Preparticipation considerations

The physician must get to know the athlete; aptitudes, attitudes, intelligence, intensity, and family variables may all come into play. It is also often necessary to “get into the head” of the athlete regarding rituals, such as lucky things done or worn, to bring success. It is useful to explore the youth’s ideas about performance at different levels of blood glucose, attitudes about knowing blood glucose by how it feels versus testing with a blood glucose meter, and fears about hypoglycemia. Also, explore how and when concentration or visualization is used to prepare for sports so that diabetes-related actions will be incorporated and reliably executed without the athlete feeling loss of ability to excel.

The next thing to know is the sport: the balance between aerobic and anaerobic exercise, how intensively the sport is played and practiced, the duration of the exercise, the risks of injury, and especially the risk for injury to self or others if distracted by hypoglycemia. These are only a few of the critical aspects of a sport. It is vital to understand the nature and intensity of the training and of the competition—and how those two aspects may affect the athlete in different ways—so that appropriate adjustments in management can be made.

One must know the teammates and the coach: their attitudes, abilities, methods, and willingness to assist in the diabetes management are critical to a successful plan for participation. This is included but not always emphasized in the scientific literature regarding athletes with diabetes. Where appropriate, and with permission of the athlete and family, direct contact with teammates and the coach may be very helpful.

Knowledge of the physiology of exercise, at least at a basic level, is needed in order to understand the changes in fuel use, blood sugar levels, or insulin effects.

Knowledge, both of the effects of diabetes complications on participation in the particular sport and of the risks of sports participation in the presence of complications is important.

Knowledge of the diabetes management resources that benefit the athlete is another key area. Necessary information includes: how insulin works, what delivery devices are used for the insulin, what monitoring devices are in use, which insulin administration protocols are being followed, what sources of carbohydrate are available to support exercise, or to treat hypoglycemia, who has access and knowledge of the use of emergency glucagon kits for severe episodes of hypoglycemia, and how to access support groups and information that the athlete can employ for improvement of the process.

Follow-up of the recommendations to assess how well they have worked during the sports season, is not an element of knowledge to be gained, but it is the only sure way to allow for necessary adjustments.

The athlete

Getting to know the athlete before the start of the season will give the best chance for making a plan that has the participation and buy-in of the adolescent. The preparticipation interview regarding diabetes management for sports is ideally part of routine diabetes care, and it certainly may be done in the primary care setting by a knowledgeable physician.

Important factors include the type of diabetes management currently employed by the athlete; types of insulin and delivery devices; and how well the management is working, eg, glycohemoglobin level, number of severe episodes of hypoglycemia, or any ill effects on growth from the diabetes. To make useful adjustments in insulin dosing or carbohydrate intake, the athlete or his or her support team must be willing and able to make the kinds of calculations needed. These include carbohydrate counting, knowing the insulin-to-carbohydrate ratio for food coverage and the insulin dose for excessively high blood glucose, and tracking the blood glucose trends before, during, and after training and competition by frequent monitoring of capillary blood glucose levels. We use the slogan “just test it.”

When the athlete is a highly intelligent and curious individual, reinvention of management ideas may occur between office visits. One basketball player in our clinic discovered that the effect of the short-acting insulin analog given soon before eating did not persist long enough to adequately cover his evening meal—he had previously needed to wait 45 minutes after using regular insulin before eating to get good effect. He hit upon using 50% of each type of insulin so that he had no waiting and regained excellent control. This kind of discovery humbles and gladdens diabetes doctors!

The athlete

Getting to know the athlete before the start of the season will give the best chance for making a plan that has the participation and buy-in of the adolescent. The preparticipation interview regarding diabetes management for sports is ideally part of routine diabetes care, and it certainly may be done in the primary care setting by a knowledgeable physician.

Important factors include the type of diabetes management currently employed by the athlete; types of insulin and delivery devices; and how well the management is working, eg, glycohemoglobin level, number of severe episodes of hypoglycemia, or any ill effects on growth from the diabetes. To make useful adjustments in insulin dosing or carbohydrate intake, the athlete or his or her support team must be willing and able to make the kinds of calculations needed. These include carbohydrate counting, knowing the insulin-to-carbohydrate ratio for food coverage and the insulin dose for excessively high blood glucose, and tracking the blood glucose trends before, during, and after training and competition by frequent monitoring of capillary blood glucose levels. We use the slogan “just test it.”

When the athlete is a highly intelligent and curious individual, reinvention of management ideas may occur between office visits. One basketball player in our clinic discovered that the effect of the short-acting insulin analog given soon before eating did not persist long enough to adequately cover his evening meal—he had previously needed to wait 45 minutes after using regular insulin before eating to get good effect. He hit upon using 50% of each type of insulin so that he had no waiting and regained excellent control. This kind of discovery humbles and gladdens diabetes doctors!

