Training Load. Very light training (low intensity exercise or skill-based exercise) Moderate intensity exercise for 1 hour per day 5-7g/kg/day

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1 Fuelling Success The overall dietary requirements of athletes with or without diabetes are essentially similar; 50-70% of energy taken as carbohydrate, 5-10% as protein and less than 30% as fat (1). Exact nutritional requirements will vary with body mass, training schedule and overall training goals (weight loss v s weight gain etc). Training Load Very light training (low intensity exercise or skill-based exercise) CHO Recommendations 3-5g/kg/day Moderate intensity exercise for 1 hour per day 5-7g/kg/day Moderate to high intensity exercise for 1-3 hour per day Moderate to high intensity exercise for 4-5 hours per day 7-10g/kg/day > 10-12g/kg/day Table 1 (2) There is evidence to suggest that low glycaemic index (GI) meals may improve performance in individuals with diabetes (3). 1. Burke L, Deakin V. Clinical Sports Nutrition. McGraw-Hill: Australia Table 1: Burke LM. Practical sports nutrition. Australia: Human Kinetics Wee S, Williams C, Gray S, et al, Influence of high an dlow glycaemic index meals on endurance running capacity. Med Sci Sports Exerc 1999;31 (3):

2 Case Study- Harry 21 year old Plays for the first team at his local rugby club 82.5Kg- lost 2 Kg in last month (unintentional) Trains 1-2 hours per day, mixture of cardio, technical drills and weight training. DAFNE Diary Date Time Midnight 3am 7am 9am 11am 2pm 4pm 6.30pm 8pm 10pm CP Monday BG QA BI Date Time 7am 10am 12:00 3pm 4pm 6pm 10pm CP Tuesday BG QA BI Date Time 8am 9am 10am 1pm 4pm 6pm 9.30pm CP Wednesday BG QA BI Date Time 7am 11am 2pm 5pm 10pm CP Thursday BG QA BI Training Schedule: Monday Drills/pitch training pm Tuesday Weight training 7-9pm Wednesday Cario work and ball skills 7-9pm Thursday Weight training 7-9pm DAFNE regimen: I:C ratio 1:10g (all meals) Correction factor: 1:3mmols/l BG targets as per DAFNE BI: Levemir 7 units am, 6.5 units pm Harry comes to see you in clinic because he is worried about the frequency of hypos he has been experiencing and his recent weight loss. He brings with him a food diary (over the page). Using the Fuelling Success fact sheet, would there be any dietary advice you would like to discuss with Harry?

3 Harry s food diary 7am ~5.5CPs 80g oats & 150mls milk 1 x scoop Whey protein 11am~ 4CPs 50g rice & protein portion (tuna/chicken) Salad & 2 eggs 2pm ~ 4CPs Same as above 4pm ~7.5CPs Banana & 4 x slices of Soreen 6.30pm ~4CPs 300g mashed sweet potato 3 portions vegetables 250g protein portion 8pm RUGBY TRAINING 9.30pm ~ 7.5CPs Soup & 4 x slices cheese on toast

4 Case Study: Lucy Carbohydrate supplementation during exercise A general recommendation for CHO requirements during exercise is 30-60g of CHO per hour of exercise (1). CHO requirement during exercise can also be based on body mass. In the absence of reductions in insulin dose, concentrations closer to 10g/100ml have been shown to be most effective in preventing hypoglycaemia in individuals with type 1 diabetes, however, higher concentrations may lead to gastric discomfort (eg 15g/100mls)(2). Lucy is a 38 year old 50Kg Training for a marathon Currently training for 1-2 hours 6 days per week.. She is currently using a 2:1 ratio with breakfast with a -60% bolus insulin dose. Lucy contacts you because she is struggling to get up to 2 hours of running without going hypo. She comes to see you and brings with her some data from her last training run and a food diary. Time 7am 10am 10am 10.30am 11.00am 11.30am 12:00pm CP 5.0 RUN 75ml 75ml 75ml 2 RUN BG 8.1 STARTED STOPPED QA 4 BI 5-3 Lucy is currently using an isotonic sports drink throughout but is still struggling to maintain her BG levels during her longer runs. She has tried gels and is open to suggestions. She also brings with her a food diary. What advice could you offer Lucy to address her following concerns: a) How much carbohydrate should she be aiming for during her runs? How much is Lucy currently getting? b) What could she do to help her maintain her BG levels? c) What other factors would you discuss with Lucy? 1. Burke L, Deakin V. Clinical Sports Nutrition. McGraw-Hill: Australia Perrone C, Laitano O, Meyer F. Effect of carbohydrate ingestion on the glycaemic response of type 1 diabetic adolescents during exercise. Diabetes Care 2005;28:

