Prevention

• Athletes should wear medical identification bracelets at all times
• Take medications in appropriate doses at recommended times
• Eat regular meals and snacks
• Establish and follow diabetes care plan
• For sports and exercise
• Check blood glucose before activity
  • Avoid exercise if glucose level:
    • <100 mg/dL
    • >250 mg/dL with ketones present
    • >300 mg/dL regardless of ketone presence
• Plan meals/snacks to be eaten before and after activity
  • Should contain carbohydrate and protein
• Consult physician on altering insulin dosages before activity
  • Special considerations: insulin delivery via pump
    • Pump should be disconnected for collision sports
      • Athlete should monitor blood glucose carefully during participation when pump is disconnected
    • Pumps do not need to be disconnected for non-collision sports, however:
      • Exercise facilitates glucose uptake by muscle
      • Not as much insulin will be necessary
      • Type of exercise affects glucose levels differently
    • Experiment with exercise type and pump use while carefully monitoring blood glucose to determine individual recommendations for exercise
• Adjust medication before activity
• Check blood glucose during and after activity
• Type I diabetic athletes can experience late hypoglycemia after exercise.  These athletes should consume carbohydrate before bed to prevent hypoglycemia while sleeping

Predisposing Factors

Recognition

• Normal blood glucose is 72-100 mg/dL (Table 1)

Table 1. Recognition of Hypoglycemia and Hyperglycemia Causes and Signs and Symptoms.

Assessment

• Signs and symptoms (Table 1)
• Time of last meal/insulin dosage
• Finger stick to measure blood glucose level
• Urine testing for ketosis

Ketones

Ketones are produced through a process called ketogenesis.   When there’s not enough insulin in the blood, glucose builds up because it can’t be used for energy.  Without glucose, the body breaks down fat for energy, and the byproducts are ketones.  Ketones are not harmful if blood glucose is not high.  It just means that your body is using fat for energy.  However, if blood glucose is high and left untreated, a condition called diabetic ketoacidosis may develop, which is life threatening.

Ketone Testing:

• You should test for ketones when you plan to exercise and blood glucose is >250 mg/dL.
• Even if you don’t plan to exercise, you should test for ketones when blood glucose is >250 mg/dL for two tests in a row.

How to Test:

Ketone testing kits are available at most pharmacies or drug stores.  They usually require you to urinate in a small cup, dip in a strip, then match the strip to the colors on the bottle.

If the Test is Positive:

• Consult your physician, as you may need additional insulin.
• Drink plenty of water or other non-calorie beverage (to wash-out the ketones).
• Test blood glucose every 3-4 hours, and test for ketones if blood glucose remains >250 mg/dL.
• Do not exercise if blood glucose is >250 mg/dL and ketones are present, as this may cause more ketones to be released.

Treatment

• Check blood glucose levels
• Hypoglycemia:
  • If conscious
    • 1 serving of a sugary snack or beverage
      • 3-4 glucose tablets
      • 1 serving of glucose gel
      • 1 Tbsp honey or sugar
      • 4 fl oz fruit juice or regular soda
      • 5-6 pieces of hard candy
    • If no improvement, call 911
    • If improvement, recheck blood glucose every 15 minutes
    • Administer additional carbohydrate if blood glucose remains <70mg/dL
    • Once blood glucose is within a normal range, athlete should consume a carbohydrate and protein snack
  • If unconscious
    • Call 911
    • Administer glucagon
    • Monitor vitals
• Hyperglycemia:
  • If conscious
    • Assess urine for ketones
    • Administer water or other non-carbohydrate beverage
    • If ketones present, keep drinking and recheck in 15 minutes
    • If no ketones, exercise if blood glucose is <250mg/dL
  • If unconscious
    • Call 911
    • Monitor vitals

Return To Play

• Athletes with mild hypoglycemia and hyperglycemia may return to activity when blood glucose is within a normal range without ketones.
• Athletes with moderate hyperglycemia (<250 mg/dL) may continue with activity as long as no ketones are present in the urine and signs and symptoms do not increase.

References

1. Bernhardt DT, Roberts WO. Preparticipation Physical Evaluation. 5^th ed. American Academy of Pediatrics. 2010.
2. Centers for Disease Control and Prevention. Diabetes Public Health Resource. Available at: http://www.cdc.gov/diabetes/index.htm. Accessed on September 21, 2011.
3. National Diabetes Information Clearinghouse (NDIC). Available at: http://diabetes.niddk.nih.gov/index.aspx. Accessed on September 20, 2011.
4. Yeargin SW, Yeargin BE, Anderson JM. Anaphylactic Shock, Hypothermia, Diabetes, and Wilderness Medicine.  In: Casa DJ, ed. Preventing Sudden Death in Sport and Physical Activity. Sudbury, MA: Jones and Bartlett Learning. 2012: 201-231.
5. American Diabetes Association. Diabetes Basics. Available at: http://www.diabetes.org. Accessed on September 20, 2011.
6. Jimenez CC, Corcoran MH, Crawlay JT, Guyton Hornsby W, Peer KS, Ohilbin RD, Riddell MC. National Athletic Trainers’ Association position statement: management of the athlete with type I diabetes mellitus. J Athl Train. 2007;42(4):536-545.