CEU: Position Statement Series: Management of the Athlete with Type I Diabetes Mellitus - 198

Hey, this is Sandy. And Randy? And we're here on AT Corner. Being an Ath Eye trainer comes with ups and downs and we're here to showcase it all. Join us as we share our world in sports medicine. Welcome back to another episode of AT Corner. For this week's episode, we'll be doing our first Education episode of 2025, and what better way than to start with a position statement series talking about the management of

type 1 diabetes in athletes. Honestly, position statement series is probably one of my favorites. It's a nice quick review because I feel like I've read this thing multiple times. Obviously we went over it as a student, and yet I read it every time and I'm like, Oh yeah, that's a good thing to know. That's a good thing to remember. So it is nice to go over it every now and then. This is a free CU Thank you so much. Athletic training chat and clinically pressed if you were

listening to it as it comes out. However, if it is a little bit older, it will be on the clinically priced website at still an affordable price. You can go ahead and find that link by going to our show notes where you can also do the course evaluation and quiz and those will get you your category A certificate. We also have on our Instagram a little tutorial about how to claim your C us. So what are we talking about specifically today, Randy?

Yeah. So we're going to describe the pathophysiology of type 1 diabetes mellitus. We'll discuss the athletic trainer's role in the management of the athlete with type 1 diabetes mellitus and then discuss educating athletes and stakeholders about type 1 diabetes mellitus. It's really going to be focused. We're literally going through this actual position statement and hitting all the points that the position statement was trying to highlight for what US athletic trainer should be

doing. Awesome. Have you had an athlete with diabetes? Yes, I've had a few. Usually every year I have about a handful. Really. Yeah, it's actually been a couple years since I've had an athlete with diabetes. Interesting. Yeah, I feel like every year I have about a handful. Interesting. That is kind of funny that the difference and I don't feel like we have that big of a difference in like population. Yeah, I don't know.

So. That's just one thing that yeah, I've I've had a lot of athletes with with diabetes. Cool, I'm interested to hear your experience. Yeah. And one thing that's interesting at least for for where I'm at or like what I've been like just with like college level athletes, I feel like for us like when we get them, like they've kind of had it for a while. That is, that is something that I've noticed. So they're like, they're good,

like. Sometimes, sometimes right, Sometimes they yeah, they might have just recently got diagnosed in like high school. For sure. But yeah, everyone that I've had, they've had it for a while, so it's like they kind of know what they need to do. It's almost now my role is making sure I support what they need to do and if something goes wrong, I'm ready, right? As opposed to necessary educating them on a ton.

I feel like for probably the secondary school athletic trainer, I feel like that there's probably a lot more educating on like, because I feel like that's when they're really starting to learn what works for them, what doesn't. Whereas I haven't really been put in that position a ton at the collegiate level. I only have 4 exercise based. Not really diabetes as a whole. Oh, interesting. Yeah. Anyway, we'll talk about that. So why don't we get started with what is like just defining what

is diabetes? So basically it's just an

impairment of the endogenous management of blood glucose, right. So you know, we have our. Endogenous, meaning it comes from within. Yes, yeah. So basically the, you know, our body needs like energy, it needs like glucose to help the cells function, right? And how it gets that is taking the glucose from the bloodstream and getting it into the working cells, right? That can happen passively.

But for the for the most part, it's very efficient to have insulin to help grab that glucose and put it into the cell, right? So when we talk about diabetes, right, there's some kind of issue with the actual insulin that helps bring that blood glucose into the working cells, right? So when we kind of look at our blood glucose levels, right, we have to understand what low blood sugar would look like. And then high blood sugar. So in low blood sugar, this is referred to as hypoglycemia.

This is anything less than 60 milligrams per deciliter for hyperglycemia or our high blood glucose levels. This is for kind of like someone undiagnosed or someone who does not have diabetes. This is anything greater than 110 milligrams per deciliter, or if you're after eating it could be higher than 140 milligrams per deciliter that would be considered hyperglycemic. I'll just also just to note you can be in a hypoglycemic or hyperglycemic state without

having diabetes. Yes, diabetes is more the long term effects of having a higher blood sugar essentially. So it's more of a chronic thing. Yes, acutely. You can have like really high, like I'm pretty sure I've been hyperglycemic before, but it's not like a chronic thing. Or like if you don't eat then you'll be hyperglycemia. I'm sure we've all dealt with that athlete who doesn't eat and then goes to practice. Exactly. So now the actual diagnosis of diabetes, right?