5 Commercial Isotonic Sports Drink Typical Values Typical Values per 100ml per 500ml bottle Energy 118kJ 590kJ - 28kcal 140kcal Fat 0g 0g of which saturates 0g 0g Carbohydrate 6.4g 32.0g of which sugars 3.6g 18.0g Fibre 0g 0g Protein <0.1g <0.1g Some athletes might benefit from making their own sports drink to suit their own carbohydrate and fluid requirements. Standard orange juice contains 10g CHO/100mls could this be helpful to Lucy?

6 Sport Gels Typical Values Per Serving (60ml) Per 100g Energy 367kj/86kcal 612kj/144kcal Protein 0.0g 0.0g Carbohydrate 22g 36g of which sugars 0.6g 1.1g Fat 0.0g 0.0g of which saturates 0.0g 0.0g Fibre 0.1g 0.1g Sodium 0.01g 0.02g

7 Case Study: Lucy continued. The performance benefits of CHO-loading for events lasting longer than 90 minutes are widely accepted. Typically a CHO loading regimen involves 3 days of a CHO intake between 8-12 g.kg -1.day-1 (1) Lucy s Food Diary Breakfast 3.5Cps 2 x Weetabix 150mls milk Cup of tea 10:30am- 2.5CPs Banana Coffee (skimmed milk) 12.30pm-7.5CPs Soup with 1 x bread roll Low fat yoghurt Orange Apple 3pm-2CPs Cereal bar 7pm- 6.5CPs Pasta/rice with chicken/fish Veg/stir fry Total carbohydrate: 22 CPs 1.

8 Changing Tactics DAFNE to CSII (insulin pump therapy) Which of the following are NICE criteria for CSII therapy? Professional sportsperson Attempts to reach target haemoglobin A1c (HbA1c) levels with multiple daily injections result in the person having disabling hypoglycaemia HbA1c levels have remained high (8.5% or above) with multiple daily injections (including using long-acting insulin analogues if appropriate) despite the person and/or their carer carefully trying to manage their diabetes. HbA1c levels have remained high (7.5% or above) with multiple daily injections (including using long-acting insulin analogues if appropriate) despite the person and/or their carer carefully trying to manage their diabetes. Pregnancy Insulin pump therapy is recommended as a possible treatment for children under 12 years with type 1 diabetes mellitus if treatment with multiple daily injections is not practical or is not considered appropriate.

9 Case Study: John John is a 30 year old A&E nurse 73Kg Competitive road cyclist Currently training for 1-2 hours 3-5 days per week when he is not working night shifts. Latest HbA1c 61mmols/mol (7.7%). John attends his clinic appointment with his DAFNE diary below. He has recently attended a cycling camp for Type 1 diabetes in Majorca and saw other cyclists using CSII and Continuous Glucose Monitoring (CGM). After discussing it with the other athletes at the camp, John is very keen to be considered for CSII funding and is convinced it would benefit his diabetes management. Time Comments CP BG mile bike ride 19.1mph QA BI Time Comments CP BG QA BI Night shift Time Comments CP BG miles bike ride 18mph QA : Sports gel & flapjack=5.2cps BI Time : :01 Comments CP BG QA BI Time Comments CP BG QA BI Time Comments CP mile bike 20mph BG QA BI Night shift Time 00:40 03: Comments CP BG QA 12 BI Night shift Could John optimise his DAFNE approach? In you opinion, does John meet the NICE criteria for CSII? Would you support John s application for CSII funding?