It was September 2010, and Casey Terrell had just moved from Pinedale, Wyoming, to work toward an associate degree in music at Western Wyoming Community College in Rock Springs. That’s when he noticed being abnormally thirsty and that, despite being hungry, not being able to eat more than a couple of bites at a time.

On the bright side, the 5-foot-10 trombonist was losing weight, something the erstwhile 270-pounder welcomed. But then one night, his body seemed to go into a revolt of pain and vomiting. His roommate drove Terrell to the hospital.

Morphine didn’t help, and tests were inconclusive until the one that sampled his blood sugar. That one came back “off the charts,” as Terrell put it.

Terrell, then 18, had joined the roughly 1.3 million people in the United States with Type 1 diabetes, an autoimmune disease in which the body’s own immune defenses attack the pancreas cells that produce insulin. Insulin ushers the glucose in our blood – sugar derived from the carbohydrates we eat – into our cells where it’s converted into the fuel that keeps us going. (Type 2 diabetes, in contrast, typically comes from some combination of the body not responding as well to the insulin being produced and the pancreas not being able to produce enough insulin for the body’s needs. It’s much more prevalent, with about 31 million U.S. cases.)

A visit to UCHealth and University of Colorado School of Medicine endocrinologist and diabetes specialist Dr. Cecilia Low Wang would set him on the right path. But that visit wouldn’t happen for another eight years.

Type 1 diabetes also called ‘juvenile diabetes’

Type 1 diabetes may also go by “juvenile diabetes,” but it can strike in early adulthood and much later. At any age, it thrusts the patient into a life in which everything they eat and everything they do can upset a delicate blood-sugar balance most of us blithely enjoy. If the scale tips too far, for too long – particularly in the direction of high blood sugar – Type 1 diabetics risk consequences including cardiovascular disease, nerve damage, kidney damage, eye damage, and foot damage, not to mention just feeling lousy.

A few visits to a primary care doctor taught Terrell that, as Low Wang would later put it, “People with Type 1 diabetes should have specialist care.” He found an endocrinologist in Salt Lake City, a nearly three-hour drive from Rock Springs. He learned to sample the blood from his fingertip and to adjust his insulin intake.     He watched what he ate, but he wasn’t perfect. He threw himself into his studies, joined the forensics team, and became student-body president. His student life seemed a paragon of control. All the while, his lack of understanding regarding his diabetes resulted in high blood-sugars and piling on pounds, to the point, as he put it, “I was afraid of the scale.”

Terrell earned his associate degree and, in part thanks to the forensics team, decided to hang up his trombone and go into law. He moved to Laramie, and got his bachelor’s degree in political science at the University of Wyoming. Three years after leaving Rock Springs, he enrolled in law school at Wyoming.

Law school and Type 1 diabetes proved to be a rough mix.

“Diabetes is a bear for a thousand reasons,” Terrell said. “You could fill a novel with all the things that impact your blood sugar. But chief among them are stress, sleep habits, and hormones – all are intertwined with the misery that comes out of law school.”

He excelled academically despite the misery, but the misery got to him, too: in particular, the mental challenges facing diabetics, who can feel judged (“You’re diabetic – should you be eating that?”) and lonely amid day-to-day uncertainties and the prospects of potential long-term bad outcomes the condition threatens. Despite being in his early 20s, his state of mind grew fatalistic. He came to liken his body, now about 310 pounds of it, to a car tire.

“I’m going to take it as many miles as it’ll go, but eventually, the treads are going to wear out, and that’ll be the end of it,” he said. “Diabetes is in your face every day. If it’s going badly, it does not feel that far off to be, like, ‘I’m not here for long.’”

A different automotive analogy applied to the mental-health aspects of diabetes care.

“A lot of times we focus on the car without thinking about the driver,” Terrell said. “You can treat the diabetes, but if you don’t acknowledge the things going on in the human that has it, it’s just destined to crash.”

A new perspective on how to control his Type 1 diabetes      

A young woman named Callie, a fellow student at Wyoming, helped steer him back onto the road to a healthy place. Before long they were dating seriously and starting to think long-term. Callie’s mom, recognizing the inadequacy of Terrell’s care in Wyoming, came upon UCHealth’s Low Wang. In spring 2018, Terrell drove the two-and-a-half hours from Laramie to UCHealth University of Colorado Hospital on the Anschutz Medical Campus during his last semester of law school for his first appointment with Low Wang.

He had been through enough doctors to be skeptical.

“Alright,” Low Wang said. “Let’s start from the beginning.”

He did, and for more than two hours, he told the story that started in that dorm room in Rock Springs. He walked out knowing he had found the right physician.

That doesn’t mean Low Wang or any other specialist treating Type 1 diabetes could offer some magic pill so he might live happily ever after. Treating Type 1 diabetes is a process Low Wang describes as “a kind of lifelong learning.” But she did have tools at her disposal, and Terrell would benefit.

One of those tools was a hybrid closed-loop system combining a Dexcom G6 continuous glucose monitor (GCM) with a Tandem t:slim X2 insulin pump. That combination can detect changes in blood sugar and then automatically adjust insulin delivery based on those changes.

Other tools had nothing to do with technology. Low Wang referred Terrell to dietitians and diabetes educators, ophthalmologists and foot specialists. While Low Wang couldn’t do much to lessen the stress and schedule of law school, the steps she and the UCHealth team suggested, combined with Terrell’s own efforts, brought his blood sugar under control. He graduated, took a job with a law firm in Sheridan, Wyoming, and married Callie at home plate at Coors Field in September 2019 weighing about 255.

On the run: Exercise can be complicated when controlling Type 1 diabetes

While his work schedule remains demanding, it’s not law school. By late 2019, he had started on regular gym workouts under Low Wang’s guidance – now typically remote given the 430-mile driving distance from Sheridan to Aurora.

Even exercise can be complicated for people with Type 1 diabetes, she says. Aerobic and endurance exercise can drop blood sugar and keep it dampened for 18 to 24 hours. In contrast, the adrenaline and cortisol released during strength training can actually increase blood sugars, she says.

Terrell gravitated toward running, starting with a 5-kilometer race in early 2019 and a mini-duathlon that July – both of which Callie trained for with him.

“When I crossed the finish line, I’m hyperventilating because I’m crying,” Terrell said. “I still cry when I finish races sometimes. I think it comes down to thinking I never would do that. I can’t explain the impact of resigning yourself to a future and then proving yourself wrong.”

Those other races included an informal running of the Bighorn Trail Run’s 18-miler in June 2020 (the actual race was cancelled due to COVID-19) and, this past June, the Bighorn’s 32-miler. Before that one, he checked in with Low Wang.

She talked him through the dangers of low blood sugar, the importance of hydration and steady carbohydrate intake, and how to handle the settings of the hybrid closed-loop system, among other things. Then she said, “Best of luck. We believe in you.”

That belief proved well-founded. Twelve hours after he started, Terrell crossed the finish line with tears in his eyes after completing his first ultramarathon.

“I can’t accurately express the value, when you have an illness like this, of somebody caring for you, or feeling like you’re being cared for,” he said. “Because otherwise, it can be such a heavy lift.”

He has raced again since, and will continue to. He’ll also tend to the big garden he and Callie planted, go fly fishing and hunting, and, come winter, continue with a new hobby of skiing. While his story alone serves as an example of how a person with Type 1 diabetes can, with the right team, take control again, he does have advice for those who are embarking down the path toward living life while managing Type 1 diabetes.

“It’s not like a puzzle that you solve. It’s a journey, but you being an active participant in caring about yourself in that process is critical,” Terrell said. “And you’re worth it. So do it.”