The family and the athletic staff

The family plays a vital, if not always front-seat role, in diabetes care of an adolescent. Involve family members in the planning because they, along with the adolescent, are the primary contacts for educating the coaching staff about the needs of the adolescent to safely participate. Discussion about the appropriate blood glucose-level strategy is a central part of the preparticipation interview. Ideas that a high blood sugar at the start of exercise will lead to a better performance are probably not correct. Using out-of-range starting glucose levels to protect against hypoglycemia does not seem successful in youth seen in this clinic. It is also important that the athlete test real-time capillary blood glucose levels during the exercise, counting on how it feels to recognize hypoglycemia is not always accurate and can be dangerous.

Defining roles for the athlete, family and coaching staff should be decided early in the season: who will have the fast-acting source of carbohydrate, whether there will be a glucagon kit and who will know how and when to give it, and where the testing supplies will be kept and when they may be used. Validation of worries about hypoglycemia and developing a plan with the athlete to help avoid it will build the trust needed to keep the athlete on track with blood sugars. The fear of hypoglycemia is a major impediment to improving blood glucose control. To not recognize that, and thus miss the opportunity to help minimize risks while maintaining good control of levels, is to ask for hyperglycemia as the pre-exercise condition.

The sport

Different sports have their own effects on diabetes management. Moderate aerobic exercise is associated with hypoglycemia while bursts of anaerobic exercise may actually raise blood glucose. The very helpful tables of carbohydrate use and “exercise exchanges” (minutes of exercise requiring 15 g of carbohydrate based on size and type of exercise) from the work of Riddell and Bar-or can be found in the Handbook of exercise in diabetes , and their table of exercise exchanges can be found online in the International Society for Pediatric and Adolescent Diabetes (ISPAD) Clinical Practice Consensus Guideline for 2009 entitled Exercise in children and adolescents with diabetes . Recognize that these, like all other numeric calculations for diabetes care, are starting points, they are only approximations of the truth, which is to be found by testing levels when the individual athlete is exercising. It is only by monitoring the outcomes that they can be validated and adjustments made to fit an individual.

There is also a need to be certain that information regarding the effect of training and practice, as differentiated from the effect of competition, be kept in mind. Many sports have much longer practice times than game participation times in order to promote endurance, yet the athletes often “leave it all on the field” during a game. The role of exercise duration and the role of exercise intensity need to be assessed. One question to ask is: How much is practice biased toward aerobics and conditioning and how much is a game like repetitive sprints?

In addition, depending on the sport, some of the most intensely pleasurable experiences are related to level of skill, such as a perfectly executed golf or tennis swing, a weightless-feeling basketball during a well-executed hook shot, or the sensation of the “sweet spot” of the bat crushing the baseball with no shock to the hands. Clear-headed concentration is needed both to attain those skills and to enjoy them. “Practice does not make perfect, perfect practice makes perfect” is not just a slogan, it is the core of motor memory training and well-controlled levels of blood glucose will facilitate this process. Risk of injury during episodes of hypoglycemia is a serious matter in sports with rapid movements; sports in which collisions routinely occur; and in sports such as climbing, scuba diving, and swimming, in which diminished attention could lead to a catastrophic event. The primary safety concern is avoidance of unrecognized hypoglycemia.

Additionally, in activities where an injured or incapacitated partner might risk the health or life of the other partner, such as technical climbing, mountaineering, or scuba diving, there is also a moral imperative to minimize the risk of hypoglycemia. Gradual acclimatization to these sports should be recommended with much attention to the effect on blood glucose so that appropriate adjustments in management can be made. For example, it did not seem necessary to stop mountaineers with diabetes from climbing Mt Everest or Denali because they were capable climbers. Helping them to keep their diabetes safe was the needed intervention. World-class athletes with diabetes have earned Olympic Gold Medals and been professional athletes for decades, even with the older more cumbersome diabetes management systems. One vignette regarding practice and competition comes to mind from our clinic. A very competitive sprint swimmer with diabetes had miserable experiences and slowing times when swimming 500-yard races in practice. We even went so far as to test him for the overtraining phenomenon, which is a transient hypopituitary state that is the equivalent of the oligomenorrhea seen in some intensely training female endurance athletes. In spite of his complaints about the 500-yard races, his times in the 50-yard races were quite good; in fact, he obtained a high ranking in the state and he felt well when sprinting. He elected to tolerate the “misery” of endurance training as he was in no danger and he had a successful year.