There are two types, all right. So type one, this is kind of

referred to as that insulin deficiency, right? This is actually an autoimmune disease where basically the insulin producing cells within the pancreas are destroyed by your own body. So essentially you can't produce that much insulin anymore. All right, So now you have a lower number and now it's a lot harder to get blood or glucose from the blood to the working cells in type 2. This is kind of viewed as that kind of like acquired. It kind of happens a little bit later in life.

This is where you kind of see like those like kind of lifestyle like possible increase weight or obesity. Having chronically high blood sugar leads to this decreased insulin receptor sensitivity. So basically you're still producing the insulin, but basically just the insulin as isn't as sensitive at grabbing the glucose. It's like tolerance. Yeah, right. So now it's just not doing the job that it should effectively

be doing, right? But they're still there, just not doing as effective a job as they should be. Right. So for the position statement really the management was focused on type 1 diabetes, right. So this is this is where the position statement really kind of focused on. So not so much Type 2, so unsure if there's necessarily any changes necessarily to that management, but yeah.

I feel like usually when you're talking about Type 2, they're going to have a lot more like lifestyle factors that for sure they're focusing on in their treatment plan. For sure, and I feel like too for the most part type 2 tends to happen a little bit higher age levels. Which we still have athletes. Which we still do, but I think for the more traditional setting, that's not the predominant population, but for sure it can happen. We still have athletes of all ages.

Or if you think like industrial. For sure. So for type 1 diabetes, some signs and symptoms to keep an eye on for athletes who may have been undiagnosed, if they're starting to complain of frequent urination, if they're starting to have increased thirst or hunger, or what's also referred to as polyphagia, which is basically insatiable hunger. Like you just aren't full. You just you're eating, but you still feel hungry. That's uncomfortable.

Yes, for sure. Weight loss, visual disturbances, fatigue and ketosis, right? This is basically the release of ketones from just a reliance on burning fat because there's no glucose going into the blood or going into the cells. So your cells are like I need energy and it starts burning fat to try and create that energy. And that's where you get like that sweet smelling breath.

Yes, for sure. So if you have if you have an athlete or a patient with those kind of symptoms and they're they haven't been diagnosed with diabetes, that's probably a good idea to kind of refer them to rule that out to make sure though that they do not have undiagnosed diabetes. Who are we referring to? In this case, really their PCP or their physician will be fine, which they'll probably refer them to an endocrinologist all right to make that diagnosis.

But as long as they're you're getting that ball going and making sure that we're referring them to the appropriate provider. If if anything you could do your team physician and same thing, they might refer them to a endocrinologist. So what? Where does our role come in to that? Yes. And this is really where that

position statement really did a great job of kind of outlining, OK, what do you do as an athletic trainer with the athlete that has type 1 diabetes? Every athlete, every athletic trainer who I've talked to has kind of taken a different role with diabetes, which I think is interesting. I feel like some people are like more hands on and some are more hands off.

I feel like this is the one thing that's very unique because again, like if you're in the collegiate setting, like you're getting this athlete that has been diagnosed with this previously that there's already a. Most of the time. Most of the time that have a team of healthcare professionals managing this right now, you're being kind of added to this team, all right?

So it already feels like there's a lot of moving parts and this really kind of comes in built in with you kind of being in that support role of how can I make this easier? So the first thing that they that the position statement really talked about was creating or getting or even creating a diabetes care plan, right? So really each athlete that's been diagnosed with type 1 diabetes should have some kind of diabetes care plan for their practices and games, right?

