Type 1 Diabetic Athletes and Emergency Management for the Athletic Trainer

1. Type 1 Diabetic AthletesandEmergency Management for the Athletic Trainer Lauren Rodgers MK, LAT, ATC Assistant Athletic Trainer Boise State University 2014 IATA Summer Symposium

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)

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 isn’t 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

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.

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

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

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)

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% Vo2max 90 min after a standard meal, a 30–50% reduction in the premeal insulin (regular) dose was necessary to avoid per-exercise hypoglycemia (Rabasa-Lhoretet 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)

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

10. Signs and Symptoms HypoGlycemia HyperGlycemia 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)

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

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: • ½ 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

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

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

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

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

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 (women’s 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)ZipporaKarz(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)AdianMarples (Ironman triathlete)Michele McGann (LPGA)Corbin Mills (bike racer)MinniMinosa (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)

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 • 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 SuppVol 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.

19. Questions?