Sheri R. Colberg, PhD, and Michael C. Riddell, PhD
Despite the challenges presented by participation in long-duration athletic events, many individuals with T1D are currently training for and participating in such events. Research in this area is lacking, but a handful of studies have attempted to investigate the metabolic and hormonal effects of more extreme athletic participation in such individuals.
In an early study on T1D and distance running, researchers examined the metabolic and hormonal effects of a 3-h marathon training run.197 In that study, insulin was withheld for 16–26 h before the start of the run, although participants ate a normal breakfast 2.5 h before. Blood glucose levels decreased during the 3-h run, and post-exercise ketosis was elevated compared to controls without diabetes. Counterregulatory hormone secretion was found to be normal (or even elevated) in response to hypoglycemia during a long-distance run in these reasonably well-controlled, well-trained subjects with T1D but without long-term complications. Similarly, a study of nine males with T1D during a 75-km cross-country skiing race reported that insulin dose reductions of 30–40% before the event resulted in hyperglycemia during the early part of the race, but near normoglycemia during the remainder, likely attributable to several-fold increases in counterregulatory hormone levels.198 In another study, on the day of a marathon, runners with T1D reduced prerace insulin doses by an average of 26% and ingested 130 g of carbohydrate before, 91 g during, and 115 g after the race.199….
More recently, a study involving 14 male amateur athletes with T1D treated with insulin analogs examined responses to participation in two consecutive editions of the same half-marathon.124 For the half-marathon day, athletes reduced total insulin doses by 18.3% the first year, but only by 14.2% the second; basal insulin was reduced by 23.3% and 20.4% and short-acting insulin at breakfast prior to the competition by 31.7% and 15.3% in years 1 and 2, respectively. Athletes also consumed more carbohydrates during the event the second year (49.0 g vs. 59.1 g), with fewer glycemic excursions. Thus, athletes with T1D who are treated using insulin analogs alone may choose to make a lesser insulin reduction compared to traditional guidelines and slightly increase carbohydrate supplementation (amount and timing) to effectively balance blood glucose levels during long-distance competitions.
Others have shown reduced postmarathon insulin needs and increased insulin clearance, resulting in a decreased insulin availability that may allow enhanced muscle lipid utilization and spare glucose after long-duration exercise.200 However, in another study, after successfully managed marathon running, insulin sensitivity was not increased despite low glycogen content and enhanced glycogen synthase activity after marathon, likely due to increased lipid oxidation.199 Also examined were pre-exercise insulin reductions on consequent metabolic and dietary patterns for 24 h after a bout of running in individuals with T1D.141 Participants self-administered 100%, 75%, 50%, or 25% of their full, rapid-acting insulin dose immediately before consuming a meal and 2 h before completing 45 min of moderate running. Initially blood glucose levels were little affected; levels were highest 3 h postexercise with the lowest dose (25%) of rapid-acting insulin, which was maintained over the rest of the 24-h period despite less energy and carbohydrate intake. Based on this study, one can conclude that greater reductions in mealtime insulin may result in greater protection during the activity but may also result in a greater likelihood for post-exercise hyperglycemia.
Researchers have also studied use of continuous glucose monitoring systems (CGMS) during and after marathon participation to determine whether asymptomatic episodes of hypo- and hyperglycemia can be more effectively identified.201 Although such systems are limited in their ability to detect rapid changes in blood glucose levels, use of CGMS may help to identify asymptomatic hypoglycemia or hyperglycemia during and after a long distance run. The system may also be helpful in improving understanding about the individual changes of glucose during and after a marathon and may protect against hypoglycemic or hyperglycemic periods in future races. Of note, individuals with insulin-treated diabetes are advised not to undertake prolonged intensive exercise after severe hypoglycemia due to increased risk of acute damage to skeletal muscle and to organs such as the liver, risk of severe neuroglycopenia, and the induction of seizures.123
Physical Education Classes and After-School and Team Sports
The goals for most physical education classes are to engage children and adolescents in healthy activities so that students can learn about and achieve the health and fitness benefits of exercise and to help develop some basic motor skills (throwing, catching, running, jumping, etc…). Participating in a 30–45 min physical education class also helps achieve at least a portion of their recommended daily physical activities and helps them learn the importance of communication and teamwork with their friends, peers, and teachers. It is also important for young people to be engaged in such activities early in life so that their participation as adults can be fostered. However, for the child or adolescent with T1D and the caregiver participation in physical activity can be challenging because of the possibility for glucose instability (hypoglycemia or hyperglycemia). The International Society for Pediatric and Adolescent Diabetes encourages participation in physical activity classes for students with diabetes and the American Diabetes Association publishes guidelines on diabetes care in school and day care settings.202
Obviously, participation in vigorous exercise during physical education classes can precipitate hypoglycemia, even if the activity is for just 30 min. For students with diabetes, participation in physical education classes and team sports requires communication and collaboration between the student, his or her health care provider, parents, the school nurse, the physical education instructor, and the team coach. A diabetes care plan should be in place for the child or teen and should include specific instructions for physical activity. The Juvenile Diabetes Foundation (http://www.jdrf.org/) has a useful checklist of actions for the physical education instructor or coach:
■ Encourage exercise and participation in physical activities and sports for students with diabetes as you would for other students.
