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Saturday
Nov122011

Coaching the Athlete with Diabetes

Dr. Craig Stewart, Montana State University, MT, USA

Website: CoachesInfo


Introduction

My first encounter with an athlete with diabetes was when coaching an Under 14 competitive soccer team. I thought I had reviewed all the medical releases thoroughly, but soon discovered I had missed a very important detail. After competing in two matches some two hundred miles from home, the team and I stopped for fast food, got in the van and started the four-hour drive home. My goalkeeper was in the passenger seat next to me, and I paid no attention to him as he completed his meal and put on his head-phones. A little later, I was distracted by him taking a small satchel from his 'keeper' bag. He proceeded to pull down his warm-ups and inject himself in the upper thigh with a medical syringe. Fortunately, I have a background in special education and, having taught in public schools, was not distracted to a degree that I drove off the interstate. However, as I visited with him, I was extremely concerned that a player I had known for a significant period had Type 1 diabetes and was required to carefully monitor both his caloric intake and 'blood sugar' levels throughout the day. When necessary, he injected himself with insulin to counter any imbalances that occurred.

Problem

Both the incidence of obesity and diabetes are on the rise in the USA. It has been estimated that obesity in children has increased over 25% in the last decade. While Type 1 diabetes is more associated with children than type 2, the number of athletes who are competing with some type of diabetes should follow the trend of an increase like obesity. When combined with the continued growth in youth participation in sport, it is imperative that all coaches be aware of issues related to care of athletes with diabetes.
 
Diabetes; The condition: Diabetes is a metabolic disorder in which the body either fails to produce insulin (Type 1) or the body is unable to utilize all or some of what is produced (Type 2). Insulin is a hormone that is produced in the pancreas and functions to regulate glucose ('blood sugar') that is ingested into the intestine and absorbed into the blood. Glucose is the primary source of energy in the human organism, and if it is not all used, then it is stored as glycogen in the liver and, to some degree, in the muscles.
 
In Type 1 diabetes, the body is not making insulin at all; therefore, the individual via syringe, or in some cases, an insulin pump, injects it. This type of diabetes usually is diagnosed before age 30 and only affects about 10% of the individuals with diabetes. However, those who have Type 1 usually are at greater risk for some of the serious side effects of the condition.
 
Type 2 diabetes usually occurs later in life (after age 40), is highly related to obesity (about 80% of individuals diagnosed with Type 2 are obese) and is usually controlled by some combination of oral medication and the coordination of calorie intake and exercise.
 
While the two types are different in many respects, the primary symptoms prior to diagnosis are the same. An individual with undiagnosed or untreated diabetes could exhibit frequent urination, excessive thirst, blurred vision, unusual fatigue, weight loss and slow healing of wounds (especially on the extremities). It is extremely important that coaches be aware of these symptoms and refer their concerns to either the parents or the medical staff associated with the team. If undiagnosed, the athlete may suffer severe permanent organ damage.

Medical conditions and potential side effects

An athlete with either type diabetes can compete at the highest levels if proper care is taken. However, even diabetes that is thought to be under control has the potential to cause serious health problems. The primary concern for the athlete who thinks her/his diabetes is being successfully managed is hypoglycemia (low blood sugar). It is possible for an athlete to overdose on insulin or under eat in relationship to the caloric needs. In that case he/she could experience unusual hunger, sweating, loss of concentration, heart palpations, and nausea. Most individuals with an understanding of their condition are well prepared with some type of easily digested carbohydrate (candy, juice, pop, etc) that can counter the early symptoms. With younger athletes or even on away games, the coach has to be prepared with the same type of food that can be given in an emergency.
 
Hyperglycemia (elevated blood sugar) is not only a symptom of both types of diabetes, but can be exacerbated by exercise in some cases. Over time, uncontrolled hyperglycemia can, in addition to aforementioned problems, cause ketoacidosis or an increase in ketones in the blood. In either situation of high levels of glucose or ketones in the blood, the athlete should not participate in exercise or athletic events until both are controlled by medical staff.

Other concerns

Knowledge: Responsible coaches will be as knowledgeable as possible about the overall health of all their athletes. One can never assume that medical records and parent release forms are valid or current. Coaches must go to any length to ensure they know of any health issues of their athletes.

In the case of an athlete with diabetes, coaches must know
a) what type
b) how medicated
c) diet considerations, both in relationship to day to day activities, and in the case of drastic increases in caloric expenditures related to sport participation
d) other side effects
 
One of the effects of diabetes that can have a direct effect on athletic participation is a visional problem including sensitivity to bright sunlight. In the case of my young goalkeeper, by the time he was a varsity athlete his coaches had to present referees with a written medical explanation to referees for him to be allowed to play wearing wrap-around shades.
 