And what this is kind of includes and entails is it should really list out what their blood glucose monitoring guidelines are like how often should they be testing? All right. And what are the values we're looking for that will actually exclude activity? Like if you have this value, you're not, you're a no go. All right, I should talk about their insulin therapy guidelines. So what kind of insulin they're using, at what dosage and what are some adjustment strategies

that the athlete can do, right? So this is for like any planned activities or what do they do if their blood sugar is still high? How much insulin are they going to add? Should list other medications that they're using to help kind of manage their diabetes, like especially for like long term management. Just some guidelines for just how to recognize how to treat hypoglycemia, hyperglycemia.

And then of course, emergency contact information, including the physician that is currently managing the diabetes, making sure their information is least accessible. I think one thing to note is like who we're also sharing this with, because it's not just a plan that an AT has.

Yes. But the coaches should be involved, the assistant coaches should be involved, really anyone who and obviously talking to the athlete as well and making sure that they're comfortable sharing, but anyone who has kind of access to this student athlete in that in like a active time frame, it's important to to know what their plan is. Absolutely.

Because you know, again, coaches are with these athletes, especially depending on setting a lot more than we are, Like they're going to travel with them, they're going to be on the road, they're going to be at dinner. Who knows what's going to happen, right? So making sure that they are comfortable at least just being able to recognize what's going on. What should I do as a coach for this? You know, for this situation, right?

I think it also helps if you familiarize yourself with the type of insulin treatment that if they use an insulin treatment like yeah or their even their blood glucose monitoring device. Yes, because there are different types and so it's if you don't know it until an emergency, that's not helpful.

For sure. And one thing too is like, like making sure that it's calibrated, cause some of those blood glucose machines, they'll have like a thing to calibrate it to make sure it's working appropriately. So if like if you're at a place where you actually have one in your kit, right, remembering to make sure that it does work properly. Right. If you're like me, who hasn't had one in a couple of years, whereas versus Randy who's got a handful apparently.

Yeah, I got, I got my year, I got my yeah, seriously. But I do have one in my kit, but I do need to calibrate it, make sure it works properly. Still nothing is old. It's been there for a while. But yeah, no, that was actually an interesting thing too that the the position statement brought up and it kind of went into like what the athletic trainer should have in their kit.

And it actually, it was like saying like, oh, the patient should be bringing in like a test kit and like extra strips for you and like a urine analysis, like test for like ketones to test in the urine. And I'm like, I'm pretty sure if I asked for any of this for my athletes, they would be confused and probably don't even have it anyway. So I'm like, how, how readily available is it for the athlete

with diabetes to have these? I mean, obviously like their blood testing stuff, like obviously I'm pretty sure that it's pretty accessible. Like all that additional stuff. I'm like, do they have that? Like just at home? Yeah. I want to know. I'm going to, I am going to ask and I want to know how many of them actually say, Oh yeah, I got that. Oh yeah, I'll bring it in or. Right. I got to ask Mom. Right.

Anytime we start talking about pre-existing conditions and gathering paperwork for care plans and stuff, it we have to

talk about the a TS favorite thing and that's PP ES and kind of what we should consider for our, you know, the physicals for those incoming athletes, incoming patients. I think really like they did a good job of just describing like identifying complications from like diabetes, type 1 diabetes, right? Like the neuropathy, retinopathy, right? Make sure like there's no changes in vision, no change in like sensation at all. Make sure they're not having like any of those complications

or kidney issues. I think also another thing to ask that you've kind of alluded to and we've kind of talked about just briefly is how comfortable they are with their diagnosis and also how controlled their diabetes. Is yes. So that actually ties in to one thing that the position statement kind of talked about is kind of making sure that their lab results for A1C values are being tested every three to four months.

Oh wow, so. One thing that you could consider and like I know each place is different and like the realities of asking certain things of certain patients and student athletes are easier than maybe others. But requesting those like results from student athletes from their last labs to see where they are for their A1C values. Because it is an it does give an indicator of long term management. Like how are they managing it in the long term?

And like if you're not really because I feel like we don't really talk about it in school like what what someone's A1C should be. I know for me I wasn't comfortable of what that value should be. So it should everyone's kind of saying and then the position statement alluded to being less than or equal to 7%. So when you get that like lab print out and it. Says for someone with diabetes. Yes, with diabetes. Cause otherwise it should be less.