■ Treat the student with diabetes the same as other students, except in meeting his or her medical needs (remember to respect the student’s right to privacy and confidentiality).
■ Make sure blood glucose monitoring equipment is available at all activity sites, and encourage the student to keep personal supplies readily accessible.
■ Always allow the student to check blood glucose levels.
■ Understand and be aware that hypoglycemia can occur during and after physical activity and that a change in the student’s behavior could be a symptom of blood glucose changes.
■ Be prepared to recognize and respond to the signs and symptoms of hypoglycemia and hyperglycemia, and when a blood sugar event occurs, take initial actions in accordance with the student’s school plan.
■ To treat hypoglycemia, provide the student with immediate access to a fast-acting form of glucose. Consider taping three or four glucose tablets or hard candies to a clipboard or include them in the first aid pack at physical activities, practices, and games.
■ Communicate with the school nurse or trained diabetes personnel or both regarding any observations or concerns about the student.
Students with diabetes should be responsible for wearing a medic alert ID tag at all times. Students and their teachers should be equipped with fast-acting carbohydrate snacks at all times and instructed on the appropriate treatment of hypoglycemia (15 g of carbohydrate; wait 15 min and retest and retreat if necessary). If reductions in pre-exercise insulin are not performed in anticipation of physical education, then carbohydrate intake at a rate of 1 g carbohydrate/kg body mass/h can be implemented. If blood glucose is already elevated prior to the class (144-198mg/dL.)(>8–11 mmol/l) then additional carbohydrate may not be required. As with other types of activity, vigorous activity during school should be avoided if glucose is markedly elevated (250mg/dL.)(>14 mmol/l) in the presence of moderate or higher levels of ketones.
Parents, teachers, and the patient with T1D should be educated as to the symptoms of hypoglycemia, the individualized action plan for prevention and treatment of hypoglycemia, and for potential emergencies (loss of consciousness).
Camping provides young people with diabetes and their families with a unique opportunity to share with and learn from others with diabetes, often in a physically demanding setting. Some studies suggest that a camp experience may improve a child’s psychosocial status and levels of glycemic control, although it should be expected that the experience may increase day-to-day glycemic variability.203–206 Based on retrospective analysis of camp medical records, it is estimated that an empiric 10% reduction in basal insulin appears reasonable upon arrival to camp, as nearly equal numbers of children required dose increases as dose decreases as camp progressed.207In one study of campers, treatment in a camp setting with 0.3 g of fast-acting carbohydrate (glucose tablets, hard candy, or orange juice) was shown to be effective in resolving hypoglycemia within 15 min in most children.208 Guidelines for the staffing and management of diabetes camps can be found through numerous sources including the ADA.209,210
Individuals with T1D were once dissuaded from participating in scuba diving, primarily due to concern that hypoglycemia during immersion would be likely to occur and difficult to treat. The National Association of Underwater Instructors (www.naui.org) still prevents individuals with T1D from obtaining certification to dive through their organization, whereas the Professional Association of Diving Instructors (www.padi.com) allows individuals with T1D to be certified. The Divers Alert Network (www.diversalertnetwork.org) reports that many active divers have T1D and that the majority of such divers do not experience dive-related hypoglycemia.211 The United Kingdom is supportive of allowing persons with T1D to scuba dive, as long as certain precautions are taken (http://www.ukdiving.co.uk/information/medicine/diabetes.htm). Indeed, recent evidence suggests that scuba diving can be undertaken safely by well-controlled, experienced, and complication-free individuals with T1D, assuming that appropriate precautionary measures are taken. Important precautions to help prevent hypoglycemia include the use of a rigorous protocol of serial predive blood glucose measurements to determine glucose levels and rates of change before entering the water.212 Some authors recommend a glycemic goal of 200–250 mg/dl (11–13.75 mmol/l) before immersion with a significant reduction of insulin doses (by 30%) and the availability of rapid-acting carbohydrates either on hand or on board.213 These affirmative results resulted in the French diving federation (FESSM) now allowing individuals with T1D to dive with some restrictive qualification requirements: dives must be within the safety curve (no decompression curve), in >14oC water, within depths limited to 6–20 meters, and with mandatory guidance by a diving instructor.
