By Clara Schneider, MS, RD, RN, CDE, LDN | 10/7/2013

It has been a few years since I met the Olympic swimmer Gary Hall, but the memory is very vivid in my mind. You see, at the time my son was a young teenager swimming on a league team located at a nearby U.S .Army facility. By all accounts not up to an Olympic level, but his swimming dictated our family activities. I also remember two boys with type 1 diabetes on the team trying like my son to win blue ribbons if possible, but also enjoying every aspect of loving their sport. My favorite activity was standing on the side of the pool every Saturday morning, cheering for all the swimmers. My top heroes (of course besides my son) in the athletic world were and still are the three swimmers: Gary Hall and those two young boys.

Meeting Mr. Hall was wonderful for me. It was at the American Diabetes Association Convention. I know there is absolutely no way that he would remember me, but the occasion was an event where his doctor and Mr. Hall discussed his training and managing his type 1 diabetes. I couldn’t get over how lean he was. Here he was a handsome young man with 10 Olympic medals. He was also very gracious. I know my two young friends would love to have his autograph, which he gave with a smile and also for me a hug. What an inspiration! After meeting him, Gary Hall’s picture hung in my diabetes center for the years I directed our program. I would point to the picture when asked if people with type 1 diabetes can exercise and replied, “Yes, of course, with your doctor’s approval.” “Just look at the picture of Gary Hall,” I would add, “he has type 1 diabetes and worked hard to win 10 medals in the Olympics!”

To my knowledge my other two heroes never went on to the Olympics. They did have a lot in common though with Mr. Hall. They loved their sport and worked hard to keep their diabetes under good control.

What are the steps all people with type 1 diabetes should follow so exercise is enjoyed and done safely?

Step 1: Think about the kinds of exercise that is necessary for your life and also the exercises you would like to learn, participate in or get better at. Make a list. Items on it may be things like:

- Walk the dog.
- Housework including vacuuming, making beds, and other chores.
- Gardening and lawn work
- Starting a swim program
- Ice hockey
- Soccer
- Cardio-class or yoga at the local community center

Remember this is your list. How are you planning to exercise?

Step 2: Research your exercise. What are the time-periods you are going to devote to exercise? Perhaps you need to walk the dog for 20 minutes 2 times a day. Maybe you are going to join a ice hockey club get up at 4 a.m. for a one-hour practice five days a week and then again at 7 p.m. two days week because that is the ice time your team has. You also plan to play in one-two games over the weekend. Write down the time blocks.

Step 3: See your physician and talk about your lists. Will you be cleared for the exercise? What precautions should you take? Some of these things are the same as everyone else like proper protective gear in sports, but gloves and knee pads may also be appropriate for activities like gardening. What types of foot gear is needed for your exercise? Discussions with your healthcare team may include proper fitting shoes and socks made to keep the feet dry. Talk about taking proper care of your feet to avoid blisters and trauma. Besides wearing a medical ID, what are some important discussion points you need to address with your medical team that are unique to people with type 1 diabetes and exercise?

8 Important Points about Type 1 Diabetes and Exercise

Point 1: Do I need to adjust my insulin amounts for the activities I choose?How should I do that? Serious athletes may use a pump to regulate their needs for various levels of insulin. When insulin is needed before exercise, it is recommended to inject into subcutaneous tissue that is distal to the exercising muscle. (1) Many people with diabetes have a decrease in their blood sugar although there are people that “go high” with intense exercise. It is important to ask how to adjust your insulin based on your individual needs. It is important to think ahead to avoid hypoglycemia or hyperglycemia.