Yes. So why is it important that why am I even like 'cause like I'm not necessarily super involved in the long term management. I'm a piece of it. So like, why am I asking for this? One consideration that actually happened to me this year is it could actually affect athletes and surgery. Having a higher A1C value for a diabetic athlete that's over that 7% number could lead to actually a lot of complications

in surgery. I had an athlete who we were trying to get him in for ACL surgery and they their A1C numbers were a little bit higher and the surgeon actually cancelled the surgery and said we need, we need to figure this out before I actually operate. So if you have those values sooner, you can educate. Hey, maybe talk to your doctor about, hey, this number doesn't look great because of these reasons. We would like to bring that down. Some food for thought.

That is a really good point, especially something that you had to come across first before. Like no one really talks about that. Yeah, if I would have had that sooner. And plus, it does start that conversation if they're like, oh, I don't have that. So then, do you have a written care plan for each of these athletes? Not yet, but I'm going to work on that. I want to do that. I was reading this, I was like, this is actually real simple stuff that you can give your athlete.

Like I need you to fill this out. No, I mean like, Oh yes. Like the like all that other information, like the insulin that they use and like stuff like that. Obviously I have my game plan and my policies and procedures for like, OK, here's how we're going to treat it right? But the. Actual like when I get an athlete who has diabetes, like if I'm looking at their physical and I see that they have diabetes, like I'll ask them like their numbers right there.

Oh, that's a good idea. Like what they normally run at. Oh, that's a good idea. It's a good idea. That way I know. Yeah, what their normal? And I can write it down in like our sportswear or whatever, Yeah. And then start formulating that plan. I'm going to steal that. How do you find out their numbers just. Go off of them. Just make sure they're right. Like when I get a number like, Hey, how does, how does that normally look for you? But I like that.

I'm going to tell you what their baseline number would be. And they should know because they're monitoring I. Was going to say again, like if they've had it for a few years, like they've gotten conditioned to like they're on top of their monitoring what their number should be at what. They should also know like what spikes them and also they should know what exercise does to them and like how sometimes they have to adjust, like how much they eat before they exercise.

And how much insulin to? To prepare for. And that does come with a lot of playing around with their physician too. I mean, obviously it's not just guessing the physician has a good idea, but you know, sometimes a, we got to adjust it a little bit. And then again, that should be within kind of like that, that diabetic, the diabetes care plan is what are some of the modifications that the athlete can do for exercise and stuff

like that. So we kind of know what's going on. And again, educating, making sure that the athlete knows why that's important or if they forgot to do it. Because again, like, I again, like if they've had it for a few years, they're pretty good at knowing all this stuff, but you know it. Athletes are humans, but they don't. Always have it for a couple years like you might get the athlete who's never had it for just newly diagnosed. For sure. And then you gotta be able to

educate them on all that. Are we ready to move on to the actual practice of it? Yes.

So again, another kind of role for that athletic trainer is being able to obviously recognize and manage low and high blood sugar, right? The hypo and hyperglycemia. All right, so hypoglycemia is kind of divided into kind of two categories. You either have mild or severe. There was there is no middle. It's it's just mild or severe. All right, So how you can kind of like categorize this yourself is mild. Is the athletes able to talk to

you? They can kind of administer food fluids on their own, Like they don't necessarily need your active assistance in that process. But they might be like weak or shaky or like, you know, your typical think like if you think it. Obviously, when I think of this one, it's easiest for me to remember if I just think of like when I don't eat food, like if I skip a meal, like how do I feel? And then just put that a little

bit more extreme for sure. Whereas the severe kind of hypoglycemia is like the athletes unconscious or they are just unable to take oral fluid, foods or fluids by themselves. Like you have to really help them with that process, right? And it really at that point, at that severe part is that's really where the treatment's going to be more like injecting Glucagon, which we'll talk about like kind of like that treatment part for the symptoms of hypoglycemia, right?

