Chapter 19

Managing Diabetes as an Athlete

IN THIS CHAPTER

check Going beyond basic training levels

check Considering how adding or restricting carbs can affect your athletic performance

check Figuring out why you may not be performing at the level you want

An athlete lives in everyone, even if you don’t consider yourself one. Being athletic is more a state of mind than anything else. That said, some people with diabetes are actual competitive athletes, taking part in professional sports, the Olympics, and collegiate and high school competitions.

This chapter is geared toward helping you if you’re a competitive athlete, but it’s relevant even if you’re just a more serious recreational one. Many different factors can impact your exercise performance — which can be gauged by how well you do and how good you feel while doing it — and now just may the time for you to get a performance tune-up.

Taking Your Activity to the Next Level

Most of what you need to know about how to effectively progress your exercise training you can find in earlier chapters. How fast you progress should be an individual choice, but it does take time to establish an exercise habit and to increase your fitness level.

When your training has lapsed (or you’re just starting an exercise program), you benefit from an initial conditioning phase lasting four to six weeks. After that, you move on to an improvement phase for four to five months and then to a maintenance phase from six months on. If you already have a higher level of fitness, you may be able to shorten or skip the initial conditioning altogether.

Bumping up your training intensity

When you already have a fitness base, additional gains happen if you work out more at the higher end of your intensity range. You can do short, harder intervals or sustained higher-intensity training. Intervals are equally effective, usually more motivating, and better for avoiding overuse injuries. (Discover more about interval training in Chapter 10.)

The overload principle of training states that you must keep challenging your body to have any further fitness improvements or gains in muscle strength, or else you just reach a plateau. Increasing your intensity works both during the improvement phase and after you reach the maintenance stage. At that point, your progress slows unless you continue to overload yourself by increasing your exercise intensity, duration, frequency, or a combination of these factors. If you’re as fit as you want to get, just work on staying that way.

remember Interval training during aerobic workouts is a viable way to boost your fitness, especially if you don’t like doing sustained harder workouts.

Pumping it up until fatigue sets in

In resistance workouts, you maximize your strength gains by doing 8 to 12 repetitions of each exercise (usually 8 to 10 different exercises) until you’re feeling fatigued. If you’re a novice at resistance work, you can start out with lighter weights or more-flexible resistance bands that enable you to complete one or two sets of 12 to 15 repetitions on each exercise, but use enough weight or resistance to feel at least somewhat fatigued by the end of the last set.

If you want to get a lot stronger, your goal should be to ultimately move a greater resistance fewer times (maybe 6 to 10 repetitions). Doing hard work produces more of an overload on the muscle fibers and brings you greater gains in muscular strength and mass.

remember After you gain muscle mass, you burn more calories overall, your resting metabolism increases, and your insulin sensitivity improves.

The current resistance training recommendations don’t tell you how many sets of repetitions you should do on each exercise. It has been proven that you can gain strength by doing only one set — that is, you can get stronger doing just one maximal repetition one time a week — but you’re likely to gain more strength by performing two or three sets of each.

When doing more than one set per exercise, you can increase the weight or resistance on each successive set, slightly decreasing the number of reps each time the load increases (for example, doing 15 reps on the first set and only 10 on the second, harder set). You can also do it in reverse and decrease the weight while upping the reps on the second or third set. The idea is just to fatigue the muscles you’re using for any given exercise, and there are many ways to arrive at that goal.

tip If you have time for only one set, make it an intense, nearly maximal set that fully fatigues your muscles by the time you reach the last repetition.

Knowing why your training state matters

When it comes to managing diabetes, how well trained you are definitely matters. How hard you’re working out affects what fuels your body is using. How long your activity lasts also makes a difference because some athletic events are so short that only the first and second energy systems come into play (see more on those in Chapter 4). They can be trained, but they don’t change as much with training as the aerobic energy system that relies heavily on carbohydrates and fat for fuel.

Here’s where your training state has the biggest impact. Being aerobically trained doing a specific activity can increase how much fat your body uses when you’re working out or competing. Most energy is supplied by carbohydrates when you do an activity at a somewhat-hard to hard intensity level. You use up a lot of stored glycogen from active muscles but also use some blood glucose.

remember The amount of fat you can use as an alternate fuel during aerobic activities depends on your training state, how hard you’re working out, and how long you stay active.

After you’re more trained, if you’re working out at the same absolute intensity or pace, your muscles bump up their fat use. If you keep the relative exercise intensity the same by increasing your pace after you’re trained, then fat use increases only slightly.