Point 2: Discuss when you need to test your blood glucose. With all activity is important to test blood glucose before, during and after the activity. Ask your physician how often you should be testing. Ask what blood glucose readings you should strive for during all three time periods. The exercises you have on your list may affect your blood glucose levels differently. Common recommendations are to have a blood glucose level of at least 100mg/dl before exercising. Is this high enough for you? What does your doctor recommend? If your activity is intense, what should your levels be after exercise? By testing after you exercise you can see the trends of your values and if you need to treat to prevent lows or highs. Exercise can lower your blood sugar for up to 24 hours. (2)

Point 3: What blood glucose and ketone levels indicate that you should not exercise? General recommendations for people with type 1 are to test blood glucose before exercising. If the levels are above 250 mg/dl but below 300 mg/dl, test for ketones. If ketones are present, do not exercise. The Joslin Diabetes Center recommends: “If there are no ketones present and blood sugars are 300 or more, test within 5-10 minutes of beginning exercise. If your blood sugar is dropping, you may continue. If it is not dropping, stop exercising.” (3) Ask your healthcare team if these guidelines are for you. Also ask for insulin administration and fluid guidelines to help regulate your blood glucose. Test frequently and according to your physicians recommendations. Ask your physician if she/he will write an order for additional strips. Check with your insurance to see what will be paid for.

Point 4: Will your meter readings be affected by factors such as temperature? Know that meter values are influenced by altitude and temperature. If you participate in winter sports, know that circulation to the skin is diminished in the cold. Blood glucose readings taken from the fingertips are not as affected as those taken from other sites. You may see a lag time in your blood sugar of up to an hour at these sites. Normal lag time for alternative sites is 15-30 minutes. (4) Also know the temperature limits to your meter. Discuss with your healthcare team techniques to keep your meter at the proper temperatures and if you will need to change your meter based on its ability to function. Hints like carrying your meter in the upper inside pocket of your coat may help. Diabetes Forecast has an excellent table of meter limits (both high and low) located here. The guide lists temperatures using the Fahrenheit scale. The equation to compute these values to the Celsius scale, if needed, can be found here.

Point 5: What should I do to take care of my hydration (fluid) needs? The usual rule is to drink fluids before, during and after exercise. A person exercising needs to replace fluids lost from perspiration and to keep hydrated. (5) Recommendations for hydration before and during exercise presented at the Canadian Diabetes Association Professional Conference in 2004 suggests drinking 250ml (approximately 1 cup) of fluid 20 minutes before exercise, and continuing with an additional 250ml for every 20-30 minutes of exercise. (6) Ask your healthcare team what your fluid goals are. Ask what fluids are recommended for you to consume.

Point 6: Discuss how carbohydrates should be consumed before, during and after your exercise. Carbohydrates are usually recommended as part of a meal three-four hours before competitions or one-three hours before exercise. One-hour before competition it may be suggested to drink a sports beverage with 1-2 grams of carbohydrate per kg of body weight. One kg is equal to 2.2 pounds. More carbohydrates needed during exercise are dependent on your blood glucose readings. After exercise it may be suggested to consume slow-acting carbohydrate to protect against post-exercise late-onset. (7) Ask your medical team what is right for you. During exercise you should always have access to a source of simple carbohydrates to handle your blood glucose if it is going low. Discuss with your medical team convenient options.

Point 7: What should I do if I am part of a team to help me keep safe? If you are part of a team or your child with diabetes is part of a team, the National Athletic Trainers' Association (NATA) recommends having a diabetes care plan for practices and games. The care plan is put in place so the appropriate people will know how to take care of the special needs of the athlete with diabetes. For more information, click here.

Point 8: Is there any special equipment I should discuss with my health care team? You may want to consider special equipment based on the exercise you are considering. In swimming, one may want to explore the possibility of a waterproof pump. Other sports may have special needs as well. Explore the possibilities with your healthcare provider.

Exercise should be part of every person’s day. If you have type 1 diabetes, make sure you learn more about the exercise you want to do. Discuss with your medical team if the exercise is something that you can do safely. Maybe some of you with type 1 diabetes reading this article will end up with an Olympic medal or two or even 10 like one of my heroes. All of you should find something that is healthy to participate in like all of my heroes! Do not forget to follow their recommendations of your medical team. Please share with all of us at DiabetesCare.net the exercise you participate in and how you handle any special problems with type 1 diabetes.

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