Managing Diabetes in the Athletic Population

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1 Managing Diabetes in the Athletic Population Michael Prybicien, LA, ATC, CSCS, CES, PES Athletic Trainer, Passaic High School Overlook Medical Center & Adjunct Faculty, William Paterson University

2 Dedicated To Aiden

3 Course Objectives Identify the difference between type 1 and type 2 diabetes Identify the signs and symptoms of a diabetic emergency Recognize and properly treat a diabetic emergency Identify the importance of developing a written diabetic care plan specifically to each diabetic athlete Explain the importance of educating the athlete about his/her specific diabetic condition

4

5 25.8 million children and adults in US (8.3% of population) have diabetes 79 million people are pre-diabetes Pediatric (0-20 years of age) 1 in every 300 children /adolescents have diabetes

6 Diabetes What is it? Occurs when the body can't use glucose (a type of sugar) normally. The levels of glucose in the blood are controlled by a hormone called insulin, which is made by the pancreas. Insulin helps glucose enter the cells.

7 The Diabetic Athlete One Story

8 Type 1 Diabetes AKA Childhood, Adolescent or Juvenille In diabetes, the pancreas does not make enough insulin (type 1 diabetes)

9 Type 1 Diabetes Mean age 8-12 Autoimmune disease Unknown trigger causes alteration in immune response. The immune system attacks the insulin producing beta cells in the pancreas

10 Type 2 AKA Adult-Onset Diabetes The body can't respond normally to the insulin that is made (type 2 diabetes).

11 Risk for Type 2 Diabetes Genetic and environmental factors are strongly implicated in the development of type 2 diabetes Risk increases with: Age Obesity Physical inactivity

12 Onset of Type 2 Diabetes No noticeable symptoms during early stages. Subtle symptoms that may arise include: Feeling of fatigue Dry, itchy skin Tingling or numbness in hands and/or feet Blurred vision Increased hunger and/or thirst Increased urination Problems with sexual function More frequent infections Slow healing wounds

13 Treatment of Type 2 Diabetes The goal of treatment in type 2 diabetes is to achieve and maintain optimal: Blood glucose Lipid Blood pressure

14 Treatment of Type 2 Diabetes Blood glucose control can be obtained by following: Nutritious meal plan Exercise program Losing excess weight Implementing necessary self-care behaviors Taking oral medications or supplemental insulin

15 Exercise with Type 2 Diabetes Exercise is recommended for diabetes management 150 minutes/week of moderate to vigorous aerobic exercise At least 3 days during the week No more than 2 consecutive days Resistance training, At least 2-3 days/week

16 Exercise with Type 2 Diabetes Do NOT need to postpone exercise because of hyperglycemia Provided that they are feeling well Adequately hydrated Patients with type 2 diabetes not using insulin are unlikely to experience hypoglycemia related to physical activity Users of insulin are advised to supplement with carbohydrate to prevent hypoglycemia during and after exercise

17 Diabetes Type 1 Type 2 Diagnosis Mechanism Complications Demographics Typically diagnosed in early childhood, adolescence or early adulthood. 5-10% of cases Insulin Deficiency Hyperglycemia, weight loss, DKA Younger more fit population Usually diagnosed in adulthood but this is changing % of cases Decreased Insulin utilization Obesity, hypertension, hyperlipidemai More common in older, overweight individuals. Rare in competitive athletes.

18 Diagnosing Diabetes Mellitus Blood sugar testing Pre-participation Examination Knowing the Signs and Symptoms

19 Diagnosing Diabetes Mellitus Hemoglobin A1C (test that looks at BS over last 3 months)

20 Pre-Participation Exam Athlete s endocrinologist or primary care physician should provide an assessment of the current level of glycemic control Assess overall long-term glycemic control Annual examinations and screenings Exercise limitations or restrictions for athletes with diabetes-related complications should be determined by the athlete s physician

21 Signs & Symptoms Indicators of T1DM Frequent urination Thirst Hunger Weight loss Visual disturbances Fatigue w/ Ketosis Rapid breathing Fruity odor to the breath Inattentiveness / cognitive issues Loss of appetite / stomach irritation

22 Hyperglycemia - Guidelines Blood Glucose Levels Action 250 mg/dl 300 mg/dl Check urine of blood for ketones Ketone = no exercise No ketones = exercise w/ caution Check for Ketones Exercise in regardless of presence of ketones

23 Acute Hyperglycemia and Ketosis: Signs and Symptoms Athletes should work with physicians to determine insulin adjustments for periods of hyperglycemia

24 Why would an athlete get HYPER Glycemic 1. It can occur with high intensity exercise 2. A Decrease in Insulin combined with an increase of Hepatic Glucose Production (gluconeogenesis) during high intensity exercise. 3. Psychological Stress = Increase in counterregulatory hormones = Blood Glucose

25 Hyperglycemia How does it Effect Performance? Competing in a hyperglycemic state: 1. Risk of dehydration 2. Performance 3. Ketosis 4. Does NOT Risk of Hypoglycemia

26 Hyperglycemia Treatment The treatment plan focuses on a self-care plan predicted on: Monitoring of blood glucose

27 Blood Glucose Monitoring Frequent testing of blood sugar <110mg/dL before meals <140mg/dL after meals Hemoglobin A1C test every 3-6 months Continue to monitor: Blood pressure Cholesterol Vision Skin

