1/8/2014 Diabetes in the Outline Young Athlete The Disease The Athlete PATIENT CASE Epidemiology Chad Beattie, MD Diagnosis Pathology What is diabetes? Primary Care Sports Medicine Treatment Hawthorn Medical Associates Type I vs Type II Department of Orthopedics PPE/Preparticipation Complications Associate Faculty University of Massachusetts Considerations Complications Acute Chronic Monitoring the diabetic athlete Head Team Physician: What to have in your bag Bridgewater State University New Bedford Bay Sox Injuries and glucose control Fairhaven high School Epidemiology Total: 25.8 million children and adults in the United States—8.3% of Disclosures the population—have diabetes. Diagnosed: 18.8 million people None Undiagnosed: 7.0 million people Photos are not real patients Prediabetes: 79 million people Lifetime risk of developing diabetes= 33% (men) ; 39%(women) Pediatrics: Under 20 years of age 215,000, or 0.26% of all people in this age group have diabetes About 1 in every 400 children and adolescents has diabetes Men:Women is equal Diabetes – What is it? * Shugart et al. Diabetes in Sports. Sports Health . 2010. Jan/Feb: pp 29-38 Glucose Insulin * Jimenez et al. NATA Position Statement: Management of the Athlete with Type 1 Diabetes Mellitus. J Athl Tr . 2007;42(4):536-545 1
1/8/2014 Types of Diabetes Commonly Associated Conditions: Type 1 Celiac Disease Type 2 Addison Disease Other Autoimmune conditions Hypothyroidism • AKA • AKA •Childhood / Adolescent Diabetes •NIDDM •Juvenile Diabetes •Adult-Onset DM •IDDM Response to INSULIN INSULIN Mean age of onset: 8-12 Pathophysiology: Felt to be an autoimmune condition Alteration in immune response places beta-cells at risk for imflammatory damage Autoantibodies to Islet cells have been identified “ Use it or Lose it ” Decrease in Beta cell function and Mass = Insulin secretion 2
1/8/2014 Where it all starts: The Pancreas Risk Factors: BMI>25 Hypertriglyceridemia African american > Latino > Native american > Asian American Sedentary lifestyle Family Hx of DM Gestational diabetes Normal Glucose Metabolism Commonly Associated Conditions: HTN Hypercholesterolemia Stroke Absorption ED Infertility Pancreatic cancer Acanthosis nigricans FOOD Abnormal Glucose Metabolism DM 1 DM 2 Diagnosis Typically diagnosed in early Usually Dx in adulthood, childhood or adolescence or although this is changing early adulthood Mechanism Insulin Deficiency Decreased Insulin utilization Complications Hyperglycemia, weight loss, Obesity, HTN, hyperlipidemia DKA Demographics Younger, more fit population More common in older, overweight individuals 3
1/8/2014 Glucose Metabolism during Complications Exercise In 2004: 70% of all diabetes related deaths were due to cardiac disease 16% of all diabetes related deaths were due to stroke Insulin is suppressed → More glucose released from liver Risk of stroke or heart disease is 4 x higher in diabetics #1 cause of blindness in the US Muscles = ↑ sensitivity to insulin = more efficient glu uptake into muscle #1 cause of kidney failure > 200,000 people a year are on dialysis b/c of diabetic nephropathy Blood glucose levels decrease 70% of diabetics have neuropathy #1 cause of atraumatic amputations in the US Glucose Metabolism The Diabetic Athlete a fte r Exercise One Athletes Story Insulin levels rise → Excess glucose gets stored in muscle and fat. Diabetes – so what? A 16yo high school female soccer player and T&F athlete presents for her annual examination and reports feeling well except for increased burning with urination and some urinary frequency over the past 5 days. Her physical examination is unremarkable and her vital signs, including her blood pressure are within normal limits. She submits a urine sample 4
1/8/2014 The urine analysis shows : Diagnosis Color Yellow Scenario 1 – Incidental Clarity Clear Spec Grav 1.030 Glucose Positive Scenario 2 – The symptomatic athlete Ketone Positive Nitrite + Leuk Est + WBC 4-8/hpf Scenario 3 – The hospitalized youngster Protein Positive Diagnosis Urinary Tract Infection Famous Diabetic Question Type 1 DM Athletes Gary Hall Jr – Olympic Champion 50m freestyle Kelli Kuehne Diabetes work-up Treatment Diagnostic Criteria Exercise Fasting blood glucose >126 mg/DL Random blood glucose > 200 mg/DL Nutrition HbA1C level >6.5% Medications (insulin) Glucose tolerance test: blood glu >200 mg/DL, 2 hours after a glucose load 5
