type i diabetes mellitus management in the athletic population

8/6/2019 Type I Diabetes Mellitus Management in the Athletic Population

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Type I Diabetes Mellitus

Management In the AthleticPopulation

Kelly Bachus, Danielle Violette, Patrick Violette,

Kim Anderson, Matt Whitesell



Purpose

� Type I Diabetes is typically diagnosed before the age of 30, and

would be the most common type among high school and

intercollegiate athletes that VSM provides coverage for � We wanted to research the most up to date standard of care for

Type I diabetic athletes to create an evidence based Diabetic Care

Plan for all of VSM to utilize



Research Methods

� 30 literature review articles used to find the most current

information about Type I Diabetes Mellitus and how it affects

athletes¶ participation� Used guideline for our Diabetic Care Plan from Jimenez, et al in

the µNational Athletic Trainers¶ Association Position Statement:

Management of the Athlete With Type 1 Diabetes Mellitus¶ article

from the Journal of Athletic Training

� Consulted with Dr. Alex Diamond and Dr. Kristina Wilson in

Vanderbilt Sports Medicine, and Dr. Bill Russell and Dr. Amy

Potter in Vanderbilt Endocrinology



Pre Participation Examination and Clearance

� History Questionnaire must include:

± Do you have frequent urination?

± Do you have excessive thirst?

± Do you have frequent hunger?

± Have you had any unexplained weight loss?

± Do you have unexplained fatigue?

± Do you have blurred vision?

± Do you have a family history of diabetes? What type?

± Do you have diabetes?

� ***If they answer yes, consult with team physician and refer to

endocrinologist



� Existing Diabetes Type I Diagnosed Athletes must submit medical

records documenting:

± H bA1c testing (desired <7% for adolescent, <6% for adult)

± Yearly dilated eye exam

± Yearly kidney function exam

± Yearly neurological exam

± If they have been diabetic for >15 years, a graded exercise

stress test should be performed

± Type (s) and delivery method of daily insulin:

� Insulin to carbohydrate ratio at meals

� Sliding scale (correction factor) for high glucose

� Pump basal rate(s) or long acting injected insulin




� During Pre-participation Exam evaluate and discuss:

± Diabetes self care skills

± General physical exam

± Educate athlete on effect of their sport on their diabetes

± Make sure they have a medical alert tag ± Athletes need to establish a relationship with a local

endocrinologist

± Complete a diabetes information sheet to keep in their chart

and travel folder (see below)

± Educate on proper foot care and foot wear for their sport

� Inspect feet daily for blisters, abrasions, lacerations

� Cut toe nails straight across

� No walking barefoot

� Avoid poor fitting shoes

± Be aware of training limitations




Blood Glucose Monitoring and Insulin Therapy

� Pre exercise blood glucose should be 110-250 mg/dl

± Check 2-3 times before exercise at 30 min intervals

± Decrease the insulin bolus dose up to 50% at the pre exercise

meal� During exercise >1 hour blood glucose should be checked every 30

min

± �250 mg/dl with ketones present²no activity allowed

± �300 mg/dl no activity allowed




� Post exercise

± Shortly after exercise, they should eat a snack or meal

± If they tend to experience late onset hypoglycemia, measure

blood glucose 2-4 hours post exercise and again before goingto bed

± Check once during the night if they experience nighttime

hypoglycemia

± If nighttime hypoglycemia reoccurs decrease the evening meal

insulin bolus by 50%




� Insulin pump Use in Athletes

± Decrease basal rate 20-50% 1-2 hours before exercise

± Decrease bolus dose up to 50% at meal prior to exercise

± Decrease bolus dose up to 50% one hour prior to activity ± Disconnect the pump prior to exercise for no longer than one

hour and monitor blood glucose frequently

± Pump can be worn during non-contact sports. It is

recommended you secure and pad the pump to decrease

jostling during impact activities

± Re-connect the pump immediately after competition

± Check blood 30 minutes after reconnecting the pump to ensure

proper function




� Strategies to optimize Insulin Therapy

± Know the athlete¶s type of insulin used (both fast and long

acting)

± Know their dosages during the day

± Know their corrections for high blood sugar (carb ratio, should

be established between the athlete and their

endocrinologist/nutritionist)

± Know adjustment strategies for planned activities

± Rotate injection sites for most effective insulin absorption

± If having trouble with insulin therapy document blood sugar and insulin dosages for a week to have more information to

relay to the endocrinologist/nutritionist



Emergency Situations: Hypoglycemia ± Signs and Symptoms

� Early: hunger, irritability, drowsiness or confusion, rapid

heart rate, sweating, dizziness, or loss of color, typically

develops when the blood glucose is below 70 mg/dl

� Late: brain neuronal glucose deprivation occurs and

causes blurred vision, fatigue, difficulty thinking,

decreased motor control, aggressive behavior, seizures,

convulsions, and loss of consciousness

± Prevention

� Frequent blood glucose monitoring

� Carb intake adjustment pre-exercise or fast acting carbsupplement during exercise