Symptoms are really start to kind of appear when blood sugar gets below 70 milligrams per deciliter. Now remember within normal is still 60 thinking above 60. Right. But the symptoms you'll start to get as it gets closer to that 60 and then obviously as it goes below it just well, it gets worse. So they'll complain of headache, they'll have hunger. But the key thing with hypoglycemia is they'll complain of hunger, but no thirst. They will not feel thirsty, they

will feel hungry. They may have blurred vision, dizziness, decreased performance. They may have pylor diaphoresis, which is sweating, tachycardia, fatigue and then slurred speech and confusion. And obviously as it keeps going lower just gets worse and worse and worse. The treatment for you. Mean not eating is not going to help your performance. Not at all. You'd be surprised how many of my athletes don't want to eat before, don't understand it. It's. The nerves, Randy.

So for the treatment of hypoglycemia, the position statement did a really good job of in the appendix they have a nice little table that kind of really breaks down the step by step for treating both mild and severe hypoglycemia. So it is definitely worth a look. And if anything, you kind of like like copy and paste that bad boy and put it on whatever infographic you want and, you know, put in your policies, pursue like it's outlined

perfectly and it looks great. Basically, for kind of that mild form, you can administer 10 to 15 grams of fast acting carbohydrates. So that's kind of like 4 to 8 glucose tablets or two tablespoons of honey. That's actually really important to know because I feel like people are really, they're like, those glucose tablets are big. They are huge. So I think when people see them, I think they think 1. Yeah.

No, no. But like 4:00 to 8:00 you, you got to think about like that's a, that's a lot. Yeah, I know. I I used to have those glucose tablets and they broke in my kit. Oh, no. Kind of wanted to taste them, see what it tastes like. Sugar. Straight up sugar. That sounds amazing. With a citrus. Hint, that sounds amazing. It did smell very citrusy in my kit after that. Well, that's kind of nice. So, right, so you administer it, you measure the level their blood like their blood glucose

level. Then you wait 15 minutes, then measure again. And then if you need to, like if you're not seeing a rise in that blood sugar, you add, you do it again. So same process 10 to 15 grams carbohydrates and then repeat that OK, measure weight 15 measure after two attempts to raise it. If it does not increase this, is this an EMS call? You activate the E no. Just think about how long that's taken so. Far though, Exactly. Like, it's not a quick, it's on instant treatment.

It's not like when someone's having an anaphylactic shock and you administer an EpiPen boom. Right. Yeah, it's not, it's not just like instant, right. It is a long process. And yeah, obviously if blood glucose is not rising at that point, like that's OK, You, you need more attention than what I can give.

Now, if it's on the flip side, the side that we always want and glucose does start to go back towards normal or get above that kind of that nice 70 number, the athlete can now start to have a snack. So like a bagel or like something like that, I think and actually eat food, food instead of like there's rapid sugar. Now in your severe cases, again, this is the patient that cannot help themselves. They can't put anything in like orally or they're unconscious.

This is when a Glucagon is administered. And the position statement again did a great job of kind of talking about the two types of kind of Glucagon you can get. The biggest thing is if you have the Glucagon, which is an injection, there are instructions on it depending on which type you have. So make sure you are familiar with how to use it if you have it. Basically kind of the same idea as kind of like the EpiPen, right? It could be injected in the arm,

thigh or buttock. And really, this should. War, there's a lot of tissue. Yes, this should work pretty fast, right? So it should work in about 15 minutes. The athletes should be able to come too, when they do. 15 minutes in the moment, it's not that fast. Yeah, in the moment it's not. But compared to like the mild where you're 30 plus minutes, right, this, this is relatively faster. When the athlete does awaken, if they were unconscious, they may have some nausea or vomiting afterwards.

So. I mean, their body just went through it. I couldn't. Exactly. And it's getting. Shocked with a. Crap ton of sugar, right? It's going to be like whoa. So for so that's for hypoglycemia. Now on our flip side, for hyperglycemia, this is kind of anything that you're looking at that blood glucose is starting to get over 200 milligrams per deciliter. And obviously for a diabetic patient, right, that could definitely go even higher.