1/8/2014 Insulin Treatment • Multiple Daily injections (MDI) Exercise is Medicine: Improves glucose metabolism Improves insulin sensitivity Can reduce the use of PO medications and insulin Participation in team sports = ↓ Macrovasc complication and ↓ mortality * * LaPorte et al. Pittsburgh Insulin-Dependent Diabetes Mellitus Morbidity and Mortality Study: Physical activity and diabetic complications. Pediatrics . 1986;78:1027-1033 Diet – Glycemic Index Insulin Pump Insulin The PPE Insulin Action How to use Length Humalog Rapid Bolus in MDI Minutes Novolog History / Discussion should include: Humulin Fast 2-4 hours Bolus in MDI Basal/Bolus in pump Assessment of self-care skills and knowledge of disease Novolin Humulin N Intermediate Basal dose inj 4-10 hours Discuss how exercise will affect blood glucose control Novolin N An assessment of current glycemic control (HgbA1c) Lantus Long Basal dose inj 1 day Detemir Information regarding the presence of DM-related complications 6
1/8/2014 Common Problems Encountered with The PPE Diabetic Athletes “ Medical ” “ Orthopedic ” Physical examination should include: Hypoglycemia Fascial Disease Immediate Delayed Adhesive Capsulitis Complication Examination Hyperglycemia Tendon pathology Ketoacidosis Brain Cognitive evaluation Proliferative Retinopathy Flexor tenosynovitis Heart Complete cardiovascular examination Nephropathy Peripheral Neuropathy Nerve entrapments PVD Peripheral pulses Eyes Dilated ophthalmologic exam annually Kidneys Urinalysis to assess proteinuria annually Nerves Monofilament and reflex exam Pre-participation Considerations Hypoglycemia Typically only happens to patients who take insulin ADA guidelines recommend screening for diabetic Exercise is the #1 cause complications before participation Diabetic athletes should wear MedicAlert bracelet • ↑ Absorption of insulin during exercise • ↑ Sensitivity to insulin during exercise • Exogenous insulin does Not decrease during exercise like endogenous insulin does Hypoglycemia Acute Complications Hypoglycemia Symptoms occur with blood glucose < 70mg/dL Symptoms: Hyperglycemia Tachycardia Sweating Palpitations Hunger Anxiety Headache / dizziness Blurred vision, seizure, coma 7
1/8/2014 Hypoglycemia Hypoglycemia Treatment = PREVENT IT Insulin Adjustments → Blood Glucose Monitoring Insulin Pump: ↓ basal rate by 20-50% 1hr before exercise → Carbohydrate supplementation ↓ Bolus by 50% at meal preceding exercise Disconnect pump at exercise onset → Insulin Adjustments Multiple Daily injector Treatment = Give Glucose! ↓ Bolus by 50% at meal preceding exercise Hypoglycemia Hypoglycemia Mild Hypoglycemia Athlete following commands 10-15g of glucose tablets or honey Blood Glucose monitoring Re-check blood glu in 15 mins Before Exercise : 2-3 times to check the trend → levels <70mg/dL = Postpone exercise 10-15g of glucose tablets or During exercise: q 30 mins honey After: q 2 hrs x 2 to check for Post-Exercise hypoglycemia Glucagon Hypoglycemia Hypoglycemia Carbohydrate Supplementation Pre-Exercise → Carb rich meal 2-4 hours before exercise. → Additional 15-30g of Carbs within 1 hour of Severe Hypoglycemia exercise Athlete unable to follow During → Additional 30-100g for every hour of exertion commands Post → 1.5g/Kg of CHO per hour x 4 hours → Restart insulin at this meal Glucagon 8
1/8/2014 Hyperglycemia 1 – Under-insulinization ↓ Insulin = ↑ Hepatic Glucose production Normal Glucose Metabolism Hyperglycemia Hyperglycemia 2 - Hormones Why would an athlete get HYPER glycemic? ↑ Catecholamine ↓ Muscle ↑ FFAs HIE = = = ↑ Blood Glu utilization of glucose ↑ Ketones Hyperglycemia Hyperglycemia 3 - Psychological Stress Typically occurs with High-Intensity Exercise (70% VO2 max or >85% MHR) ↑ Counterregulatory ↑ Stress = = ↑ Blood Glu hormones * Insulin mgmt strategies from practice may not work on game day 9
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