Lauren Rodgers MK, LAT, ATC Assistant Athletic Trainer Boise
State University 2014 IATA Summer Symposium Type 1 Diabetic
Athletes and Emergency Management for the Athletic Trainer Slide 2
What is Diabetes? Diabetes mellitus refers to a group of diseases
that affect how your body uses blood glucose, commonly called blood
sugar. Glucose is vital to your health because it's an important
source of energy for the cells that make up your muscles and
tissues. It's also your brain's main source of fuel. If you have
diabetes, no matter what type, it means you have too much glucose
in your blood, although the reasons may differ. (Mayo Clinic, 2013)
Slide 3 Diabetes Mellitus Type 1 (IDDM) is a genetic mutation that
triggers an auto-immune response Environmental trigger causes the
immune system to destroy the beta cells in the pancreas that
produce insulin Type 2 (NIDDM) is an insulin-resistance because the
body isnt able to utilize the insulin being produced Accounts for
90-95% of 29.1 million people with diabetes Type 2 diabetics can
become insulin dependent if not controlled Gestational Diabetes
Increased insulin resistance caused by hormones being released in
the placenta Slide 4 Diabetes Statistics American Diabetes
Association, 2014 Prevalence: In 2012, 29.1 million Americans, or
9.3% of the population, had diabetes. In 2010 the figures were 25.8
million and 8.3%. The prevalence rate for adults age 20 and older
in 2012 was 12.3%, compared to 11.3% in 2010. New Cases: The
incidence of diabetes in 2012 was 1.7 million new diagnoses/year;
in 2010 it was 1.9 million. Deaths: Diabetes remains the 7th
leading cause of death in the United States in 2010, with 69,071
death certificates listing it as the underlying cause of death, and
a total of 234,051 death certificates listing diabetes as an
underlying or contributing cause of death. Cost of Diabetes
(Updated March 6, 2013) $245 billion: Total costs of diagnosed
diabetes in the United States in 2012 $176 billion for direct
medical costs $69 billion in reduced productivity After adjusting
for population age and sex differences, average medical
expenditures among people with diagnosed diabetes were 2.3 times
higher than what expenditures would be in the absence of diabetes.
Slide 5 Blood Glucose Blood Glucose (BG) is the accumulation of
glucose in the blood stream Measured in mg/dL Blood sugar ranges:
Normal 80-150 Pre-meal 70-120 Post-meal < 200 Hemaglobin A1C:
predicts average blood sugars over past 3 months Slide 6 Diabetes
Management Glucometer Continuous Glucose Monitor (CGM) Multiple
Daily Injections (MDI) Multiple daily injections of short-acting
insulin for any carb-intake Once daily injection of long-acting
insulin for sustained blood sugar control Pump Therapy Continuous
infusion of short-acting insulin into adipose tissue Traditional
Pump Tubeless Pump Slide 7 Effects of Exercise on BG Insulin
sensitivity is increased, so your cells are better able to use any
available insulin to take up glucose during and after activity
(Zinman et al, 2004) When your muscles contract during activity, it
stimulates another mechanism that is completely separate of
insulin. This mechanism allows your cells to take up glucose and
use it for energy whether insulin is available or not (ADA, 2014)
Exercise Type Intermittent High-Intensity Exercise vs. Moderate
Exercise (Guelfi et al, 2007) Increase in BG vs Decrease in BG
Increased Insulin sensitivity up to 31 hours later (MacDonald,
1987) (Gallen, 2004) Slide 8 Unique Physiological Concerns for Type
1 Diabetics Glucose production and glucose utilization balance
(Guelfi et al, 2007) Reducing pre-exercise insulin 25%
pre-exercise, 50% post-exercise (Campbell, 2013) Reducing
Short-Acting Insulin 45-min exercise session at 50% Vo 2max 90 min
after a standard meal, a 30 50% reduction in the premeal insulin
(regular) dose was necessary to avoid per-exercise hypoglycemia
(Rabasa- Lhoret et al, 2001) Reducing basal insulin (pump only)
Complete suspension decreased hypoglycemic incidence by 27%
(DirecNet Study Group, 2006) Meal Selection Heat and cold effects
insulin absorption Trial and Error (Gallen, 2004) Slide 9 Two Types
of Diabetic Emergencies HypoGlycemia Low blood sugar as a result of
too much insulin or not enough food BG < 70 Can result in LOC if
BG gets < 50 HyperGlycemia High blood sugar as a result of not
enough insulin or too much food BG > 200 Above 600 will likely
go into a diabetic coma Slide 10 Signs and Symptoms
HypoGlycemiaHyperGlycemia Mild hypoglycemia Nausea Extreme hunger
