WRESTLING WITH TYPE 1 DIABETES:

A COMPETITIVE BLUEPRINT

Brian BroderickMBA 592Dr. EdmondsApril 7, 2016

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Agenda■ Overview of Type 1 Diabetes■ Sport of Wrestling■ Introduce 4 Diabetic Wrestlers■ General Questions■ Importance of Diet and Nutrition■ Practice■ Weigh-ins■ Competition Days■ Conclusion

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History of Type 1 Diabetes■ 1st symptoms discovered in 1552 B.C.

– Hesy-Ra - Egyptian Physician– Proclaimed the disease led to frequent urination and emaciation

■ For thousands of years, no one knew how to survive with diabetes

– Children would typically die within a few days– Elders lived with life-threatening complications

■ 1675 – “Water Testers”– Individuals would “taste” urine to test for sweetness

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■ 1600-1700’s: exercise was prescribed and herbs were used for treatment

■ 1800’s – Doctors realized the importance of diet and nutrition– French Physician Apollionaire Bouchardat

■ During Franco-Prussian War– Diabetic patients’ symptoms improved on food rationing diet– Oat cure, potato therapy, milk diet, opium, or starvation diet

■ 1921 – Insulin was discovered– Canadians Frederick Banting and Charles H. Best

History of Type 1 Diabetes

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■ 1959 – Type 1 and Type 2 diabetes were now clearly defined

– Type 1 – insulin dependent– Type 2 – non-insulin dependent

■ 1963 – First insulin pump was designed

■ 1970 – Introduction of instant glucose meters– Prior to arrival of glucose meters, colored dipsticks were

used

History of Type 1 Diabetes

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■ 1978 – Recombinant DNA testing began– Scientists insert a human gene into the genetic material of a

common bacterium– Prior to rDNA insulin, insulin was stockpiled from animal

pancreatic tissue– Not approved for use by the FDA until 1996

■ 1983 – First biosynthetic insulin was introduced– Allowed pharmaceutical companies to genetically

manufacture insulin

History of Type 1 Diabetes

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Overview of Type 1 Diabetes■ 29 million Americans diagnosed with some form of diabetes

– Approximately 10% or 3 million are type 1 diabetic

■ Type 1 Diabetes– Diabetes Mellitus– Juvenile Diabetes/Childhood-onset Diabetes– Insulin-dependent Diabetes– Petitioning for Beta Cell Apoptosis (BCA) Diabetes

■ Chronic illness which the individual has for the rest of their life– Pancreas transplant– Beta cell/islet transplantation

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What is Type 1 Diabetes?■ Auto-immune disease when the pancreas no longer

produces insulin

■ Insulin is a hormone produced by beta cells that allow glucose to be transported to the body’s cells

– Glucose stored in the cells can later be used as an energy source

■ Normal blood glucose range is 80 – 120 milligrams/deciliter

– Blood glucose > 140 mg/dl is considered hyperglycemia– Blood glucose < 80 mg/dl is considered hypoglycemia

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The Role of Insulin in the Body

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Hypoglycemia; < 80 mg/dl■ Causes of Hypoglycemia

– Taking too much insulin, not enough carbohydrates, postponing or skipping a meal or snack, increased activity or physical activity, and drinking alcohol

■ Symptoms of low blood sugar– Shakiness, nervousness, anxiety, clamminess or excessive perspiration,

irritability or impatience, confusion, rapid heartbeat, extreme hunger, nausea/dizziness, sleepiness, anger, blurred vision, lack of coordination, seizures, and unconsciousness

■ Treatment– 15 grams of fast-acting carbohydrates such as 4.5 ounces of juice or

non-diet soda, glucose tablets, gel tubes, cake icing, or candy– Extreme Cases

■ Glucagon Emergency kit may need to be administered by another individual

■ Glucagon stimulates the liver to release stored glucose into the bloodstream when blood glucose levels are too low

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■ Causes of Hyperglycemia– Not enough insulin used to cover carbohydrates during meal,

not enough long-acting/basal insulin, using expired insulin, not injecting insulin properly, being less active than normal, illness or infection, stress or anxiety, and certain medications

■ Symptoms of high blood sugar– Extreme thirst/hunger, fatigue, blurry eyesight, numbness or

tingling of feet, unexpected weight loss, frequent urination, sensation of “feeling overheated”, and being easily irritated

■ Treatment– Insulin therapy or adjust insulin dosages– Fluid replacement (helps dilute sugar in blood)

Hyperglycemia; > 140 mg/dl

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Insulin Types

■ Basal Insulin (long-acting)– Slow, continuous trickle of insulin that stays at

a low level in the blood at all times■ Humulin and Novolin■ Levemir, Lantus, & Toujeo

■ Bolus Insulin (fast-acting)– Large bursts of insulin that are released as

blood glucose rises, typically after meals■ Humalog, NovoLog, Apidra

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Basal vs Bolus Insulin

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Insulin Treatment■ Syringes or Multiple Daily Injections (MDIs)

■ Pump Therapy or Continuous Subcutaneous Insulin Infusion (CSII)

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The Sport of Wrestling

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History of Wrestling■ Oldest traces of wrestling date back to 13,000 B.C.

of cave drawings found in France

■ Beni-Hassan tombs have over 400 pairs of wrestlers carved on walls and ceilings dated back to 1900 B.C.

