1. The Diabetic Athlete: Implications, participation Jason Blackham, MD August 21, 2008 Sports Medicine Rounds

2. Objectives ] Physiology of insulin ] Exercise effects on insulin regulation ] Pre-participatory screening ] Guidelines for the diabetic athlete

4. Insulin ] Glucose transport into ] Muscle ] Fat cells ] Liver ] Decrease release of ] Free fatty acids from fat cells ] Glucose from liver

5. Exercise on insulin ] Decreases insulin ] Stimulates glucose transport into muscle ] Increases cortisol ] Therefore, increase in insulin sensitivity ] Allows free fatty acids and glucose to be mobilized for energy

6. Warnings ] Post exercise hypoglycemia at 2 and 18 hours though can last 30 hours ] Too much insulin with exercise, suppress glucose release from liver and fatty acids from adipose tissue ] If BS >250, then it increases with exercise ] If BS is elevated and not enough insulin, then post exercise hyperglycemia occurs due to lack of increase in post exercise insulin

7. Warnings ] Anaerobic exercise may increase BS ] Too little insulin, fatty acid metabolism leading to ketones and DKA ] With hypoglycemic event, risk of further hypoglycemia

8. Pre-participatory screening ] Good control of blood sugars ] HbA1c < 7.5% ] Measuring BS at least 4x/day, prefer 6x ] Most BS are 80-180 ] Know symptoms and what to do for ] Hypoglycemia ] Hyperglycemia ] Know how to adjust insulin/carbs before and after exercise

9. Pre-participatory screening ] Screen for complications ] Retinopathy ] Neuropathy ] Nephropathy ] Cardiac screening? ] Foot/skin care ] Lipids ] Ever had DKA or hospitalized for diabetes

10. Guidelines for exercise ] If BS < 80-100, ] eat extra carbohydrate prior to exercise, recheck in 30 minutes. ] If BS 100-200, goal ] If BS >200-250, ] Check urine ketones, if + no exercise ] If BS > 250-300, ] Don’t workout, wait until under control

11. Guidelines for exercise ] How to avoid hypoglycemia ] Decrease pre-exercise insulin by 50-80% ] Increase pre-exercise carbohydrate ] Don’t exercise when insulin is peaking ] Measure post exercise BS ] Don’t exercise when sick

12. Guidelines for exercise ] Know where to inject- ] Don’t inject in working muscle ] Heat increases absorption ] Cold decreases absorption ] Massage increases absorption ] Insulin storage between 40-80 degrees ] Nutritionist, diabetic nurse