Feeling nervous or jittery Cold, clammy, wet skin and/or excessive
sweating not caused by exercise A rapid heartbeat Numbness or
tingling of the fingertips or lips Trembling Moderate hypoglycemia
Mood changes, such as irritability, anxiety, restlessness, or anger
Confusion, difficulty in thinking, or inability to concentrate
Blurred vision, dizziness, or headache Weakness, lack of energy
Poor coordination Difficulty walking or talking, such as staggering
or slurred speech Fatigue, lethargy, or drowsiness Severe
hypoglycemia Seizures or convulsions Loss of consciousness, coma
Low body temperature Early signs of hyperglycemia include:
Increased thirst Headaches Difficulty concentrating Blurred vision
Frequent urination Fatigue (weak, tired feeling) Weight loss Blood
sugar more than 180 mg/dL Prolonged hyperglycemia in diabetes may
result in: Frequent infections Slow-healing cuts and sores
Decreased vision Nerve damage causing painful, cold, or insensitive
feet, loss of hair on the lower extremities Stomach and intestinal
problems (ADA, 2014) Slide 11 Managing Diabetic Emergencies Assess
the signs and symptoms, and if they are coherent ask the athlete
how they feel and what they have done in the past hour to manage
their diabetes Blood Sugar Testing Meter, Strips, Lancet Knowing
the numbers Slide 12 Hypoglycemia Treatment If blood sugar is below
70, administer 15-20 g of sugar, wait 15 minutes, then test the
blood sugar again Best forms of sugar: cup of regular soda or juice
4-6 pieces of hard candy Glucose tablets or gel 1 TBSP of honey or
table sugar Foods high in fat or fiber take longer to digest and
raise the blood sugar, so avoid chocolate or bread to treat low
blood sugar Glucagon Pen for Hypoglycemia Emergencies Slide 13
Hyperglycemia Treatment Different types of insulin do different
things Short-acting (meals) Long-acting (daily) Typical correction
scale is 1:50 For every 50 points the individual is above their
range, take one unit of short-acting insulin Different for everyone
so check Encourage the athlete to drink plenty of water If BG is
above 250, check for ketones when possible If unable to help
themselves with the shot, you must call 911 or transport to the
hospital If BG is above 600, transport to the hospital Likely in
DKA Slide 14 Diabetic Ketoacidosis (DKA) Inability to use the sugar
in the blood stream causes the body to utilize fat and muscle
breakdown to fuel the body, creating ketones (fatty acids) to build
up, creating pH imbalances (Mayo Clinic, 2013) Symptoms include:
Flushed, hot, dry skin Blurred vision Feeling thirsty Drowsiness or
difficulty waking up Rapid, deep breathing A strong, fruity breath
odor Loss of appetite, belly pain, and vomiting Confusion Brain
swelling, and eventually coma or even death Slide 15 Supplies for
the Athletic Trainer NATA Position Statement: Management of the
Athlete with Type 1 Diabetes Mellitus (2007) Provided by the
athlete: Diabetes Care Plan Blood glucose monitoring equipment and
supplies: testing strips, lancets, insulin (check exp. date
frequently) Supplies to treat hypoglycemia: glucose tablets, sugar
packets, orange juice, regular soda, Glucagon Pen Ketone Testing
supplies: Urine or blood Sharps container Spare batteries Slide 16
Take Home Message Get to know your athletes Insulin Types, Pump vs.
Injections Signs and Symptoms Personality Know the Numbers
Hypoglycemia vs. Hyperglycemia Have a Plan Slide 17 Famous Athletes
with Diabetes Walt Arnold (former football player, K.C. Chiefs)
Walter Barnes (former football player, Phila. Eagles) Doug Burns
(Mr California 97, subsequent Mr. Universe) Bill Carlson (Ironman
triathlete) Bobby Clark (former hockey player, Phila Flyers) Ty
Cobb (former baseball player) Mallory Code (womens Pro Golfer) Tony
Conigliaro (former baseball player, Boston Red Sox) Jay Cutler
(quarterback, Denver Broncos) James Buster Douglas (professional
boxer) Kenny Duckett (football player, Dallas Cowboys) Mike Echols
(Cornererback, Tennessee Titans) Darren Eliot (former hockey
player, L.A. Kings) Pamela Fernandes (Olympic Gold Medal cyclist)
Missy Foy (Olympic Ultra Marathoner) Curt Fraser (former hockey
player, Minnesota Northstars) Smokin Joe Frazier (former boxer)
Kris Freeman (Olympic Skier, silver medalist) Rich Gedman (baseball
player, Boston Red Sox) Bill Gullickson (former pitcher, Houston
Astros) Gary Hall, Jr. (Olympic swimmer/gold medalist) Tom Hallion
(Major League Umpire) Jonathan Hayes (former football player, K.C.