All this information matters to how well you can keep your blood glucose stable and near-normal during exercise. You want to be able to use more fat and spare your body’s carbohydrate supply to do well in prolonged athletic events or endeavors. You want to avoid hypoglycemia that makes you slow down or stop so you can excel at your sport or any activity you choose to do with diabetes.

remember Take your training to the next level to get as fit as you can doing each activity that you participate in.

To a certain extent, you have to start the process over with each new activity you do, although being trained for one sport or activity does convey a higher starting level because your heart, lungs, and blood vessels may already be trained to operate at a higher level from your other types of training.

Carb Loading Effectively for the Athlete

Almost all serious exercisers benefit from carbohydrate (carb) loading before long-distance events and carb reloading afterwards. Having an adequate intake of carbs at both times enables you to begin exercise with fully restored or even overfull stores of muscle glycogen (glucose stored in muscle and used during exercise).

The original carb-loading protocol before events was three to seven days of eating a high-carb diet (8 to 10 grams of carbs per kilogram of body weight). This diet was combined with a day or two of complete rest or a reduced exercise volume known as tapering.

But even a single day with a higher carb intake and rest or tapering can effectively maximize carb stores. Carb loading has been blown out of proportion and misapplied to all sorts of sporting events (like 5K walks) during which you have no risk of running out of muscle glycogen. You don’t need to spend a week, or even three days, over-consuming carbs and potentially lowering your insulin sensitivity and raising your blood glucose by doing so.

remember If you eat enough calories and rest the day before your event, you’ll have enough muscle glycogen stored to make it through most athletic endeavors. However, you need to effectively manage your blood glucose that day for full glycogen storage.

Most athletes make sure to take in plenty of carbs after their event or workout as well to restore glycogen in muscles as soon as possible. It can be different for people with diabetes, though, because it takes having enough insulin in your blood to restore glycogen effectively.

Not taking enough carbs after exercise can make it hard to do your next workout, but some people purposefully don’t eat enough to keep their insulin action higher for longer after workouts or sporting events. Insulin action stays higher until the glycogen in your muscles is fully restored. That usually takes one to two days when you eat a normal diet — but it can take much longer if you’re eating low-carb (head to the following section).

tip Consider your event and your normal training schedule when deciding how many carbs to eat and when to eat them. If you need some extra help, consider meeting with a sports dietitian, especially one that is a certified diabetes educator if you can find one, to help design a food and carbohydrate plan to maximize your ability to train and compete.

remember If you eat enough calories and at least 40 percent of them come from carbs, your intake likely is adequate for refilling of muscle glycogen stores after workouts as well.

Training Well with Low-Carb Eating

Even though your body improves its ability to use fat and ketones as a fuel for exercise when you’re on a low-carb regimen, fat is never your body’s first choice of fuels during moderate and intense workouts lasting more than a couple of minutes. If your body can get carbs, it uses them rather than fat, particularly as your workout gets more intense. It happens simply because using carbs is more fuel efficient — that is, you get more energy out of carbs for a given quantity of oxygen.

remember Carbs are like using a higher-octane fuel, resulting in more bang for the buck. If you want to exercise intensely and you eat a very low-carb diet, you likely won’t be able to perform at your highest potential level.

If you’re eating enough calories to cover what your body needs on a daily basis (including what you use during exercise), you can get by with consuming 40 percent or less of your calories from carbs. Eating more than that doesn’t necessarily benefit exercise because it’s not a case of “some is good, so more is better.” Most people who are training overeat carbs, given the limited amount and intensity of training that they do. (See the preceding section for more on proper carb loading before an event.)

Scrutinizing whether low-carb eating hurts performance

Fully restoring muscle glycogen if you deplete any during exercise takes 24 to 48 hours, assuming you’re eating adequate amounts of carbs. If you’re on a low-carb regimen, the process takes longer, and you may be trying to do your next workout with less muscle and liver glycogen on board.

remember If you can do less intense exercise as well as you want to while eating low-carb and performing optimally at the highest level doesn’t matter to you as much as just finishing your events with a respectable time, then an active low-carb lifestyle may work just fine for you.

Despite what you may think, running low on carbs doesn’t automatically bump up your fat use during exercise. As everyone says in the exercise world, “Fat burns in a carbohydrate flame.” What that means is that if you don’t have carbs left in your muscles, you can’t use fat as a fuel very well either. Without glycogen, your fat use is compromised, and you have to slow down your pace to a level where you just don’t need much carbohydrate.