28 Hyperglycemia Treatment Insulin Administration The pump Injections

29 Injection Sites

30 The Pump & Sensor The Pump The Sensor

31 Types of Insulin Insulin Action How to Use Length Humalog Rapid Bolus (Inj) Minutes Novalog Rapid Bolus (Inj) Minutes Humilin Fast Bolus (Inj) 2-4 hours Novolin Fast Basal / Bolus (P) 2-4 hours Humulin N Intermediate Basal Dose INJ 4-10 hours Novolin N Intermediate Basal Dose INJ 4-10 hours Lantus Long Basal 24 hours Levimar Long Basal 24 hours

32 Heat and Cold Heat may insulin absorption rates Cold may insulin absorption rates

33 Recognition, Treatment, and Prevention of Hyperglycemia Should avoid exercise during periods of hyperglycemia w/ ketones Should consult with their physician Athletes should drink non-carbohydrate fluids. Athletes should test for ketones when: Pump - single reading over 250 Injections consecutive reading over 250

34 Hypoglycemia

35 Blood Glucose Levels <70 mg/dl Tachycardia Sweating Palpitations Hunger Nervousness Headache Trembling Dizziness

36 Hypoglycemia As glucose continues to fall, symptoms of brain neuronal glucose deprivation occur and may cause: Blurred vision Fatigue Difficulty thinking Loss of motor control Aggressive behavior Seizures Convulsions Loss of consciousness If hypoglycemia is prolonged and severe, brain damage and even death can result

37 Recognition, Treatment, and Prevention of Hypoglycemia PREVENT IT!!! Blood glucose monitoring Before exercise 2-3 times During exercise every 30 min(minimum) After exercise every 2hours x 2 Carbohydrate supplementation Rule of 15

38 Recognition, Treatment, and Prevention of Hypoglycemia Insulin adjustments (consult a physician) Mild Hypoglycemia - if the athlete is conscious and able to swallow and follow directions Severe Hypoglycemia - if the athletes is unable to swallow, follow directions, eat as directed or is unconscious. Treatment requires a requires a glucagon injection

39 Hypoglycemia Causes insulin therapy & exercise (#1) Signs and symptoms occur when blood glucose levels fall below 70 mg/dl but can be different pending the size and makeup of your athlete.

40 Diabetic Athlete Complete in a safe and effective manner ADA recommendation /Maintain blood glucose levels range (100 pre-meal-180 post meal mg/dl) Near-normal blood glucose level reduces: Risk of dehydration Lethargy Hypoglycemia Autonomic counter-regulatory failure

41 Diabetes Figuring it Out Diabetes is best managed by a team of several health care professionals. Critical roles for the healthcare provider include: 1. Prevention, recognition, and immediate care of hypoglycemia and hyperglycemia 2. Exercise nutrition 3. Hydration counseling 4. Recognize the intensity of the exercise session in order to adjust glucose and insulin levels accordingly

42 Proactive Plans Healthcare providers need to have: 1. Diabetes care plan 2. Supplies for medical kits 3. Well-designed pre-participation exam (PPE) 4. Prevention, recognition, and treatment plans for diabetic situations 5. Procedures for insulin administration 6. Travel recommendations 7. Athletic injury and glycemic control plan

43 Diabetes Care Plan The plan should identify and include: Blood glucose targets for practices and game, including exclusion thresholds. Insulin therapy guidelines List of other medications Guidelines for hypoglycemia Guidelines for hyperglycemia Emergency contact information

44 Diabetic Care Plan Athletes with diabetes should have a medic alert tag

45 Supplies for Kit The athlete or parents of the athlete need to supply the following items: A copy of the diabetes care plan Blood glucose monitoring equipment and supplies Supplies to treat hypoglycemia (glucose products / sugary food/drinks) Supplies for urine or blood ketone testing A sharps container for syringes and lancets Spare batteries /Spare infusion sets and reservoirs for insulin pumps

46 Athletic Injury and T1DM Trauma = Stress = Blood Glucose Blood Glucose = Infection = wound/fx healing Target Ranges Important ADA recommendation /Maintain blood glucose levels range (100 pre-meal-180 post meal mg/dl)

47 Diabetic Complications Risk of stroke or heart disease is 4 x higher #1 cause of blindness in US #1 cause of kidney failure in US #1 cause of atraumatic amputations in US 70% of diabetics have neuropathy

48 Avoiding Diabetic Complications Closely monitor blood sugar levels Nutritional habits Exercise regularly Take medications as prescribed Do not smoke Avoid excessive alcohol Regular physical exams

49 Educational Programs Needed to establish: Healthy lifestyle Diet Physical activity Diabetes management Improve self-efficacy and diabetes control Improve safety and quality of care

50 Travel Recommendations Notify airport security screener of the medical condition Prescriptions and letter from the physician Travel with twice the amount of medications and supplies needed for the trip Health insurance card and emergency phone numbers Athletes with diabetes should carry prepackaged meals and/or snacks Discuss the travel plans with his/her diabetes health care team before departure

51 Summary Athletes can compete successfully with type 1 or 2 diabetes Healthcare providers need to be proactive and coordinate a care plan for each athlete Recognition and proper management of diabetic emergencies are critical to the care of the athlete Each athlete needs to be educated about their condition and know how to best manage and control the disease

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