� Insulin dose adjustments

� Avoid exercising during peak of insulin

� Prevent dehydration



Emergency Situations: Hypoglycemia� Treatment

± Check if they are alert and able to eat or drink without assistance

± Administer 15 g of fast acting carbs (4 Dex4 tabs, 15 gm sports gel, 4 oz

juice or soda)

± Repeat glucose check every 15 min until blood glucose returns to normal

range

± Once glucose is up, give complex carbohydrate snack (bagel, sandwich)

± If athlete is unconscious keep athlete on their side (hypoglycemia and

glucagon can often cause nausea)

± Call 911

± Inject 1 mg glucagon in the upper thigh muscle (see instructions below)

± Check glucose after 15 min

± If still unconscious give a second glucagon dose if available

± If consciousness is regained and athlete is able to swallow, provide food

± Monitor closely for 2 hours, checking their glucose every 15-20 min



Emergency Situations: Hyperglycemia ± Signs and symptoms

� Nausea, dehydration, decreased cognitive performance, decreased

visual reaction time, sluggishness, fatigue

� Ketosis: Also may have rapid breathing, fruity odor to breath,

unusual fatigue, sleepiness, inattentiveness, loss of appetite,

increased thirst, and frequent urination

± Prevention

� Frequent blood glucose monitoring

� Pre-exercise insulin dosage adjustments

� Frequent blood glucose testing

± Treatment

� Administration of small bolus of rapid acting insulin

� When blood glucose is �250 mg/dl, test urine or blood for

ketones; if ketones are moderate or high, exercise is

contraindicated

� When blood glucose is �300 mg/dl no activity is allowed



Sick Day Plan (VUMC Division of Pediatric Endocrinology)� Check blood glucose (BG) every 4 hours around the clock until

they are well

� Give BG correction (sliding scale) every 4 hours even if your child

is not eating. Use novolog, humalog or apidra

�Test every urine for ketones or test blood ketones every 4 hours

� Offer fluids every 15 minutes while awake. If BG under 200, offer

liquids with carbs. If BG over 200, offer sugar-free fluids.

� Call 615-322-7842 for any ONE of these reasons:

± Persistent vomiting (more than 3 times) with moderate to large

urine ketones (or blood ketones greater than 1.5 mmol/l)

± Altered behavior

± Persistent rapid breathing



Sick Day Plan (VUMC Division of Pediatric Endocrinology)

� When you call, be prepared to provide:

± The past 48 hours of blood sugars

± Ketone levels

± Any other symptoms your child may be experiencing

� For pump users:

± If blood sugar over 240 and moderate or large ketones, give a

correction for elevated blood sugar with a syringe and change

site

± Always continue the basal rate

� For shot takers:

± Always give the basal insulin (lantus, NPH, or levemir)

� Follow these critical steps to keep your child¶s diabetes in control

when they don¶t feel well!



Items to Have Access to at all Times� Emergency contact information

± Family members

± Physicians-emergency help line to nurse and nutritionist

� Consent for treatment if they are a minor including consent to perform

glucagon injection

� Have the athlete¶s diabetes information sheet (see Diabetes Care Plan)

� Athlete wears medical alert tag at all times

� Blood glucose monitoring equipment including extra blood glucose

test strips

� Supplies to treat hypoglycemia including glucose tablets, fruit juice,

carbs, glucagon

� Supplies for urine or blood ketone testing

� Sharps container to properly dispose of needles and lancets

� Insulin and extra supplies (spare batteries, spare infusion sets and

reservoirs for insulin pumps)

� A copy of the diabetes care plan



Performing a Glucagon Injection on a Diabetic Athlete

INJECTION OF GLUCAGON:

� Glucagon (1 mg) is the white powder in the vial.

� The appropriate dose for all adults is 1 mg.

� The syringe contains only water.

� Pop the cap from the glucagon vial� Remove the cover from the needle on the syringe.

� Inject entire contents of the syringe into the vial

(do not remove syringe)

� Gently mix (as indicated on the inside lid)

� Draw back the entire contents of the vial into the

syringe� Inject the entire contents into the upper thigh

muscle

� Insert the full length of the needle



Conclusion

� Be aware of the signs and symptoms of diabetes mellitus

� Have good communication with and understand the uniqueness of

the diabetic athlete

� Be prepared for diabetic emergencies

� Utilize the Vanderbilt Diabetic Care Plan as a guideline in your

supervision



Acknowledgements

� Thanks to Dr. Diamond, Dr. Wilson, Dr.

Russell and Dr. Potter for their help andinput!



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