Do you need to restrict carbs so severely if you’re exercising regularly? Probably not. Even people with type 2 diabetes can handle carbs better when doing regular physical activity that depletes some muscle glycogen. You feel less tired and more energetic when eating some carbs during and after exercise to speed up muscle glycogen repletion.

remember On days off from exercise, a lower-carb diet may help keep your insulin sensitivity heightened for longer.

Anyone with type 1 diabetes needs to keep blood glucose as near to normal as possible to get optimal glycogen into muscle and liver storage depots. It won’t be effectively restored if your blood glucose is running on the high side.

Using the window of opportunity for carbs

Taking in some carbs post-exercise is likely the most important time — particularly during that window of opportunity from 30 minutes to 2 hours after a workout when glycogen repletion rates are highest. That period is also when you need the least insulin to cover any carbs you eat.

remember Your carb intake doesn’t have to be a lot. Start with 15 to 30 grams, depending on how long and hard you worked out.

Troubleshooting Exercise Blood Glucose for Competitive and Serious Recreational Athletes

Many different factors can impact your blood glucose responses, and the more you know about them, the better equipped you are to figure out what works best for you in almost every situation. This process always takes some trial and error.

Sometimes it’s still difficult to figure out what is causing the blood glucose or other exercise responses you’re having. Try these strategies if you’re experiencing any of these issues with being active with diabetes.

Managing hypoglycemia

Getting low blood glucose during physical activity not only is annoying but also can compromise your ability to complete your event or competition. No one likes to get low during exercise.

If you’ve been experiencing any exercise-related lows, consider taking some of these actions or precautions to avoid it, especially if you use insulin:

  • Check your blood glucose more often if you’ve had a bad low or exercised hard in the 24 hours prior to your latest workout.
  • Keep in mind that doing new or unaccustomed exercise is more likely to result in lows, both during and following the activity.
  • Exercise when your blood levels of insulin are lower (like before meals or first thing in the morning before taking any meal insulin).
  • Take in extra carbohydrates before, during, and after activity (the amount dependent on the intensity, duration, starting blood glucose levels, and so on).
  • Consume some protein and/or fat after exercise and also at bedtime to counteract lows later on (and overnight).
  • If possible, choose pre-exercise foods that allow you to take the smallest doses of insulin to cover them to keep circulating insulin levels lower.
  • Prior to doing longer duration exercise, lower your insulin levels during exercise by lowering your closest pre-exercise dose(s).
  • Lower pre-exercise insulin you take within two to three hours before doing an activity (or set a lower basal rate if you use an insulin pump).
  • Remember that how quickly insulin is absorbed depends on the size of the dose: Smaller doses (one to three units) are absorbed more rapidly than larger doses (five or more units), which linger for longer.
  • If using an insulin pump, you can lower your basal rate prior to the start of exercise for one to two hours as well as during (and after) the activity.
  • If giving basal insulin (like Lantus/Basaglar or Levemir), consider splitting the dose (although not necessarily evenly) to give it twice daily to allow for easier dose reductions pre- and post-activity.
  • If low following exercise, reduce your dose of rapid-acting insulin given after any activity, or lower basal insulin for 4 to 12 hours.
  • Your insulin needs are lower when you’re regularly active, and you may need permanently lower basal (and mealtime) insulin doses.
  • Doing an all-out sprint for 10 to 30 seconds helps counteract most lows during exercise, but only if your insulin levels aren’t too high.
  • Avoid massaging the area where you just gave some insulin (because massaging it can speed up its absorption).
  • Getting in a hot tub or other prolonged heat exposure can speed up the absorption of any insulin taken (causing lows first, then highs later).

Handling hyperglycemia

If you’ve been experiencing high blood glucose related to being active, consider these possible ways to troubleshoot and correct your levels:

