The Diabetic Athlete Matt Bayes, MD, CAQSM BlueTail Medical Group St. Louis, MO
Thanks to: David Olson, MD University of Minnesota
Objectives At the conclusion of this lecture you will be able to: Discuss where to find clinical guidelines Define diabetes mellitus Define risks and benefits of exercise in the diabetic athlete, including diabetic emergencies Understand sport physiology and diabetes Discuss pre-participation evaluation and participation issues in the diabetic athlete Know specific management issues in Type I and II DM
Clinical Guidelines Position statements via American Diabetes Association Standards of Medical Care for Patients with Diabetes Mellitus. Diabetes Care. Vol. 27, Supplement 1, January 2004 Physical Activity/Exercise and Diabetes. Diabetes Care. Vol. 27, Supplement 1, January 2004 www.diabetes.org great site for Physician info!
Clinical Guidelines Clinical Review Articles Harris GD, White RD: Diabetes in the Competitive Athlete. Curr Sports Med Rep 2012 Nov;11(6):309-15 Weiland DA, White RD: Clinics in Family Practice 2002;4(3) The daily management of athletes with diabetes. Clin Sports Med, Jul 2009
Defining Diabetes Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. ~90% Type II ~10% Type I
The Diabetes Epidemic
Type I Diabetes/IDDM Can occur at any age, typical onset < 30 yo therefore many athletic encounters involve athletes with this condition Autoimmune mediated decrease in insulin production in the islet cells of the pancreas Demonstrate hyperglycemia and weight loss Prone to ketoacidosis, with death occurring if exogenous insulin is not administered and the acidosis is reversed
Type II Diabetes: NIDDM Impairment in insulin production and release by pancreatic beta cells Reduced sensitivity to insulin in muscle, liver and fat tissues Excessive hepatic glucose production in the basal state Rare to see Type II in elite athletes Seen in weekend warrior athletes or with higher BMI: football linemen, rugby, ageing first basemen
Prevalence of Non-Insulin Dependent Diabetes by Age
Type II DM: Initial Conservative Therapy A 3-4 month trial of dietary counseling Regular exercise regimen to improve insulin sensitivity and glucose utilization Lack of improvement in blood sugars and glycosylated hemoglobin with lifestyle changes reflects the need for oral agents or insulin
Exercise benefits both Type I and II DM Reduced cardiovascular disease risk Enhancement of physical fitness Improved social and emotional wellbeing
Exercise Risks in DM General: If external goals outweigh the importance of blood glucose control and avoidance of complications Specific to weight category sports (wrestling, boxing): common to omit insulin to lose weight prior to weigh-in, leading to poor glucose control and risk of ketoacidosis
Potential Complications of Exercise in Diabetics Hypoglycemia Hyperglycemia (with and without ketosis) Dehydration Hypotension Foot ulcers (with peripheral neuropathy) Orthopedic injuries Accelerated DJD
Contraindications in Diabetic Athletes Contraindications are based on potential risks of a particular activity in the presence of specific complications of DM Patients without complications, steady control and knowledge can participate in most activities Must be careful with scuba, sky diving, auto racing and others where hypoglycemia could cause disaster
Diabetes Control and Complication Trial Study by the Diabetes Control and Complications Trial Research Group Clearly demonstrated the beneficial affects of tight glucose control in the development and progression of complications in Type I diabetes Hypoglycemic episodes are 3 times more likely in intensively controlled patients than those more traditionally treated
Effect of Exercise on Blood Sugar After 10 U of Regular Insulin
Sport Physiology and Diabetes Augments the effects of insulin: Increases 20x the muscle s ability to take up glucose 40 min exercise session can insulin sensitivity by 40% and continue for the subsequent 48 hours These are not diminished in the diabetic condition, benefits Type II > Type I
Metabolic response to exercise Can be various release patterns and insulin absorption from SC insulin Increased exposure of insulin to receptors on muscle cells as blood flow increases Thus risk of hyperglycemia during initial exercise and hypoglycemia later as the injected insulin does not regulate to the falling level of glucose
Preparticipation Assessment History Length of known diabetes (Type) Medication regimen Discuss any secondary medical problems related to their diabetes Type of exercise planned Previous exercise Goals of patient (Weight loss, BS control)
Pre-exercise Evaluation History and Physical must check for: Cardiovascular disease Peripheral Vascular Disease Retinopathy Nephropathy Neuropathies (Autonomic/Peripheral) Hyper/Hypoglycemic episodes and frequency
Pre-exercise Evaluation Base line fasting blood glucose, HBA1c, lipid profile Before beginning intense exercise program should be doing frequent glucose monitoring & urine ketone monitoring Transition from sedentary to trained athlete poses the greatest risk of hypoglycemia
Glucose monitoring and exercise 2-3 readings 30 min apart pre-exercise to trend blood glucose direction Every 30 min during exercise Every 2 hours for up to 4 hours post exercise to monitor for delayed hypoglycemia
Pre-Exercise Blood Glucose 100-250 mg/dl: Safe to begin exercise Most athletes prefer 120-180 mg/dl <100 mg/dl: Administer glucose (tablet or juice) >250 mg/dl: Check for urine ketones + ketones: Avoid exercise, hydrate, recheck - ketones: Proceed cautiously, hydrate, recheck
