Type 1 Diabetes Clinical Management of the Athlete Ian Gallen Editor Type 1 Diabetes Clinical Management of the Athlete Editor Ian Gallen Diabetes Centre Wycombe Hospital High Wycombe UK ISBN 978-0-85729-753-2 e-ISBN 978-0-85729-754-9 DOI 10.1007/978-0-85729-754-9 Springer London Dordrecht Heidelberg New York British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Control Number: 2012934821 © Springer-Verlag London Limited 2012 Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licenses issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. The use of registered names, trademarks, etc., in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) This book is dedicated to my parents Louis and Barbara for their lifelong love, encouragement and support, to my wife Susan for our happy life together and to our children Robert and Hannah who make my life meaningful. I thank all my outstanding and inspirational medical teachers, the many colleagues with whom I have been privileged to work and the people with diabetes who have trusted me to help them. Foreword I was diagnosed with diabetes at the start of training for the 2000 Sydney Olympic Games, having won gold medals in rowing events at the previous four Olympic Games. The diagnosis was a shock, and I felt my sporting world was over. I had a grandfather who had the condition in his late 60s, and even though I was very young at the time and didn’t know very much about diabetes, I felt I knew enough to know that I wouldn’t be able to carry on my sporting path. I was sent up to my local dia- betic center where my diabetes was confi rmed, and I was taught to inject insulin and all the life-changing routines and dietary adjustments that needed to be implemented immediately. At the end of the consultation when I was expecting to be told that this was it, my sporting career was over, my consultant said to me, “I can’t see any rea- son why you can’t still achieve your dreams in 3 years time by competing at the Sydney Olympics in 2000.” This was a bigger shock to me than being told I wouldn’t be able to compete. All my instincts and limited knowledge as a newly diagnosed diabetic told me otherwise. He did say it would be a tough path, but immediately I thought if he thinks I can do it, I will give it my best shot. The path over the next few months was very traumatic. Firstly, of coming to terms with the condition and, secondly, as an athlete with a certain pride in your performance at the highest level is about consistency within training and racing. In the early days of my diabetes, it was the consistency that had gone. The main issue was not actually the controlling of the diabetes; it had more to do with the refueling of my body. To compete in rowing at Olympic level, you have to train somewhere in the region of 18–24 sessions a week, averaging about 1½ h a session of intensive endurance work, splitting these sessions between three and four a day. There is very little time to regain the energy when you are limited to the insulin you can take because of the fear of hypoglycemia. I was put onto the normal diabetic diet, and session after session I was not gaining the energy to perform. The way I felt after each session was convincing me I was never going to be the athlete that I was. Over time, my consultant changed the patterns of refueling. In fact, this meant going back to my old diet. He knew that I had been successful on this before, but he had to come up with a regime that allowed me to eat 6–7,000 cal a day and still control my diabetes. When you are fi rst diagnosed, you are given so much information, and this is vii viii Foreword so diffi cult to take on board – even as an athlete when you need to have the freshness of mind to adapt to your needs. I feel that if you could be drip-fed information over time, this would be a better process. There wasn’t any information for athletes to achieve at the highest level, and books like this really do help the athlete and give the consultants a good foresight. Since I was diagnosed in 1997, the world looks at diabetes and elite sport in a very different way, and there are so many more diabetic athletes achieving their dreams now. With all the help I was given, I decided very early on that diabetes was going to live with me, not me live with diabetes. I very much welcome this book, in which leading experts highlight the many advances in the understanding of the effects of diabetes and insulin treatment during and following exercise, and on how diabetes management can be optimized. This will help clinicians in turn help those people with diabetes who want to play sport, and even for some like me achieve the highest level of sporting success. Sir Steve Redgrave Preface In this year of the London Olympic Games, our attention is drawn to sport and physical performance. Type 1 diabetes is initially a disorder of the young, and in this age group and for many older people physical activity is a very important compo- nent of lifestyle. Whilst it is of undoubted importance for physicians to optimize insulin therapy programs and other treatments to avoid or treat the chronic compli- cations of type 1 diabetes, people with diabetes also seek to normalize their life- style. Some will want to advance their sporting ambitions, and the examples of outstanding sportsmen with diabetes, such the rower Sir Stephen Redgrave, or the Rugby Union player Chris Pennell, show us that type 1 diabetes per se is not a bar- rier to maximum physical performance in sport. These examples encourage people with type 1 diabetes to engage in all types of physical activity, and they will seek best advice on how to manage their diabetes with exercise. There are some signifi cant barriers for people with type 1 diabetes performing sports and exercise. They are likely to experience marked fl uctuations in blood glu- cose control and frequent hypoglycaemia with exercise. The occurrence of hypogly- caemia may seem both unpredictable and inexplicable to the person with diabetes, which may force the response of excess replacement of carbohydrate before and following exercise, with resultant hyperglycaemia, adding to the burden of dysgly- caemia. Perhaps of more concern to people with diabetes is the risk of hypoglycae- mia during and nocturnal hypoglycaemia following exercise. When hypoglycaemia is severe, requiring assistance from another person, it may cause embarrassment to people with diabetes, and is likely to cause concern to parents, teachers and coach- ing staff as to the safety of physical activity. Excessive fatigue and weakness during prolonged exercise compared with peers without diabetes may be experienced, and this may reduce the wish to continue in sport. For the outstanding athlete with dia- betes, there is potential that diabetes and insulin treatment may cause loss of maxi- mum physical performance, which also may discourage progression in sport. We now know many of the causes of impaired physical performance and how these may be rectifi ed through augmented diabetes management strategies. Evidence from people with type 1 diabetes suggests that advice from healthcare professionals to people with type 1 diabetes on the management of physical exercise ix x Preface may be simplistic. Over the last decade, we have established a specialist clinic to help sportspeople and athletes manage their diabetes and physical activity success- fully to reduce dysglycaemia with and following exercise, and to normalize physical performance. Athletes and sports people explained in our clinic what problems they had found during exercise, and how they had tried to overcome those diffi culties. This experiential evidence has produced many effective clinical strategies. These are now strongly supported by the growth in the clinical research knowledge base of the effects of diabetes on the physiological response to exercise, on the effect of exercise on the response to hypoglycaemia and on effective dietetic and insulin management of diabetes during and following exercise. There have also been sig- nifi cant technological improvements in the support of the management of type 1 diabetes with continuously infused insulin infusion pump therapy and continuous sub-cutaneous glucose monitoring equipment. People with type 1 diabetes will seek to be effectively supported in any sporting ambition, presenting an interesting challenge to healthcare professionals.