Other possible physical side effects are the need for hydration and the care of any sites on the extremities for infection. Hydration is an important factor for any athlete, but in the athlete with diabetes it is even more important. The strain that the condition places on the body to maintain homeostasis is severe. In an attempt to eliminate excess glucose, athletes with diabetes will urinate more than normal. The fluid lost must be replaced immediately to prevent further damage and a reduction in performance.
 
In addition to the strain on the kidneys and total body hydration, an athlete with diabetes is also at risk for infections. The ability of the body to fight infections is compromised by diabetes. Therefore, coaches must be aware of cuts or scraps suffered by the athlete, as well as, blisters or 'hot spots' on their feet. Even greater care than normal should be given to these seemingly 'minor' medical issues. They should be referred to the team medical staff or discussed with parents as soon as possible. It is highly recommended that athletes have extra clean, dry socks at all practices and matches to assist in foot care.
 
STRESS - the final concern: A coach of an athlete with diabetes should also be aware of the unique relationship between increased levels of stress and hormonal changes in the body. In the normal individual, one of the basic adjustments to stress (even good stress such as increased excitement prior to an important match) is an increase in some hormonal levels which may result in elevated glucose levels. The "fight or flight' syndrome prepares our body to meet the challenge or escapeÉ as quickly as possible. There is no reason to believe that an athlete who has diabetes would react any differently. Unfortunately, the sudden increase in hormones may work again this athlete. Knowledge of this phenomenon by both the coach and the athlete will assist both in meeting the medical challenge as well as the athletic ones.

Conclusion

There have been numerous athletes who have had successful, productive careers and dealt with their diabetic conditions. Coaches need to be aware of the potential of an increase in the number of athletes they might encounter and how to ensure safe and successful athletic careers.
 
Careful coordination and communication between the athlete, his or her family and their physician with the coach and the medical staff of the athletic program is essential. Diabetes is an extremely serious health condition, but with the proper precautions, it should not affect most athletes who suffer from it.

References

Diabetes and Stress. Retrieved January 29, 2003 from http://www.diabetes.org/main/homepage.jsp
 
Diabetic Ketoacidosis, The Merck Manual. Retrieved January 29, 2003 from http://www.merck.com/pubs/mmanual/section2/chapter13/13b.htm
 
Diabetes Mellitus (DM). Retrieved January 29, 2003 from http://www.pharmacy.gov.my/self_care_guide/miscellaneous/ (the Diabetes Mellitus.pdf)
 
Ebeling, P.; Tuominen, J. ; Bourey, R.; Koranyi, L.; & Koivisto, V. (1995) Athletes with IDDM exhibit impaired metabolic control and increased lipid utilization with no increase in insulin sensitivity. (insulin-dependent diabetes mellitus) Diabetes, v44 n4 p471(7)
 
Fahey, P.J.; Stallkamp, E.T & Kwatra, S. (1996). The athlete with type I DIABETES: managing insulin, diet and exercise. American Family Physician. v53 n5 p1611(9)
 
Healthy habits to help manage and prevent type 2 diabetes (Nutrition Fact Sheet) (2002) Journal of American Dietetic Association. Nov. v 102, i11,p1725(2).
 
Hormones of the Pancreas. Retrieved January 29, 2003 from http://www.users.rcn.com/jkimball.ma.ultranet/BiologyPages/P/Pancreas.html
 
Hornsby, W.G. & Albright, A.L. (2003) Diabetes . In Durstine, J.L & Moore, G.E. , editors. Exercise Management for Persons with Chronic Diseases and Disabilities, 2nd edition, (pp.133-141) Champaign, Ill., Human Kinetic Press.
 
Leski, Mark, M.D. Diabetes in the Active Population (book chapter excerpt) Retrieved January 29, 2003 from http://www.med.sc.edu:1082/pdf%20files/Diabetes%20in%20the%20active%20population.pdf
 
Nelson, K.M., Reiber, G. & Boyko, E.J. (2002) Diet and exercise among adults with type 2 diabetes: findings from the Third National Health and Nutrition Examination survey (NHANES III). Diabetes Care. v25, i10, p1722(7).
 
The diabetes prevention program (DPP): description of lifestyle intervention. (2002) Diabetes Care. v25,i12,p2165(7).
 
Safety Tips. Retrieved January 29, 2003 from http://www.diabetes.org/main/health/exercise/safety/25ways.jsp
 
Sherman, M.; Ferrara, C. & Schneider, B. (1996). Nutritional strategies to optimize athletic performance. Clinical Diabetes, v14 n1 p3(6)


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