Chiefs) Vance Heffner (pro golfer) Chuck Heidenrich (professional
skier) Catfish Hunter (Hall of Fame baseball player) Jason Johnson
(pitcher, Baltimore Orioles) Zippora Karz (ballerina, New York City
Ballet) Billy Jean King (tennis legend) Ted Kluszewski (former
baseball player, Cincinnati Reds) Ed Kranepool (former baseball
player, NY Mets) Kelli Kuehue (LPGA two-time champion, pumper) Jay
Leeuwenburg (Guard/Center in NFL) Mark Lyle (professional golfer)
Gary Mabult (UK soccer champion) Adian Marples (Ironman triathlete)
Michele McGann (LPGA) Corbin Mills (bike racer) Minni Minosa
(former baseball player, Chicago White Sox) Adam Morrison (pro
basketball player, LA Lakers) Calvin Muhammed (former football
player, Washington Redskins) Fred Patek (former baseball player,
K.C. Royals) Mike Pyle (former football player, Chicago Bears)
Steve Redgrave (Olympic rowing gold medalist) Dan Reichert
(pitcher, Kansas City Royals) Ham Richardson (tennis player) Jackie
Robinson (former baseball star) Sugar Ray Robinson (former boxer)
Ron Santo (former baseball star, Chicago Cubs) Art Shell (former
football player, Oakland Raiders) Mike Sinclair (former NFL
defensive end) Bill Talbert (tennis star) Michael Treacey (sky
jumper) Sherri Turner (pro golfer) Jerry Udjur (former baseball
player, Detroit Tigers) Scott Verplank (pro golfer) Jersey Joe
Walcott (boxing) Joanne Washam (pro golfer) Wade Wilson (former NFL
quarterback) Slide 18 References American Diabetes Association.
(2014). Exercise and Type 1 Diabetes. Retrieved July 7, 2014, from
http://www.diabetes.org/food-and-fitness/fitness/exercise-and-type-1-diabetes.html?loc=ff-slabnav
http://www.diabetes.org/food-and-fitness/fitness/exercise-and-type-1-diabetes.html?loc=ff-slabnav
Guelfi, K.J., Ratnam, N., Smythe, G.A., Jones, T.W., and Fournier,
P.A. (2007). Effect of intermittent high intensity compared with
continuous moderate exercise on glucos production and utilization
in individuals with type 1 diabetes. American Journal of Physiology
Endocriniology and Metabolism Vol. 292.
doi:10.1152/ajpendo.00533.2006 Zinman, B., Ruderman, N., Campaigne,
B., Devlin, J. Schneider, S. (2004). Physical Activity/Exercise and
Diabetes. Diabetes Care Supp Vol 87:1. 58-62. Gallen, I.W. (2004).
Review:Helping the Athlete with Type 1 Diabetes. British Jounrnal
of Diabetes & Vascular Disease. Vol 4:87. doi:
10.1177/14746514040040020401 MacDonald, M.J. (1987). Post-exercise
late-onset hypoglycemia in insulin-dependent diabetic patients.
Diabetes Care Vol 10. 584-588. doi 10.2337 Campbell, M.D., Walker,
M., Trenell, M.I., Jakoviljevic, D.G., Stevenson, E.J., Bracken,
R.M, et. Al. (2013). Pre- and Postexercise Rapid-Acting insulin
reduction preserve glycemia and prevent early- but not late-onset
hypoglycemia in patients with Type 1 diabetes. Diabetes Care Vol.
36:8. 2217-2224. Rabasa-Lhoret, R., Bourque, J., Ducros, F.,
Chiasson, JL. (2001). Guidelines for premeal insulin dose reduction
for postprandial exercise of different intensities and durations in
Type 1 diabetic subjects treated intensively with a basal-bolus
insulin reimen. Diabetes Care Vol 24:4. 624-630. doi: 10.2337 The
Diabetes Research in Children Network (DirecNet) Study Group.
(2006). Prevention of hypoglycemia during exercise in children with
Type 1 diabetes by suspending basal insulin. Diabetes Care Vol
29:10. 2200-2204. Jimenez, C., Corcoran, M., Crawley, J., Hornsby,
W., Peer, K., Philivin, R., Riddell, M. (2007). National Athletic
Trainers Association Position Statement: Management of the Athlete
with Type 1 Diabetes Mellitus. Journal of Athletic Training. 42
(4). 536-545. Slide 19 Questions?
