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Volume Number December Journal of Athletic Training by the National Athletic Trainers Association Inc www

journalofathletictrainingorg National Athletic Trainers Association Position Statement Management of the Athlete With Type 1 Diabetes Mellitus Carolyn C Jimenez PhD ATC Matthew H Corcoran MD CDE James T Crawley MEd PT ATC W Guyton Hornsby Jr PhD CDE

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Volume Number December Journal of Athletic Training by the National Athletic Trainers Association Inc www






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Volume42Number4December2007uctuationsthatcouldaffectinsulinaction,insulinshouldnotbestoredinthecargoholdoftheairplane.15.Whentraveling,athleteswithtype1diabetesareadvisedtocarryprepackagedmealsandsnacksincasefoodavail-abilityisinterrupted.Iftraveloccursoverseveraltimezones,insulintherapymayneedtobeadjustedtocoor-dinatewithchangesineatingandactivitypatterns.AthleticInjuryandGlycemicControl16.Trauma,eveninpersonswithoutdiabetes,oftencausesahyperglycemicstate.Hyperglycemiaisknowntoimpairthewoundhealingprocess;thus,forathleteswithtype1diabetes,anindividualizedbloodglucosemanagementprotocolshouldbedevelopedforuseduringinjuryrecov-ery,includingfrequencyofbloodglucosemonitoring.Diabetesmellitusisachronicendocrinedisordercharacter-izedbyhyperglycemia.Personswithdiabetesareatriskformacrovascular,microvascular,andneuropathiccomplications.Forthosewithoutdiabetes,normalfastingbloodglucoselevelsare60to100mg/dL(3.3to5.5mmol/L);normalpostprandiallevelsarelessthan140mg/dL(7.8mmol/L)2hoursafterameal.Chronichyperglycemialeadstolong-termdamage,dys-function,andfailureofvariousorgans,especiallytheeyes,kidneys,nerves,andheart.Theliteraturesupportstheim-portanceofaconsistent,near-normalbloodglucoselevel,aswellasbloodpressureandlipidcontrol,forpreventingdia-betes-relatedcomplicationsandimprovingqualityoflife.Currently,approximately20.8millionpersonsarelivingwithdiabetesintheUnitedStates.Itisestimatedthatap-proximately90%havetype2diabetesandapproximately10%havetype1diabetes.Type2diabetestypicallyoccursinadults40yearsofageandolder;however,theincidenceoftype2diabetesinchildrenisincreasing,especiallyamongAmericanIndian,AfricanAmerican,andHispanic/Latinopop-ulations.Type1diabetestypicallyoccursinchildrenandyoungadults.Type1diabetesistherarerformofthedisease,butathletictrainersworkinginmiddleschools,secondaryschools,colleges,andmanyprofessionalsettingsaremorelikelytoencounterath-leteswithtype1thantype2diabetes.Thispositionstatementfocusesonrecommendationsfortheathletewithtype1diabetes,althoughathletictrainerscanalsoplayacrucialroleinthedia-betes-managementplanofapersonwithtype2diabetes.Type1diabetesischaracterizedbyabsoluteinsulinde-ciency.Itisconsideredanautoimmunedisorderresultingfromacombinationofgeneticandunknownenvironmentalfactors.Thesignsandsymptomsoftype1diabetesdeveloprapidlyandarerelatedtohyperglycemia.Symptomsincludefrequenturination,thirst,hungerandpolyphagia,weightloss,visualdisturbances,fatigue,andketosis.Usually,athletesareabletoresumeexerciseandsportswithinweeksofstartinginsulintreatmentaslongasatreatmentplanisdevelopedandasup-portteamexists.Thetreatmentplanforpersonswithtype1diabetesfocusesonaself-careplanpredicatedonexogenousinsulin,monitoringofbloodglucose,healthynutrition,andDIABETESMANAGEMENTTEAMANDTHEDIABETESCAREPLANPropermanagementofbloodglucoselevelsduringpracticesandgamesallowstheathletewithdiabetestocompeteinasafeandeffectivemanner.Maintaininganear-normalbloodglucoselevel(100to180mg/dL,or5.5mmol/Lto10mmol/L)reducestheriskofdehydration,lethargy,hypoglycemia,andautonomiccounterregulatoryfailure.Thisgoalisbestachievedthroughateamapproach.Theteam-managementap-proachtoprovidingsupportforpatientswithdiabetesiswellestablishedinthealliedhealthliterature.38–46Inschool-agedath-letes,theteamshouldincludetheschoolnurse,coach,andschooladministrators.Inadultathletes,diabetesisbestmanagedbyateamthatincludesseveralhealthprofessionals.39,41–43,47,48atingthisteamrequiresadeliberate,well-designedplan,whichdenestheroleofeachindividualinthesupervisionandcareoftheathletewithdiabetes.Allmembersoftheteamshouldbetrainedandwillingtoassistanathletewhoisexperiencingadiabetes-relatedemergency.Criticalrolesfortheathletictrainerincludeprevention,rec-ognition,andimmediatecareofhypoglycemiaandhypergly-cemia(withandwithoutketoacidosis);exercisenutrition;hy-drationcounseling;andhelpingtheathletetorecognizetheintensityoftheexercisesessioninordertoadjustglucoseandinsulinlevelsaccordingly.41,49–51Theathletictraineralsofa-cilitatescommunicationamongtheothermembersofthedi-abetesmanagementteam.Athleteswithtype1diabetesshouldhaveadiabetescareplanforpracticesandgames.Theplanshouldidentifybloodglucosetargetsforpracticesandgames,includingexclusionthresholds;strategiestopreventexercise-associatedhypogly-cemia,hyperglycemia,andketosis;alistofmedicationsusedforglycemiccontrolorotherdiabetes-relatedconditions;signs,symptoms,andtreatmentprotocolsforhypoglycemia,hyperglycemia,andketosis;andemergencycontactinforma-tion.Theathletemusthaveaccesstosuppliesformanagingglycemicemergenciesatalltimes.Whentheathleterequiresassistance,theathletictrainerand/orothermembersofthediabetesmanagementteam(eg,coach)musthaveimmediateaccesstothesesupplies.Theathleteorparent/guardianshouldprovidethenecessarysuppliesandequipment.PREPARTICIPATIONPHYSICALEXAMINATIONFORATHLETESWITHTYPE1DIABETESAthoroughPPEshouldbeginwiththeteamorprimarycarephysician.Thisexaminationshouldincludeasportshistory,assessmentofthelevelofdiabetesself-careskillsandknowl-edge,generalphysicalexaminationemphasizingscreeningofdiabetes-relatedcomplications,anddiscussionofhowsportsparticipationwillaffectbloodglucoseandbloodpressurecon-trol.AspartofthePPE,theathlete’sendocrinologistorpri-marycarephysicianshouldprovideanassessmentofthecur-rentlevelofglycemiccontrol,informationconcerningthepresenceandstatusofdiabetes-relatedcomplications,andbloodglucosemanagementstrategies.CompletionofthePPEmayrequireconsultationwithotherspecialists(eg,cardiolo-gist,ophthalmologist),especiallyinthecaseofdiabetes-relat-edcomplications.AthletictrainersarereferredtothebookofExerciseinDiabetespublishedbytheAmericanDiabetesAssociation,forfurtherreadingsonprescreeningoftheactiveindividualwithtype1diabetes. Volume42Number4December2007insulindosing;allowanceforexiblemealschedules;andavoidingtheregularuseofneedlesforinsulinadministration.Disadvantagesofinsulinpumptherapyincludepossibledam-ageduringcontactsports;riskofhyperglycemiaandketosisiftheinsulinpumpmalfunctionsorisinadvertentlydiscon-nectedfromtheathlete;infusionsetdisplacement,asheavysweatingorwatercontactmayreducetheabilityofadhesivestoholdtheinfusionsetinplace;movementorcontactleadingtoirritationattheinfusionsite,especiallyinthoseusingmetalneedleinfusionsets;andextremeambienttemperaturesF[2.22C]orF[30C]),whichcanaffectinsulinhousedwithinthepumpandinterferewithinsulinaction.TheadvantagesofMDIincludealowercostofoperationcomparedwithinsulinpumpsandtheabsenceofaconnectiontoadevice.Disadvantagesincludetheinabilitytomanipulatebasalinsulinlevelsduringexercise,theneedforregularin-jections,andthelackofexibilityregardingmealtimingandunplannedexercise.Insulinabsorptionistherate-limitingstepininsulinactivityforboththeinsulinpumpandMDI,andmanyfactorsmayaffecttheabsorptionrate.Athletesshoulduseconsistentsitesforinjectionstoeliminateabsorptiondifferencesamongbodyregions(ie,abdomenversustriceps).Appendix5listssomeofthevariablesthatcanaffectabsorptionrates.Theathleteanddiabetesmanagementteamshouldbeawareofinsulin-specicpharmacokineticandpharmacodynamicproperties.Forexample,rapid-actinginsulinanalogs(lispro,aspart,glulisine)allreachpeakcirculatinglevelswithin90minutesofadministration.Thispeakrepresentsthemaximalglucose-loweringeffectandgreatestriskforhypoglycemia.SeeAppendix4forpharmacokineticpropertiesofcommonlyusedbasalandbolusinsulins.HYPOGLYCEMIAHypoglycemiaisthemostsevereacutecomplicationofinten-siveinsulintherapyindiabetes,andexerciseisitsmostfrequentIntensiveinsulintherapyisassociatedwitha2-foldto3-foldincreaseinseverehypoglycemia(ie,thepersonwithdia-betesrequiresassistance).Theriskofseverehypoglycemiaishigherinmales,adolescents,andthosewhohavealreadyhadasevereepisode.Althoughresponsesareindividualized,signsandsymptomsofhypoglycemiatypicallyoccurwhenbloodglucoselevelsfallbelow70mg/dL(3.9mmol/L).Undermostcircumstances,hypoglycemiaistheresultofoverinsulinization,bothduringandafterexercise.Severalfac-torscontributetooverinsulinization.First,therateatwhichsubcutaneouslyinjectedinsulinisabsorbedincreaseswithex-erciseduetoincreasesinbodytemperatureandinsubcuta-neousandskeletalmusclebloodow.Second,exogenouslyadministeredinsulinlevelsdonotdecreaseduringexerciseinpersonswithtype1diabetes.Thisisincontrasttoexerciseinpersonswithoutdiabetes,inwhominsulinlevelsdecreasedur-ingexercisetopreventhypoglycemia.Theinabilitytode-creaseplasmainsulinlevelsduringexerciseintype1diabetescausesrelativehyperinsulinemia,whichimpairshepaticglu-coseproductionandinitiateshypoglycemia,usuallywithin20to60minutesaftertheonsetofexercise.Third,hypo-glycemiaduringexercisecanresultfromimpairedreleaseofglucose-counterregulatoryhormones(ie,glucagonandcate-cholamines)causedbyeitherapreviousboutofexerciseorhypoglycemicepisode.Asaresult,athleteswithtype1di-abeteswhoexperiencehypoglycemiaonthedaysprecedingcompetitionmaybeatriskforexercise-associatedhypogly-Finally,exerciseimprovesinsulinsensitivityinskel-etalmuscle.Exercise-associatedimprovementsininsulinsen-sitivitymaylastforseveralhourstodaysafterexercise.Thus,someathletesexperienceaphenomenonknownaspostexer-ciselate-onsethypoglycemia,whichmayoccurwhiletheath-leteissleeping.Athleteswhoexperiencenighttimehypogly-cemiarequireadditionalbloodglucosemonitoringinadditiontoasnack.Managingbloodglucoselevelsduringpracticesandgamesandpreventinghypoglycemiaarechallenges.Typically,hy-poglycemiapreventionusesa3-prongedapproachofbloodglucosemonitoring,carbohydratesupplementation,andinsulinadjustments.Appendix1listsstrategiestopreventhypogly-cemiaduringandafterpracticesandgames.Theathleteandthediabetesmanagementteamshouldworktogethertodeter-minewhichstrategiestoemploy.Hypoglycemianormallyproducesnoticeableautonomicorneurogenicsymptoms.Autonomicsymptomsincludetachy-cardia,sweating,palpitations,hunger,nervousness,headache,trembling,anddizziness.Thesesymptomstypicallyoccuratbloodglucoselevels70mg/dL(3.9mmol/L)inpersonswithdiabetesandarerelatedtothereleaseofepinephrineandAsglucosecontinuestofall,symptomsofbrainneuronalglucosedeprivation(neurogenicsymptoms)oc-curandmaycauseblurredvision,fatigue,difcultythinking,lossofmotorcontrol,aggressivebehavior,seizures,convul-sions,andlossofconsciousness;ifhypoglycemiaisprolongedandsevere,braindamageandevendeathcanresult.Symptomsofhypoglycemiacanbeuniquetoapersonwithdiabetes.Thus,theathletictrainingstaffshouldbefamiliarwithathlete-specicsymptomsofhypoglycemiaandbepreparedtoactappropriately.Hypoglycemiacancausesomeathletestobeespeciallyaggressiveandunwillingtocooperatewithinstruc-tions.Treatmentguidelinesformildandseverecasesofhy-poglycemiaarepresentedinAppendix2.ACUTEHYPERGLYCEMIAANDKETOSISHyperglycemiawithorwithoutketosiscanoccurduringexerciseinathleteswithtype1diabetes.Hyperglycemiadur-ingexerciseisrelatedtoseveralfactors.First,exercise(es-peciallyhigh-intensityexerciseat70%Vmaxor85%ofmaximalheartrate)cancauseadditionalincreasesinbloodglucoseconcentrationsandpossibleketoacidosisinathleteswithpoorglycemiccontrolandthosewhoareunderinsulin-ized.Withoutadequateinsulinlevels,bloodglucoselevelscontinuetoriseduetoexaggeratedhepaticglucoseproductionandimpairmentsinexercise-inducedglucoseutilization.Second,eveninwell-controlledathleteswithtype1diabetes,high-intensityexercisemayresultinhyperglycemia.High-in-tensityexercisemayleadtosignicantincreasesincatechol-amines,freefattyacids,andketonebodies,allofwhichimpairmuscleglucoseutilizationandincreasebloodglucoselevels.Thisexercise-associatedriseinglucoselevelsisusuallytran-sientinthewell-controlleddiabeticathlete,decliningascoun-terregulatoryhormonelevelsdecrease,typicallywithin30to60minutes.Third,thepsychologicalstressofcompetitionisfrequentlyassociatedwithincreasesinbloodglucoselevelsbeforecompetition.Althoughdatadonotexistforthosewithtype1diabetes,itislikelythatexcessiveincreasesincoun-terregulatoryhormonesoccurbeforeexercise,whenanticipa-torystressishigh.Athletesmayndthatbloodglucose