  • If your pre-exercise blood glucose is over 250 mg/dL and has been for more than a few hours, consider giving some insulin and waiting for the level to decrease (particularly if you have moderate or higher ketones).
  • If your blood glucose is over 300 mg/dL with no ketones, exercising is okay, but use caution because you can dehydrate more easily.
  • For early morning exercise (before breakfast), you may need a small dose of insulin (less than normal) and/or a small snack to break your fast to reduce your glucose-raising hormones like cortisol.
  • Eating a full meal within an hour of exercising can slow digestion and result in high blood glucose an hour or two afterward, particularly when you consume lower glycemic index foods and drinks. (Chapter 6 has more on the glycemic index.)
  • Stay hydrated during activities because dehydration can make blood glucose seem higher and cause you to give too much insulin later.
  • After you’ve trained for a few weeks doing a certain activity, you likely need fewer carbohydrates or smaller insulin reductions than before.
  • When you’ve participated in an activity that makes you get very sore (peaking two to three days afterward), you may be more insulin resistant because you can’t restore muscle glycogen until your muscle damage from the activity is repaired.
  • For blood glucose elevations right after exercise, cut back on your carb intake during exercise, reduce your insulin less, or take some insulin after exercise (but make it a smaller amount than normal).
  • If the stress or intensity of competitions raises your blood glucose, keep basal insulin higher during the activity and only give 50 percent or less of your usual correction dose to lower glucose during or afterward.
  • If you carb load before events, take enough insulin to cover your carb intake; otherwise, it can raise your blood glucose and limit glycogen storage. Check out the earlier section “Carb Loading Effectively for the Athlete” for details on this training approach.
  • If you disconnect your pump during activities and your blood glucose starts to rise over time, reconnect at least once an hour and supplement with at least a portion of your missed basal dose to cover it.
  • Consider an untethered pump regimen where you give some of your insulin a long-acting insulin injection (Lantus, Basaglar, Levemir, Toujeo, or Tresiba) and the remainder as a reduced basal rate through the pump. Then if you disconnect, you still are receiving some background insulin and are less likely to have hyperglycemia post-exercise.
  • Keep insulin from getting too hot or too cold, or its action may diminish and cause usual doses to not cover your insulin needs.
  • Injected or pumped insulin is absorbed faster in smaller doses, so after a larger dose, you may end up too high first and then too low later on.
  • Smaller doses of basal insulin are absorbed more rapidly than larger ones (think 5 units versus 20) and often don’t last as long as they’re supposed to (24 hours for Lantus/Basaglar, closer to 12 hours for Levemir).

Avoiding early-onset or excessive fatigue

Did you ever DNF (“did not finish”) a race or a competition? Certainly, that can happen if you twist your ankle, cramp up, or otherwise get injured. But sometimes your performance is affected when you get tired too soon during an event or if the fatigue is so bad you simply can’t go on.

Here are actions you can take to prevent fatigue that comes on early or is bad enough to make you stop before you reach your athletic goals:

  • Prevent both hypoglycemia and hyperglycemia (see the preceding sections) to delay or prevent fatigue when you’re physically active.
  • Keep your blood glucose as close to normal as possible for a day or two beforehand so your body can store optimal amounts of carbohydrate in muscle and liver (as glycogen).
  • Consume carbohydrates during exercise to provide an alternate source of blood glucose (other than the limited amount your liver can release).
  • Avoid hyperglycemia by having adequate insulin in your blood to counterbalance the release of glucose-raising hormones during exercise.
  • Try out new food or insulin strategies during practices, not events or competitions.
  • Keep yourself adequately hydrated before and during motion, especially if your blood glucose levels have been running above normal levels.
  • If muscle cramps are causing you to stop early, consider supplementing with magnesium and possibly a B vitamin complex. Also have your blood iron levels checked because anemia can cause fatigue, particularly during exercise. The following section has more on these deficiencies.

Considering other performance variables

Has your exercise performance been less than you’d hoped recently? Many different things can cause poor performance or unusual fatigue, but here are some potential causes (and solutions) to consider when you have diabetes and are athletically inclined.

Inadequate rest time

If you’re doing well with your workouts, but not with your races and events, you may simply not be resting long enough to restore glycogen, repair muscle damage (caused by every workout), and fully recover. Cutting back on your workouts (tapering) for at least one to two days before a big event is critical. During that time, keep your blood glucose as close to normal as possible so your glycogen levels are as full as possible for your race or event day.

Blood glucose and glycogen stores

Restoring your muscle glycogen between workouts takes eating enough carbohydrates and having insulin in your body that works adequately. Doing longer and harder workouts can deplete glycogen stores, and you may not be fully replenishing them fast enough because you’re either not eating enough carbs or not keeping your blood glucose in check. You must have an adequate amount of insulin available to restore the glycogen in your liver and muscles.