Cardiac/Peripheral Vascular Systems Diabetics >35yo or >25yr history of DM should have screening for silent ischemia & cardiac response to exercise w/ graded exercise test Contraindications to exercise: CAD (untreated), SBP > 200, claudication Graded Exercise Test: Provides estimation of fitness level Especially important in previously sedentary patient Check feet closely and treat aggressively
Screen all athletes Retinopathy Diabetic athletes need yearly exam If present: avoid sports that increase pressure (weightlifting, scuba) Clear via Optho if retinopathy is present
Autonomic Dysfunction May have abnormal HR & BP response to exercise & position change causing orthostatic hypotension Impaired temperature regulation Prone to dehydration
Nephropathy Control hypertension Regular evaluation of renal function (BUN/Cr) and presence of proteinuria (microalbumin)
Musculoskeletal May show decreased flexibility: caused by glycosylation of connective tissue in poorly controlled DM Proprioceptive issues putting them at risk if athlete has peripheral neuropathy
Medications Many forms of insulin injections Many types of oral hypoglycemic meds Insulin pumps Continuous glucose monitoring www.diabetes.org
Preventing/Managing Hypoglycemia In the athlete hypoglycemia is immediate or delayed Immediate: during or shortly after exercise, most common in Type I due to inadequate glucose intake to meet metabolic demands Other causes: Excessive exogenous insulin, or injection of insulin into site of exercising muscle causing increased absorption rate
Prevention of Hypoglycemia Inject insulin into the abdominal area Replace calories continuously during prolonged activity Careful glucose monitoring to adjust as needed More calories required if in cold weather or lower intensity exercise Hot environment: risk due to poor appetite and decreased caloric intake
Management of Hypoglycemia Best approach: Prevent! Be ready: Athletes have varying levels of maturity, commitment to the sport, and personal accountability If suspected: Remove from play, immediate fingerstick glucose
Management of Hypoglycemia Treat with 15-20g fast acting carb: glucose tablet or juice, repeat in 15 min if no improvement in symptom or level If conditions suggest recurrent hypoglycemia add complex carbs before return to play Avoid excess carb: hypoglycemia provokes a counter-regulatory hormonal response
Management of Hypoglycemia Severe hypoglycemia with LOC or sz is life threatening: Alert 911 Avoid forced PO glucose Glucagon SC, IM, or IV D50 1-3 ampules
Delayed Hypoglycemia AKA: Nocturnal Hypoglycemia 6-12 hrs after exercise, up to 28 hrs Associated with sz, arrhythmia, death as it often occurs in sleep Vigorous exercise severely depletes body glycogen stores, followed by poor replacement of glycogen in the postexercise interval ( Golden Period )
Delayed Hypoglycemia In ensuing hours liver and muscle extract blood glucose to replenish depleted glycogen stores and glycogen synthetase is activated Muscle tissue is more sensitive to any available insulin postexercise Subsequent severe and persistent delayed hypoglycemia often requires assistance of another person, glucagon, and hours of continuous caloric intake
Type I DM: Sprinters Anaerobic short distance sprint activities rarely cause problems Proper hydration and glycemic control maximizes performance Hyperglycemia may occur due to acute catecholamine release Delayed hypoglycemia is rare Usually unnecessary to adjust insulin dose
Type I DM: Endurance Athlete Attain a steady state balance between basal insulin rate, carb intake, and exercise requirement to keep glucose level ~130-150 mg/dl If sprint/ effort needed then carb intake or basal rate during that short period
Type I DM: Endurance Athlete: To Avoid Hypoglycemia Short bursts of anaerobic exercise before or after aerobic exercise can prevent subsequent hypoglycemia Critical Golden Period : Replace glycogen stores post-race to prevent delayed hypoglycemia (1.5 g carb/kg body weight)
Type II DM Management depends on sport and severity/duration of diagnosis Early in diagnosis: Still producing insulin, little to no exogenous insulin needed Later: Exogenous insulin needed, with adjustment to prevent hypoglycemia
Type II DM With active training it is not uncommon for exogenous insulin requirement to decrease by 50% or greater Some fit athletes with Type II DM note a plateau in medicine requirements for treating their disease
Travel Requirements Labeled travel kit, hand carried 2x needed supplies Syringes, glucose meter, lancet, test strips, alcohol swabs, insulin, insulin pump with supplies, glucagon emergency kit, ketone testing supplies Physician letter and extra prescriptions Prepackaged meals and snacks Diabetes medical bracelet worn
Conclusion Team physician must understand the pathophysiology of diabetes Important to understand the different risks in athletes with diabetes Education and assessing an athlete s comfort with their diabetes must be done at the pre-participation exam (game/practice is too late) Need to have plan in advance for checking athletes prior to game/event and plan of action for potential emergencies
Thank You!
Bibliography Harris GD, White RD: Diabetes in the Competitive Athlete. Curr Sports Med Rep 2012 Nov;11(6):309-15 American Diabetes Association. Diabetes Care. Vol. 27, Supplement 1, January 2004 American Diabetes Association. Information for Medical Professionals. www.diabetes.org. 2007 Kerr C: Improving outcomes in diabetes: A review of the outpatient care of NIDDM patients. J Fam Pract 40(1):63-74,1995 Gordon NF: Diabetes: Your complete exercise guide. Champaign, Human Kinetics, 1993 Peterson KA, Smith CK: The DCCT findings and standards of care for diabetes. Am Fam Physician 52(4):1092-1126, 1995