Volume42Number4December2007competitioncancausemajordisturbancestobloodglucosemanagement.Maintainingthedelicatebalanceamonghypo-glycemia-euglycemia-hyperglycemiaisbestachievedthroughateamapproach.Specialconsiderationsforglycemiccontrol,medication,travel,andrecoveryfrominjuryareneededfortheathletewithtype1diabetes.Thecertiedathletictrainer,whohasmorecontactwiththeathletewithdiabetesthanmostmembersofthediabetesmanagementteam,isanintegralcom-ponentoftheteam.Athleteswithdiabetescanbenetfromawell-organizedplanthatmayallowthemtocompeteonequalgroundwiththeirteammatesandcompetitorswithoutdiabetes.TheNATApublishesitspositionstatementsasaservicetopromotetheawarenessofcertainissuestoitsmembers.Theinformationcontainedinthepositionstatementisneitherex-haustivenorexclusivetoallcircumstancesorindividuals.Var-iablessuchasinstitutionalhumanresourceguidelines,stateorfederalstatutes,rules,orregulations,aswellasregionalen-vironmentalconditions,mayimpacttherelevanceandimple-mentationoftheserecommendations.TheNATAadvisesitsmembersandotherstocarefullyandindependentlyconsidereachoftherecommendations(includingtheapplicabilitytoanyparticularcircumstanceorindividual).Thepositionstate-mentshouldnotberelieduponasanindependentbasisforcarebutratherasaresourceavailabletoNATAmembersorothers.Moreover,noopinionisexpressedhereinregardingthequalityofcarethatadherestoordiffersfromNATA’spositionstatements.TheNATAreservestherighttorescindormodifyitspositionstatementsatanytime.WegratefullyacknowledgetheeffortsofAnnAlbright,PhD,RD;RebeccaM.Lopez,MS,ATC;MarkA.Merrick,PhD,ATC;StephenH.Schneider,MD;andthePronouncementsCommitteeintheprep-arationofthisdocument.1.WassermanDH,DavisSN,ZinmanB.Fuelmetabolismduringexerciseinhealthanddiabetes.In:RudermanN,DevlinJT,SchneiderSH,KriskaA,eds.HandbookofExerciseinDiabetes.Alexandria,VA:AmericanDiabetesAssociation;2002:63–100.2.TheDiabetesControlandComplicationsTrialResearchGroup.Theeffectofintensivetreatmentofdiabetesonthedevelopmentandprogressionoflong-termcomplicationsininsulin-dependentdiabetesmellitus.NEnglJ3.UKProspectiveDiabetesStudy(UKPDS)Group.Intensiveblood-glucosecontrolwithsulphonylureasorinsulincomparedwithconventionaltreat-mentandriskofcomplicationsinpatientswithtype2diabetes(UKPDS4.LudvigssonJ,NordfeldtS.Hypoglycaemiaduringintensiedinsulinther-apyofchildrenandadolescents.JPediatrEndocrinolMetab.11(suppl1):159–166.5.TheDiabetesControlandComplicationsTrialResearchGroup.Hypo-glycemiaintheDiabetesControlandComplicationsTrial.6.SigalRJ,KennyGP,WassermanDH,Castaneda-SceppaC,WhiteRD.Physicalactivity/exerciseandtype2diabetes:aconsensusstatementfromtheAmericanDiabetesAssociation.DiabetesCare.7.AlbrightA,FranzM,HornsbyG,etal.AmericanCollegeofSportsMedicinepositionstand:exerciseandtype2diabetes.MedSciSports8.AmericanCollegeofSportsMedicineandAmericanDiabetesAssociationjointpositionstatement:diabetesmellitusandexercise.MedSciSports1997;29:i–iv.9.MolitchME,DeFronzoRA,FranzMJ,etal.Nephropathyindiabetes.DiabetesCare.2004;27(suppl1):S79–S83.10.BoultonAJ,VinikAI,ArezzoJC,etal.Diabeticneuropathies:astatementbytheAmericanDiabetesAssociation.DiabetesCare.11.FongDS,AielloL,GardnerTW,etal.Retinopathyindiabetes.2004;27(suppl1):S84–S87.12.BergerM.Adjustmentsofinsulinandoralagenttherapy.In:RudermanN,DevlinJT,SchneiderSH,KriskaA,eds.HandbookofExerciseinDiabetes.Alexandria,VA:AmericanDiabetesAssociation;2002:365–376.13.SchiffrinA,ParikhS.AccommodatingplannedexerciseintypeIdiabeticpatientsonintensivetreatment.DiabetesCare.14.SchiffrinA,ParikhS,MarlissEB,DesrosiersMM.Metabolicresponsetofastingexerciseinadolescentinsulin-dependentdiabeticsubjectstreat-edwithcontinuoussubcutaneousinsulininfusionandintensiveconven-tionaltherapy.DiabetesCare.15.RiddellMC,PerkinsBA.Type1diabetesandexercise,partI:applica-tionsofexercisephysiologytopatientmanagementduringvigorousac-tivity.CanJDiabetes.16.ZinmanB,RudermanN,CampaigneBN,DevlinJT,SchneiderSH.Physicalactivity/exerciseanddiabetes.DiabetesCare.2004;27(suppl1):S58–S62.17.WrightDA,ShermanWM,DernbachAR.Carbohydratefeedingsbefore,during,orincombinationimprovecyclingenduranceperformance.JAppl18.KalergisM,SchiffrinA,GougeonR,JonesPJ,YaleJF.Impactofbedtimesnackcompositiononpreventionofnocturnalhypoglycemiainadultswithtype1diabetesundergoingintensiveinsulinmanagementusinglis-proinsulinbeforemeals:arandomized,placebo-controlled,crossovertri-DiabetesCare.2003;26(1):9–15.19.ZinmanB.Insulinpumpwithcontinuoussubcutaneousinsulininfusionandexerciseinpatientswithtype1diabetes.In:RudermanN,DevlinJT,SchneiderSH,KriskaA,eds.HandbookofExerciseinDiabetes.andria,VA:AmericanDiabetesAssociation;2002:377–381.20.ZinmanB,TildesleyH,ChiassonJL,TsuiE,StrackT.InsulinlisproinCSII:resultsofadouble-blindcrossoverstudy.1997;46:440–443.21.FrancescatoMP,GeatM,FusiS,StuparG,NoaccoC,CattinL.Carbo-hydraterequirementandinsulinconcentrationduringmoderateexerciseintype1diabeticpatients.22.FranzMJ.Nutrition,physicalactivity,anddiabetes.In:RudermanN,DevlinJT,SchneiderSH,KriskaA,eds.HandbookofExerciseinDia-Alexandria,VA:AmericanDiabetesAssociation;2002:321–338.23.WassermanDH,ZinmanB.ExerciseinindividualswithIDDM.1994;17:924–937.24.FranzMJ,BantleJP,BeebeCA,etal.Nutritionprinciplesandrecom-mendationsindiabetes.DiabetesCare.2004;27(suppl1):S36–S46.25.BrubakerPL.Adventuretravelandtype1diabetes:thecomplicatingef-fectsofhighaltitude.DiabetesCare.26.CryerPE,DavisSN,ShamoonH.Hypoglycemiaindiabetes.27.BolliGB.Howtoamelioratetheproblemofhypoglycemiainintensiveaswellasnonintensivetreatmentoftype1diabetes.DiabetesCare.22(suppl2):B43–B52.28.AmericanDiabetesAssociation.Preventingandtreatingseverehypogly-cemia.Availableat:http://www.diabetes.org/preventing.jsp.AccessedSeptember10,2007.29.AmericanDiabetesAssociation.Hypoglycemia.Availableat:http://www.diabetes.org/type-1-diabetes/hypoglycemia.jsp.AccessedSeptem-ber10,2007.30.PerkinsBA,RiddellMC.TypeIdiabetesandexercise:usingtheinsulinpumptomaximumadvantage.CanJDiabetes.31.BergerM,CuppersHJ,HegnerH,JorgensV,BerchtoldP.Absorptionkineticsandbiologiceffectsofsubcutaneouslyinjectedinsulinprepara-DiabetesCare.32.GossainVV.Insulinanalogsandintensiveinsulintherapyintype1dia-IntJDiabDevCtries.33.U.S.DepartmentofHomelandSecurityTransportationSecurityAdmin-istration.Hiddendisabilities:travelerswithdisabilitiesandmedicalcon- Volume42Number4December2007fortreatmentofunstableanklefracturesusingtransarticularxationinpatientswithdiabetesmellitusandlossofprotectivesensibility.AnkleInt.83.BibboC,LinSS,BeamHA,BehrensFF.Complicationsofanklefracturesindiabeticpatients.OrthopClinNorthAm.84.YoungME.Malnutritionandwoundhealing.HeartLung.1988;17:60–67.85.HotterAN.Physiologicaspectsandclinicalimplicationsofwoundheal-HeartLung.86.CooperDM.Optimizingwoundhealing:apracticewithinnursing’sdo-NursClinNorthAm.87.GoodsonWHIII,HuntTK.Woundhealinginexperimentaldiabetesmel-litus:importanceofearlyinsulintherapy.SurgForum.88.FlynnJM,Rodriguez-delRioF,PizaPA.Closedanklefracturesinthediabeticpatient.FootAnkleInt.89.BagdadeJD,WaltersE.Impairedgranulocyteadherenceinmildlydiabeticpatients:effectsoftolazamidetreatment.1980;29:309–311.90.PierreEJ,BarrowRE,HawkinsHK,etal.EffectsofinsulinonwoundJTrauma.91.ClementS,BraithwaiteSS,MageeMF,etal.Managementofdiabetesandhyperglycemiainhospitals.DiabetesCare. CarolynC.Jimenez,PhD,ATC;MatthewH.Corcoran,MD,CDE;JamesT.Crawley,MEd,PT,ATC;W.GuytonHornsby,Jr,PhD,CDE;KimberlyS.Peer,EdD,LATC;RickD.Philbin,MBA,MEd,ATC;andMichaelC.Riddell,PhD,contributedtoconceptionanddesign;acquisitionandanalysisandinterpretationofthedata;anddrafting,criticalrevision,andnalapprovalofthearticle.AddresscorrespondencetoNationalAthleticTrainers’Association,CommunicationsDepartment,2952StemmonsFreeway,Dallas,TX75247.Addresse-mailtocjimenez@wcupa.edu.Appendix1.StrategiestoPreventHypoglycemia StrategyComment BloodglucosemonitoringAthletesshouldmeasurebloodglucoselevelsbefore,during,andafterexercise.Athleteswhoexerciseinextremeheatorcoldorathighaltitudeorexperiencepostexerciselate-onsethypoglycemia,whichmayleadtonighttimehypoglyce-mia,requireadditionalmonitoring.1.Measurebloodglucoselevels2to3timesbeforeexerciseat30-mininter-valstodeterminedirectionalglucosemovement.2.Measureglucoselevelsevery30minduringexerciseifpossible.3.Athleteswhoexperiencepostexerciselate-onsethypoglycemiashouldmeasureglucoselevelsevery2hupto4hpostexercise.Athleteswhoexperiencenighttimehypoglycemiashouldmeasurebloodglucosevaluesbeforegoingtosleep,onceduringthenight,andimmediatelyuponwaking.Carbohydratesupplementation(Note:TheathleteBeforeexerciseshoulddiscussspeciccarbohydratequantitiesandtypeswithhisorherphysician.)Consumptionofcarbohydratesbeforeexercisedependsontheprevailingbloodglucoselevel.Ingeneral,whenthebloodglucoselevelis100mg/dL(5.5mmol/L),carbohydratesshouldbeconsumed.Duringexercise1.Additionalcarbohydratesupplementationmaybeneededforpracticesorgameslasting60minwhenthepre-exerciseinsulindosagehasnotbeenreducedbyatleast50%.2.Athleteswhoareexercisingatthepeakofinsulinactivitymayrequiread-ditionalcarbohydrates.Athletesshouldeatasnackand/ormealshortlyafterexercise.Insulinadjustments(Note:Theseareveryimportantformoderate-intensitytohigh-intensityexercisesessionsof30min.)Physiciandeterminesinsulinreductionstrategies.1.Insulinpump(mayuseoneormoreofthefollowingstrategies)a.Reducebasalrateby20%to50%1to2hbeforeexercise.b.Reducebolusdoseupto50%atthemealprecedingexercise.c.Suspendordisconnecttheinsulinpumpatthestartofexercise.Note:Athletesshouldnotsuspendordisconnectfrompumplongerthan60minwithoutsupplementalinsulin.2.MultipledailyinjectionReducebolusdoseupto50%atthemealprecedingexercise.3.NighttimehypoglycemiaReduceeveningmealbolusinsulinby50%.