Documente Academic
Documente Profesional
Documente Cultură
Approach
http://sph.sagepub.com/
Diabetes in Sports
Christine Shugart, Jonathan Jackson and Karl B. Fields
Sports Health: A Multidisciplinary Approach 2010 2: 29
DOI: 10.1177/1941738109347974
The online version of this article can be found at:
http://sph.sagepub.com/content/2/1/29
Published by:
http://www.sagepublications.com
On behalf of:
Additional services and information for Sports Health: A Multidisciplinary Approach can be found at:
Email Alerts: http://sph.sagepub.com/cgi/alerts
Subscriptions: http://sph.sagepub.com/subscriptions
Reprints: http://www.sagepub.com/journalsReprints.nav
Permissions: http://www.sagepub.com/journalsPermissions.nav
vol. 2 no. 1
SPORTS HEALTH
[ Primary Care ]
Diabetes in Sports
Christine Shugart, MD, Jonathan Jackson, MD, and Karl B. Fields, MD*
Context: Exercise is recommended for individuals with diabetes mellitus, and several facets of the disease must be considered when managing the diabetic athlete. The purpose of this article is to review diabetes care in the context of sports
participation.
Evidence Acquisition: Relevant studies were identified through a literature search of MEDLINE and the Cochrane database, as well as manual review of reference lists of identified sources.
Results: Diabetics should be evaluated for complications of long-standing disease before beginning an exercise program,
and exercise should be modified appropriately if complications are present. Athletes who use insulin or oral insulin secretogogues are at risk for exercise-induced immediate or delayed hypoglycemia. Diabetics are advised to engage in a combination of regular aerobic and resistance exercise. Insulin-dependent diabetics should supplement carbohydrate before
and after exercise, as well as during exercise for events lasting longer than 1 hour. Adjustment of insulin dosing based on
planned exercise intensity is another strategy to prevent hypoglycemia. Insulin-dependent athletes should monitor blood
sugar closely before, during, and after exercise. Significant hyperglycemia before exercise should preclude exercise because
the stress of exercise can paradoxically exacerbate hyperglycemia and lead to ketoacidosis. Athletes should be aware of
hypoglycemia symptoms and have rapidly absorbable glucose available in case of hypoglycemia.
Conclusion: Exercise is an important component of diabetes treatment, and most people with diabetes can safely participate in
sports at recreational and elite levels with attention to appropriate precautions.
Keywords: diabetic athlete; medication adjustment; insulin pump; benefits and risks of sport
PHYSIOLOGY OVERVIEW
An increase in plasma glucose concentration after a meal
stimulates insulin secretion by the beta cells of the pancreas.11
29
Shugart et al
THE CHALLENGES OF
MANAGING THE DIABETIC
ATHLETE WITH COMPLICATIONS
Smoking cessation, blood pressure control, and lipid
management are important in preventing complications
of diabetes.14 Glycemic control is addressed through diet,
exercise, and medications. However, reasonable glycemic
control is an essential consideration before initiation of an
exercise program for the diabetic athlete. The physician
should establish a baseline hemoglobin A1c (HbA1c). In
type 1 diabetics with levels higher than 9%, no vigorous
exercise is advised until baseline control is improved
(normal HbA1c in individuals without DM is less than 6%).23
For type 2 diabetics with a poorly controlled HbA1c, the
exercise program should begin gradually. The physician may
allow sequential increases in exercise intensity as long as
diabetic control improves.
Many diabetics develop macrovascular and microvascular
complications of their disease, such as coronary artery disease,
peripheral vascular disease, autonomic neuropathy, peripheral
neuropathy, retinopathy, nephropathy, and musculoskeletal
problems.14 American Diabetes Association (ADA) guidelines5-7
recommend evaluating diabetics for complications before
initiating an exercise program. Identification of complications
will allow physicians to appropriately modify the exercise
prescription to minimize risks.3,5,6
Diabetic athletes should wear a MedicAlert-type bracelet or
necklace indicating their diagnosis and specifying if it is DM1
or DM2.