Iron levels

Having low iron body stores can cause you to feel tired all the time, colder than normal, and just generally lackluster. You can be iron deficient without having full-blown anemia. A simple blood test can check your hemoglobin (iron in red blood cells) and your overall iron status (serum ferritins). If your body’s iron levels are low for any reason (such as having dialysis), taking iron supplements can help; so can eating more red meat, which has the most absorbable form of iron.

Magnesium status

Most adults with diabetes are magnesium deficient, especially when their blood glucose levels are higher than optimal, which causes more loss of magnesium through your urine. About 50 percent of the body’s magnesium supply is found in the bone; nearly another 50 percent is inside body tissue cells and organs, and less than 1 percent is in the blood. It’s a critical mineral because it impacts over 300 enzyme-controlled steps in metabolism, including protein synthesis, muscle and nerve function, immune function, blood pressure regulation, and blood glucose management.

Symptoms of low magnesium levels include agitation and anxiety, restless leg syndrome, sleep disorders, irritability, nausea and vomiting, abnormal heart rhythms, low blood pressure, confusion, muscle spasm and weakness, hyperventilation, insomnia, poor nail growth, and even seizures. Having a magnesium deficiency likely compromises your blood glucose and exercise, and you may even experience some muscle cramping (unrelated to dehydration). Low magnesium can also lead to potassium imbalances.

Refining and overprocessing foods causes a loss of almost all the magnesium found in those foods originally, and the abundance of these foods leads to a widespread magnesium deficiency even in people without diabetes. You can eat more foods with magnesium in them naturally — such as nuts and seeds (especially almonds), dark leafy greens, legumes (like black beans), soymilk, yogurt, oats, avocados, fish, and even dark chocolate. However, taking a supplement may also help correct deficiencies in your diet. (Magnesium in the aspartate, citrate, lactate, and chloride forms is absorbed better than magnesium oxide and sulfate.)

B vitamin deficiencies

With diabetes, thiamin (vitamin B1) deficiency is also a likely culprit affecting your athletic performance, particularly if you’re not eating a healthful diet. The eight vitamins in the B family are integrally involved in metabolism and even red blood cell formation. People who take metformin to control diabetes may end up deficient in vitamins B6 and B12, both of which are essential for proper nerve function and muscle contractions. Thiamin (B1) is depleted by alcohol intake, birth control pill use, and more. Taking a generic B complex vitamin daily can help you avoid these issues, and excesses of most B vitamins are harmless (and simply peed out).

Insulin delivery

Insulin pumps can help manage blood glucose and deliver rapid-acting insulin analogs like Humalog, Novolog, Apidra, and Fiasp. The body metabolizes these altered insulins differently than it does long-acting Lantus/Basaglar.

The rapid-acting insulins have little to no insulin-like growth factor (IGF) affinity, and most adults are reliant on IGF rather than human growth hormone (which is only higher in youth) to stimulate muscle growth and repair. Lantus and Basaglar stimulate IGF activity, so you may want to talk with your doctor about combining insulin pump use (for meal boluses) with basal insulin injections to get more IGF activity to promote muscle repair between workouts.

tip Choose Lantus/Basaglar or Toujeo for your basal insulin needs because Levemir (another basal insulin) is less effective at raising levels of bioactive IGF.

Thyroid issues

Many people with diabetes also have thyroid hormone imbalances. Having lower levels of functioning T3 and T4 hormones can cause early fatigue and poor exercise performance, among other things. However, just checking your main thyroid hormones (TSH, T3, and T4) may not be enough. You may also want to consider getting your thyroid antibodies checked if your thyroid hormones levels are normal and nothing else is helping your exercise training. Specifically check for antibodies to thyroid peroxidase, especially if you have diagnosed celiac disease.

Moving forward when you’re still stumped

remember With diabetes as an added variable to consider in exercise training, the answer to what is affecting your performance isn’t always simple and clear-cut.

If you’ve been through all the confounding factors in the preceding sections and had everything check out okay, consider other possible issues. The fix may be as simple as monitoring your hydration status (and staying better hydrated, especially when your blood glucose runs higher). Or you may need to bump up your daily carbohydrate intake; adding even just 50 grams per day to your diet may help. Check for other possible vitamin and mineral deficiencies (vitamin D, potassium, and so on). If you use statins to lower your cholesterol, be aware that some statins cause unexplained muscle fatigue, so you may need to talk with your doctor about trying a different one. Your performance can also be impacted by frequent hypoglycemia or hypoglycemia-associated autonomic failure (see Chapter 4 for a discussion of that issue).

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