During a simulated dive to 27 meters in a hyperbaric chamber, well-controlled adults with T1D who were free of long-term complications were able to effectively self-regulate blood glucose levels to avoid hypoglycemia.214 However, long-term complications of diabetes (such as diabetic proliferative retinopathy) may need to be excluded before a diver with diabetes may be permitted to dive.215 In addition, it may be advantageous for divers to use CGM to help limit hypoglycemia.154 In a CGM-related study, 117 dives were undertaken by 24 adults, half with T1D; hypoglycemia (<70 mg/dl) was detected using CGM in six individuals and on nine occasions, but in none of these cases were hypoglycemic symptoms present during or immediately after diving.154 The number of hypoglycemic episodes, 10 min prediving or immediately postdiving, were related to the duration of diabetes, percentage of SMBG values below target (<72 mg/dl), and total duration below low limit (<70 mg/dl). These results led to the conclusion that well-informed, well-controlled individuals with T1D can dive safely and that the use of CGM and repetitive self-monitoring of blood glucose on a schedule allows identification of individuals who are suitable for diving. Use of CGM under diving conditions has also been reported to be reliable and reasonably accurate.216
■ Blood glucose levels should be >150 mg/dl before the dive, and the dive should occur following a meal.
■ If the blood glucose is <150 mg/dl, 5 g of glucose should be consumed for every 25 mg <150 mg/dl. Carbohydrates in the form of simple sugars, such as fruit juice, milk, or glucose tablets or liquid, should be ingested.
■ The diver should carry liquid sugar in the wet suit during the dive and use as needed.
■ The diver should measure blood glucose after the dive and ingest glucose as needed.
■ The diver should always dive with a companion who understands how to recognize and treat a hypoglycemic reaction. When under water, divers should have a prearranged means to communicate the likely incidence of hypoglycemia.
■ Glycemic control should be stable during the days of planned diving.
■ Alcohol should not be consumed 24 h before or during the diving activities.217
Treatment of Overweight and Obesity with Physical Activity
Engaging in regular physical activity generally lowers overall insulin requirements and reduces the risk of weight gain associated with excess insulin use.218–222 In rats with alloxan-induced T1D, intensive insulin treatment induces insulin resistance by impairing glucose metabolism–related mechanisms in muscle and liver (i.e., by increasing insulin resistance).223 With the expectation that insulin resistance develops in hyperinsulinized diabetic patients as well, the authors of that study suggested using insulin-sensitizer approaches (like increased physical activity) to effectively treat T1D.
In adults without diabetes, exercise has been shown to have beneficial effects on body fatness in the absence of prescribed dietary change, with a progressive loss of body fat associated with higher exercise energy expenditures in both men and women.224 Even greater free-living activity energy expenditure (such as walking, household chores, and work-related physical activity) can aid in weight loss and weight maintenance.225 Similarly, in individuals with T1D, physical activity can improve insulin action, albeit acutely, and potentially lower insulin requirements and body weight. For example, in one study involving 13 previously sedentary individuals with T1D (ages 13–30 years), engaging in either 12 weeks of aerobic or resistance exercise training lowered their insulin needs, waist circumference, and post-training blood glucose levels, although their A1C levels were not significantly improved.7 Moreover, all adolescents with T1D can benefit from combined aerobic and strength training undertaken twice weekly for 20 weeks, which results in lower daily insulin requirements, improved physical fitness, and an enhanced sense of well-being.226 Similar training has also been shown to reduce cardiovascular risk and insulin resistance risk factors in diabetic adolescent girls.227 Exercise truly is a powerful medicine for anyone with T1D, especially if overweight or obese from insulin use.
A number of key research areas still need development in the area of exercise and T1D. These include:
■ What are the health benefits of resistance training for patients with T1D?
■ What is the impact of exercise in various environments on the pharmacokinetics and pharmacodynamics of rapid-acting and long-acting insulin analogs?
■ What are the appropriate insulin adjustments for resistance and anaerobic type exercise that results in hyperglycemia?
■ What are the appropriate postexercise basal rate adjustments to limit postexercise hyperglycemia in the pump-treated patient?
■ What should be the low-glucose suspend level for sensor-augmented, pump-treated patients engaged in physical activity?
■ What is the appropriate insulin dose adjustment (correction) for postexercise hyperglycemia in the patient on a multiple daily injection regimen?
■ What is the optimal feeding strategy to prevent exercise-associated hypoglycemia (type of carbohydrate, timing of ingestion, and dosage)?
■ What other noninsulin adjustment strategies help to prevent exercise-associated hypoglycemia (e.g., caffeine, protein supplementation, glucagon stimulants or agonists, adrenergic agonists, etc.)?
■ What are the optimal approaches to prevent severe nocturnal hypoglycemia?
■ What limitations, if any, should be placed on individuals wishing to per-form extreme or higher risk activities (scuba, skydiving, Ironman, etc.)?
■ What are the optimal insulin-adjustment and nutritional strategies to help facilitate weight (fat) loss via increased physical activity in T1D?
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Anne Peters, MD, and Lori Laffel, MD, MPH, Editors
Jane Lee Chiang, MD, Managing Editor
Used with permission by the American Diabetes Association. Copyright © 2013 American Diabetes Association.
Please note: We are proud to have Dr. Anne Peters as a member of our Advisory Board member for Diabetes In Control, Inc.