levels can attribute to infection) and get medical help if it worsens.

Is there anything else you would like add/talk about?

I don’t believe diabetes defines anyone, but it certainly impacts who they are what they do. As continue to learn and grow, I view T1D as positive adjective as it forces you to become independent and value the meaning of life. If you know someone who lives with T1D, give them a pat on the back and thumbs up.