Right. I was going to say like I've had someone at 220 and you wouldn't have for sure. Like they they didn't have any of these symptoms. For sure. I think it's definitely individual and especially when we start talking about the monitoring, you'll hear how high the values can get. But essentially we're looking at they could have abdominal pain with hyperglycemia, they're going to have higher thirst, but

no hunger, right? So they're going to feel thirsty because their bodies want to try to like I need to get rid of this extra glucose. This is where you get that fruity odor, breath dehydration because again, they're trying to urinate more and more. So you're going to lose more water, lethargy, confusion. And then worst case would be that loss of consciousness. Basically a coma can can actually be provoked by hyperglycemia. You. Have had this in the wild. What? The hyperglycemic loss of

consciousness. I have had this in the wild. I have. Man, I've I kind of forgot about that story. Almost twice I think. Really. Yeah, that other girl. Oh yeah, right. I've also been hyperglycemic. You have? I have. I had my normal tea. Oh, sorry, this was my college tea, so it was a lot more sugar than what it is now. And then cinnamon roll pancakes. Oh gosh. Yeah, it was not good. Driving home did not feel great. No, I think everyone's kind of felt that like uncomfortable,

way too much sugar shakiness. But just think of that like times. Yeah, for sure. Where your body literally already has a hard time controlling it. Like just that feeling of it your your body needs help controlling that. Right. Do you want to talk about that guy? Yeah, that one was was, that was an interesting one we were waiting for. We were waiting at a restaurant and this dude just like collapsed. Well we were on the 2nd floor, so like the whole floor shook because we were on like a

balcony. Yeah. And like, you know, being an AT, like, well, I'm going to go over there and make sure like, we're OK. Like, like, 'cause the person just collapsed. So I don't know. Do we have to see? No. Randy like, fought his way through the crowd to like, get to this guy. Did I fight my way? I thought I just could. Definitely push people out of the way. OK, I. Don't remember that, but I was determined to get. There, good. I'm glad. And yeah.

No one else is really acting so. Yeah, he was just laying on the ground. Yeah, I just kind of went up to him and I was just asking a bunch of questions. I can't even remember. It was a it was a long time ago, it. Was a long time ago. I can't. I do remember like. Like pre COVID, like you know, even before that it was. Yeah, like he wasn't, he wasn't diagnosed with diabetes, but like, I can't even remember what I was asking, but I felt like

just what he was answering. I was just like, you need to, like I think you referred to yeah, you need to talk to your doctor about this, 'cause I feel like he, I can't even remember. I feel like if whatever I say, I'm going to make up a, a new story. But yeah, that one was interesting. Anyway, so hyperglycemia.

So the management for this is just a little bit more difficult from at least from an AT side, this really revolves around kind of the the physician kind of overseeing this management because they're the ones who are going to have to have the athlete adjust their insulin based on whatever they're feeling. All right. Again, that's why it helps to have some parameters within their care plan that we can help advise them to do.

But a lot of that management, especially if it's someone who has been doing well with their management, all of a sudden something's changing, right? I've had a, a student athlete where they've been doing fine all year. Then all of a sudden they're like, I feel low, but their numbers not. And it's like, oh man, I don't know how to, you need to talk to your doctor, right? Because right, that's a very complex kind of situation.

Like objectively, their numbers are actually a little bit higher, but yet their symptoms, they're like, I feel like I'm low and I'm like, oh that. Is not that's. Those two things don't compute, No. So yeah, a lot for hyperglycemia, if the physician is definitely going to have a heavy hand in this one and really it's going to gear towards adjusting the bolus

injection. So the bolus injection is those injections that they do before eating or if they're going to use it if they're hyperglycemia, right. It's kind of like that quicker, like I need to get my blood sugar down like now. Yeah. So this, this a lot of times if you haven't been around someone who has to do like figure this out, like before they eat, they have to do it before they eat and they have to like kind of gauge how much they're going to eat or what they're going to

eat. So then they have to administer like a certain amount of insulin that they, they're like, oh, I think it's going to spike it this much. So I think I'm going to use this much insulin. And so that's why there's some like trial and error because like some things are going to spike you more.

Some things are not going to spike you as much or so, or like if you administer a bunch of insulin because you expect that it's going to spike you a lot, or maybe you don't eat as much and then it doesn't spike you as much as you thought. Now you have extra insulin. Now your blood Sugar's going to go lower than you expected. For sure. So it's just like then you have to like eat more to balance that out or like administer sugar to balance that out.

All right, So that's really where that kind of management's going to be geared towards as far as our kind of role in this is. It's really goes towards the monitoring. And this is where that kind of like urine analysis to actual actually measure ketones comes into play. All right, So again, to show you how crazy these numbers can get, right, if a, if a, if an athlete or a patient has a blood glucose greater than or equal to 2:50 with ketones in their urine, that's a, that's a no exercise,

right? They, they cannot be exercising today. They it's not happening. If that number is there without the ketones, exercise can be OK. So that's crazy to think about like because obviously exercise is going to help lower that. Over time, because initially when you first start the exercise, it's going to spike blood sugar because your body is releasing the glucose so that it can use it. Yes.

But in diabetes, it's not necessarily going to take it out of the bloodstream as quickly as, yes, someone without diabetes. For sure. And then if it's over 300 without ketones, you can still exercise, but you're going to use some caution and they might need to test a little bit more regularly within that exercise activity. If it's more.

Yeah. If it's greater than or equal to 300 without ketones, they can still exercise, but there's going to be a little more caution and they'll probably have to test a little bit more regularly during the exercise session. They'll still be able to exercise. It's just values at 300 and

above. It's just you're without the ketones, you're still going to just monitor them and they might have to test kind of like at different intervals just to make sure we're still doing OK. But have you ever tested someone or asked someone to test their ketones? Exactly. That's kind of limitation. I've never had that. I've never had the kit to even do it. So that is one thing that I thought was interesting that now again I want to ask my athletes,

do you have this stuff? I don't know, I feel like it's like so much more involved, not maybe that's the wrong word, more it's going to be hard to get buy in from the athlete that they have to test more than the thing they're already testing. Yes, for sure, for sure. I I think that that is the tough part. That's why I feel like, again, like I feel like I've never seen anyone really do that right. But that is a consideration to like when you're coming up with

your care plan. Or maybe if you need more information. Yes. So finally kind of like a a again, a big role for like the athletic trainer is kind of educating everyone kind of involved with this. And kind of like we said before, like at least in my experience, like having the older athlete, I feel like it's more making sure they're good and that they have everything they're need and it's educating everyone else around

them. But for sure, like if it's a newly diagnosed patient, there's going to be a lot of educating them on what this experience kind of looks like. And I feel like, I don't know, I've never had someone newly diagnosed. So I can't tell if like the healthcare system already does a good job of helping educate them on that. I'm not sure.

I know the people who I've talked to had to do like an intensive, like learn about diabetes, like almost camp kind of thing, but I'm not sure if that was just like specific hospitals or if that's just a kind of gold standard. I'm not sure how that works. Yeah, that's interesting. Yeah, 'cause I would be interested. But that's like some of these people that I know are were like diagnosed in like early high school or something. And it's like, how much can a teenager like?

Retain and. Or handle mentally or you know. Yeah, for sure. I think, I think one thing too that I think no matter if it's someone who's managed it very well or who's known about it or someone who's just been diagnosed is at least making sure they understand just some considerations about administering insulin and a lot of it is kind of environmental, right. So making sure that they realize that extreme temperatures can and affect the how effective insulin will be.

All right. So I think it was like on the cold side, it's anything under 37°F outside. And then on the hot side, it's anything above 86° like that can affect how insulin like works, right? So it may be more ineffective at those hotter temperatures. Maybe you need to do a little bit more. And this really could be considered in those athletes that do have like insulin pumps, right?

They may have to replace a whole cartridge that's in there, the whole vial of insulin if they were outside, 'cause now that vial heated up and that insulin might be no good or not as effective as they think it might be, right? So. Or if it's not responding the way they expected to, perhaps ask them if they had been in extreme temperatures. Yeah, for sure. Or making sure that they know that they're ready or like, hey, we're going to be in this hot environment, right?

Make sure you have everything you need. Or if I need, if we need to make sure we have some extra ones like kept cool in a kept in a safe cool place. And then also for from our perspective, right, making sure that our, the, that our kind of thermotherapy modalities, right? We're, we should avoid injection sites for around 4 hours. Some things for cold are one to three hours and heat is like 4

hours. So I just summed it up to just say maybe after 4 hours because that can affect how the insulin is being absorbed in that area and can actually like heat can actually increase the rate of absorption, right? So it could throw off a lot of different things. So just kind of making sure that they understand that we understand. OK. Well, where do you normally inject? Have you recently done like you know understanding that timeline before we start doing modalities, right.