30
vol. 2 no. 1
SPORTS HEALTH
Onset
Peak
Duration
10-15 min
1-2 hr
3-4 hr
30 min
2-4 hr
5-8 hr
2-4 hr
6-12 hr
16-24 hr
Detemir: Levemir
1 hr
No peak
up to 24 hr
Glargine: Lantus
1-4 hr
No peak
> 30 hr
Rapid-acting
Lispro: Humalog
Aspart: NovoLog
Glulisine: Apidra
Short-acting
Regular: Humulin R, Novolin R
Intermediate-acting
NPH: Humulin N, Novolin N
Long-acting
Diabetic Nephropathy
There is no evidence that the elevated blood pressures
generated during exercise exacerbate progression of diabetic
nephropathy.3 However, considering the serious implications of
progressive renal damage, individuals with nephropathy should
avoid vigorous activity that could cause a significant rise in
systolic blood pressure.3,5
Orthopaedic Complications
Fascial disease, adhesive capsulitis, tendon pathology, Dupuytren
contractures, flexor tenosynovitis, and nerve entrapments occur
with increased frequency in individuals with diabetes.14
Diffuse idiopathic skeletal hyperostosis (calcification of the
paraspinal ligaments) is more common in individuals with
diabetes. Neuropathic joint collapse (Charcot joint) can also
develop, marked by progressive degeneration of weightbearing
joints in the setting of peripheral neuropathy.14
Diabetic amyotrophy is a lumbar polyradiculopathy
manifesting with severe pain, dysesthesias, and muscle atrophy
of the thighs. The presence of these or other orthopaedic
conditions may affect the ability of diabetic individuals to
participate in certain exercise activities.14
31
Shugart et al
Examples
Mechanism of Action
Sports Considerations
Biguanides
metformin:
Glucophage,
Fortamet, Glumetza,
Riomet
Decrease hepatic
glucose release;
increase peripheral
glucose utilization
Gastrointestinal upset;
lactic acidosis (rare)
None known
Sulfonylureas
glimepiride: Amaryl
glyburide: DiaBeta,
Micronase
glipizide: Glucotrol
chlorpropamide:
Diabinese
tolazamide
tolbutamide
Stimulate insulin
secretion by
pancreas
Hypoglycemia
Thiazolidinediones
pioglitazone: Actos
rosiglitazone: Avandia
Increase sensitivity to
insulin
Edema; increased
fracture risk in
women; increased
cardiovascular events
with rosiglitazone
None known
Alpha-glucosidase
inhibitors
acarbose: Precose
miglitol: Glyset
Delay absorption of
complex carbs from
small intestine
Gastrointestinal upset
Incretin mimetics
exenatide: Byetta
Increase food-induced
insulin secretion;
slow gastric
emptying; decrease
appetite
Gastrointestinal upset;
rare hypoglycemia
None known
Dipeptidyl peptidase-4
inhibitors
sitagliptin: Januvia
Minimal
None known
Meglitinides
nateglinide: Starlix
repaglinide: Prandin
Stimulate insulin
secretion by
pancreas
Hypoglycemia (less
common than with
sulfonylureas)
Amylin mimetics
pramlintide: Symlin
Insulin
Injected insulin is a mainstay of diabetes therapy for type 1
diabetics and for type 2 diabetics with moderate to severe
disease. Several different preparations are used, varying
primarily in pharmacokinetics.14 Frequently, regimens consist of
long-acting basal insulin with a short-acting multidose regimen
taken at meals and bedtime (Table 2).14
Insulin pump technology continues to evolve, providing
a device for continuous subcutaneous infusion with
32
Side Effects
vol. 2 no. 1
SPORTS HEALTH
GUIDELINES
Recommendations vary based on the level of athleticism and
on the type of diabetes: DM1 or DM2. In general, athletes
with DM1 tend to be younger and are often more competitive.
There are elite and endurance athletes with DM1. Figure 1
gives a preexercise algorithm for athletes with DM1.
Most patients diagnosed with DM2 are middle aged and
often have comorbidities of obesity, hyperlipidemia, and
33
34
Figure 1. Exercise algorithm for athletes with type 1 diabetes mellitus, designed for distance/endurance events longer than 30 minutes. This algorithm represents general
guidelines; approach should be tailored to meet the needs of the individual athlete. It is intended to summarize treatment recommendations from multiple sources
and does not represent a validated clinical decision rule. Refer to text for evidence supporting each step.
vol. 2 no. 1
SPORTS HEALTH
35
Shugart et al
Whole-wheat breads
Lower fiber fruit
Most vegetables
Pizza
Energy bars (eg, Power Bar)
Some candy bars
Brown rice
Popcorn
Soft drinks/soda
High GI: 70
36
Baked potato
Carbohydrate
snacks: ~ 30 ga
vol. 2 no. 1
SPORTS HEALTH
Clinical Recommendations
SORT: Strength of Recommendation Taxonomy
A: consistent, good-quality patient-oriented evidence
B: inconsistent or limited-quality patient-oriented evidence
C: consensus, disease-oriented evidence, usual practice, expert opinion, or case series
SORT Evidence
Rating
Clinical Recommendationa
Exercise aids diabetes treatment by improving glucose metabolism8,33 and insulin sensitivity36; it can also reduce the use of oral medications and insulin.
Participation in team sports early in life has been associated with decreased macrovascular complications and mortality for type 1 diabetics.20
The physician should establish a baseline hemoglobin A1c. For type 1 diabetics with levels higher than 9%, no vigorous exercise is advised until
baseline control is improved (normal level in individuals without diabetes mellitus is less than 6%).23
Physicians should consider screening previously sedentary diabetics for coronary disease before initiation of moderate to intense exercise, particularly
if they are high risk.3,5,13
Patients with diabetes mellitus should have 5 or more days (a minimum of 150 minutes) of aerobic exercise weekly and 3 days of resistance training
weekly.6
Both insulin reduction and increased carbohydrate consumption have been shown to be effective at reducing risk for hypoglycemia in diabetic athletes.4,15,27
a
For more information about the SORT evidence rating system, see www.aafp.org/afpsort.xml and Ebell MH, Siwek J, Weiss BD, et al. Strength of
Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician. 2004;69:549-557.
2.
3.
4.
5.
6.
7.
8.
CONCLUSION
Physical activity does reduce the complications of diabetes.4-6,8,32
Many people with diabetes require exercise modifications and
restrictions owing to risk for injury or worsening disease. Little is
known about oral diabetic medication use in exercise, and oral
medications are rarely used in elite-level sports.
Type 2 diabetics are advised to exercise at an appropriate level
of intensity and duration, according to current ADA guidelines.
The greatest risks to the elite or endurance athlete
with insulin-dependent diabetes are hyperglycemia and
hypoglycemia. Hypoglycemia should be avoided through insulin
reduction or increased carbohydrate consumption. Both have
been effective in maintaining euglycemia.15,27 Guidelines are
available to estimate carbohydrate needs and insulin adjustments
for athletes.15,16,23,26,27 Blood glucose control for type 1 diabetics
in intense exercise and athletic competition is a trial-and-error
process with variations between individual athletes.
REFERENCES
1.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
37
Shugart et al
19.
For reprints and permission queries, please visit SAGEs Web site at http://www.sagepub.com/journalsPermissions.nav.
38