From bicycle to Krebs' cycle

For many years professional cycling was dominated by France, Italy, Spain and the Low Countries. The three major cycling races of the year are the Tour de France, the Giro in Italy, and the Vuelta in Spain. Like the proverbial bus, you wait 100 years for a British winner of the Tour de France then two come along at once! Last year's winner was Sir Bradley Wiggins, a British cyclist born in Belgium. This year's worthy winner was Chris Froome, a British cyclist born in Kenya and brought up in South Africa. As a reflection of British success in the Tour, the first three stages of the Tour De France will be in Yorkshire in 2014. Once, French was the common language of the peloton, but now it is English. In recent years, an Australian won the Tour de France for the first time and a Canadian won the Giro for the first time. Lance Armstrong was a medical success story, whose achievements on a bike are now totally discredited because of the use of epo and blood doping, but his achievements in the Tour de France inspired a whole generation of young people in the US to take up competitive cycling, and another American winner of the Tour does not seem far away. In track cycling the last two Olympic Games have been dominated by Great Britain ahead of Australia, with the emergence of Sir Chris Hoy and Victoria Pendleton as role models for men and women. New indoor cycling facilities are being built throughout the UK. In Glasgow a new cycling stadium, named after Sir Chris Hoy, has been built for the 2014 Commonwealth Games. It opened last year and is already heavily subscribed by the local public. Successes in professional cycling on the road and on the track have inspired ordinary people to do more cycling. Cycles that have remained unused in attics and garages have been serviced, and new cycles purchased via the Cycle to Work scheme. The number of people commuting to work has increased substantially, especially in London where there has been increased provision for cyclists. Entries to amateur competitive events have increased, and new cycling clubs have emerged all over the UK. Perhaps the most visible manifestation of the increased interest in cycling has been in ‘sportives’ in the UK. These are mass events ranging from a few hundred to many thousand cyclists. They have a defined route ranging from 10 to 100 miles, most are timed, and some are on roads that are closed to motor traffic. Several have a direct association with fund raising for charity. The most established in the UK is the Etape Caledonia in Perthshire over an 85-mile circuit. It has over 3000 entrants, and raises money for the Marie Curie cancer charity. The Prudential Ride London was run for the first time in August and included 20 000 cyclists over the 100-mile route of the 2012 Olympics road race, and dedicated places were given for people who were raising money for Diabetes UK. So, apart from raising some money for Diabetes UK in large, charity cycles, is there any other way we can harness this enthusiasm for cycling to the benefit of people with diabetes? In this themed issue of Practical Diabetes we hope to persuade you that cycling may be of benefit to the whole population and to individuals with diabetes. At a population level there are obvious benefits to be gained from cycling. As already mentioned, a culture of cycling is already part of life in France, Italy and Spain. Most people in these countries own a cycle and use it for commuting or recreation. Governments in Denmark, Germany and the Netherlands have all positively promoted the expansion of cycling as a mode of transport, including dedicated cycling lanes and tracks, and the provision of places to store cycles at places of work and transport hubs. Cycling has increased in these countries, and this has helped to stem the tide of obesity that has ravaged other parts of Europe (it has also seen successes in professional cycling for cyclists from these nations). Ideas about how cycling might be a possible solution for the increasing burden of type 2 diabetes are discussed by Sarah Wild and colleagues from the Centre for Population Health Sciences in Edinburgh.1 The majority of readers of Practical Diabetes are health care professionals caring for individual people with diabetes. Dietitians are an integral part of the diabetes team, but there is no one member of the diabetes team that advises people with diabetes how to increase their amount of physical activity. Alison Kirk and Freya MacMillan from the University of Strathclyde describe ways of increasing participation in physical activity and exercise for people with type 1 and type 2 diabetes, with a particular focus on increasing participation in cycling.2 Ian Gallen is well known as a regular contributor to Practical Diabetes and is an expert on exercise and sport in type 1 diabetes. He provides an overview of the benefits and challenges posed by cycling in people with type 1 diabetes.3 There are perhaps no greater challenges than those faced by professional cyclists, and it may come as a surprise to some readers to learn that there is a team comprised entirely of professional cyclists with type 1 diabetes. I was inspired by speaking to Phil Southerland, who established the professional team several years ago, and I am particularly grateful to Dr Rafael Castol, Medical Director of Team Novo Nordisk, who has provided detailed and specific information about what adjustments cyclists with diabetes have to do to compete in professional racing.4 I am also grateful to Kyle Rose who has provided a fascinating personal account of what it means to be a professional cyclist with type 1 diabetes.5 There are an estimated 7 000 000 000 (7.0 billion) people worldwide, 1.0 billion people own a bike and 100 000 000 (100 million) new bikes are produced every year, equating to four bikes every second. This compares with 366 million people who are estimated to have diabetes. By 2030, the world population is estimated at 8.3 billion, with an estimated 552 million people with diabetes. Most worrying is the projected increase in diabetes in China and India, and by 2030 there will be a projected 130 million people in China and 101 million people in India with diabetes. A visitor to these rapidly developing countries can observe that, while in the past the bicycle was the major, if only, form of transport for the majority of the population, the roads are now clogged with motor vehicles. As the middle class increases its income and the purchase of expensive cars, cycling is now associated with lower economic status. Continued use of cycles in these countries could easily contribute to slowing down the epidemic of diabetes, as well as having obvious benefits for the environment (the Olympic Games road race in Beijing and the Commonwealth Games road race in Delhi had to be staged at unusual times to avoid the smog!). In Africa, much diabetes is undiagnosed. Current estimates are of 14 million people with diabetes doubling to 28 million by 2030. In his speech from the podium at the end of the Tour de France, Chris Froome expressed his hope that he could act as a role model to inspire young Africans to take up cycling. I hope this themed issue of Practical Diabetes will inspire you to recommend increased physical activity, possibly cycling, to your patients with diabetes. Thanks to Professor Ian Campbell for suggesting the title of this article. Professor Miles Fisher is a member of the Glasgow Ivy Cycling Club.

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