So like again, understanding contraindications. I did have one football player with diabetes and I'm trying to remember where his pump was because I remember having to protect it, but I'm blanking on where his pump was. Oh, interesting. Yeah, because I had to be protected so it didn't get hit. I'm just for sure. I really wish I could remember right now. I'm probably gonna remember after we're done recording. Yeah, of course, that's how it always works.

Yeah, but if you have had an athlete who has had a pump that's needed to be protected during sport, let us know in our Facebook group, facebook.com/group/eighty Corner podcast. Maybe experiences with diabetic athletes could be the question of the week. For sure. So I think a lot of the

education now kind of gears towards like making sure everyone else around them who's not necessarily like medically trained is ready to kind of help with the situation of hyperglycemia or hypoglycemia. At least being able to like kind of recognize it and like, oh, yeah, go do what you need to do. Like it's not just, oh, you're being soft today, right? Like understand, like, oh, you need to take care of yourself, right. Do what you need to do.

Or even like notice when things are going bad that OK, we are in an emergency now, all right. So I think that's where a lot of the education now goes towards like coaches and like admin and like people who are going to be around these student athletes, especially for extended period of time.

And also too, like making sure, like travel plans, making sure coaches kind of understand, like, you know, they're supporting the, the student athlete with like making sure that we have a, a plan for meals. And like, you know, understanding if like a student athlete has X amount of snacks that they need to bring. Like just making sure that we just support the student athlete or the patient with what they need to do.

And I think again, it's, it's going back to making sure that they're comfortable, like if they have to help with the treatment of hypoglycemia or hyperglycemia, right? Making sure that they know where the supplies are in the travel kit, making sure they know, hey, this is where the care plan is going to be. So if you need to refer to it, it's right here. Sweet, Yeah, you got an action

item for this? I think this really boils down to with the, with the student athlete, with the athlete, with the patient that has type 1 diabetes, really listen to what they're experiencing, right? Really, they're really good about the ones that have had it and have been able to manage it. They're really good about knowing how they feel what's going on. And for the ones that have been newly diagnosed and aren't quite sure they're feeling things

right. So they know something's up, like listen to what they're saying. And you know, our job is to kind of help support that newly diagnosed patient into advocating for. Hey, you need to talk to your doctor. You need to, you know, ask them about adjusting this or ask them what what this kind of symptom is.

And then for the well managed diabetic patient like making sure that that we hear them if there's any changes or making sure that we have a plan in place and that they know what their plan is and we know their plan. So it's all about advocating. I think the plan is the biggest part of that action. Make sure we have a plan, yeah. Awesome. Well, if you guys are interested in the CU, again, make sure you Scroll down to the show notes to get that category A certificate. It is free.

If you're listening to this as it comes out. If it's a little bit older, make sure you check the status of it on clinically pressed website. It is probably set at an affordable price. If it's a little bit older, go ahead and Scroll down to the show notes. And then there's also on our Instagram, there is a pinned tutorial on how to get that certificate with the quiz and the course evaluation. Lastly, if you guys are new, we

do several types of episodes. This is ACU Education episode, but we also do episodes such as interview style episodes or we do story based episodes where we bring stories from athletic trainers all over the world and we put them on a highlight topic so you can hear the gap between evidence and experience. For sure, or the OR the interesting spin on what the evidence says because of what happened in real life. Or talking about like hear the insulin pumps and yeah.

What that's true? The things they don't teach you in. School. You know what I'm wondering if he actually took it out for games. Yeah, that can happen. I mean, there are times where it does have to be protected. So I know what you're talking about. I'm just literally trying to remember where it was. I wish I remembered it was not that recent. Oh, that's fair. Yeah, that was my last diabetic football player. Wow, interesting. I haven't had one recently anyway.

Thank you for helping us showcase athletic training behind the tape. Bye.