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History of Wrestling

■ Ancient Greeks viewed wrestling as much more than a sport

– Was viewed as a science and divine art

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Sport of Wrestling■ Fédération Internationale de Luttes Associées (FILA)

– Set standards and regulations for all international wrestling events

■ FILA recongnizes 2 different wrestling styles:– 8 International Wrestling Disciplines

■ Greco-Roman■ Freestyle

– Folk■ Backhold (Europe), Cumberland (England), catch-as-catch-can

(England), kurash (Uzbekistan), gusteengiri (Tajikistan), kuresh (Siberia), lotta campidanese (Italy), pahlavani (Iran), pehlwani (India), penjang gulat (Indonesia), schwingen (Switzerland), shuai jiao (China), ssireum (Korea), and scholastic (United States)

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Diabetic Wrestlers

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Conner Lefever■ Fort Wayne, Indiana

■ Diagnosed in 8th grade

■ Symptoms– Frequent urination– Blurred vision– Felt terrible while wrestling

■ Accolades– 2-time High School Indiana State Place Winner; 8th and 4th

– 3-time NCAA Division III Qualifier– 174 lb NCAA Division III Champion

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Travis Pascoe■ Originally from Idaho

■ Diagnosed at age 15– 425 mg/dl

■ Symptoms– Frequent urination– Lost weight without trying– Wasn’t feeling “normal”

■ Accolades– 3-time Washington High School State Champion– NCAA Division I All-American– 13th on Nebraska’s All-time Win List

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Jake Pooton■ Mount Airy, Maryland

■ Diagnosed at age 2– Blood glucose above 900 mg/dl

■ Symptoms– Flu-like symptoms

■ Accolades– 3-time Maryland High School State Place Winner; 5th, 4th,

& 1st

– Maryland State Champion; finished with 142-24 record– Sophomore High School All-American

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Kenneth Stank■ Harrisburg, Pennsylvania

■ Diagnosed in 9th grade– Blood sugar above 500 mg/dl

■ Symptoms– Lost 10 pounds unexpectedly– Terrible cramps– Felt sluggish/fatigued all the time– Could not quench thirst

■ Accolades– 2-time PA AAA High School State Place Winner; 8th and 6th

– High School Record of 127-35

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General Diabetic Wrestling Questions

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Insulin Pens/Syringes Vs Insulin Pump Therapy■ Both methods have their own advantages and

disadvantages

Insulin Pens/Syringes■ Greater mobility■ Cleanliness■ Less accurate control

Insulin Pump Therapy■ Greater BS control■ Basal suspension■ Risk infusion-set getting

ripped out/damaged

CL - “During days of wrestling competitions I switched off between my insulin pump and taking shots with syringes. This is because there are sometimes where the cannula comes out from under my skin and I might not realize it.”

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Infusion Set Sites

■ Common sites– Abdomen, hips and buttocks, outer thighs,

back of arms, and breast tissue– Should be changed every 2-3 days

■ Prevent infection■ Prevent scar tissue build-up

“Clock Rotation”

“M” or “W” Rotation

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Infusion Sites for Wrestling

■ Optimal placement for wrestling– Rotate between left and right outer buttocks

■ Additional Adhesive is recommended– SkinTac

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What was the most important factor for best managing your blood sugars?■ All subjects agreed that routine was the most important

factor

■ Consistent routine assists with:– Insulin estimation– Blood glucose consistency and patterns

KS – “Routine is huge to me. Every time I got ready for a match, I tried to do the same things.”

JP – “By allowing myself to repeat everything I do throughout the day, this makes it easier for me to see any patterns being created with my blood sugars. “

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Diet and Nutrition

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Glycemic Index

■ Measures how a carbohydrate-containing food raises blood glucose– Fat and fiber tend to lower the G.I. of foods– More cooked or processed the food = higher G.I.

■ Food with a high G.I. raises blood glucose more than a lower G.I.

– Low G.I. Foods (55 or less)

– Medium G.I. Foods (56-69)

– High G.I. Foods (70 or more)

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Glycemic Index Chart

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Glycemic Index

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Do you pay attention to the G.I. of Foods You Consume?■ CL – “I’ve never really paid attention to the G.I. in

foods. I’ve mostly just counted carbs.”

■ TP – “I just count carbohydrates.”

■ JP – “I simply count carbohydrates.”

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Have you ever supplemented any part of your diet to help optimize your blood sugar and performance (i.e. protein, vitamins, minerals)?■ Cinnamon pills

– In 1 study, reduced blood sugar levels by 24%– Lowers insulin resistance

■ Alpha lipoic acid, bitter melon, chromium picolinate, & fenugreek

– Also shown to reduce blood sugar levels– Decrease insulin resistance

■ Multi-vitamins & Vitamin C– Prevent illness

TP – “No. I just like to get the nutrition that I receive from food.”

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Follow a strict diet?

■ High-protein diet– Less chance of glucose fluctuations and spikes

CL – “I never took any supplements. I get all of my nutrients through the food that I was eating for breakfast, lunch, and dinner as well as what I ate for snacks.”

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Wrestling Practice

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Exercise’s Effect on Blood Sugar

■ Moderate-intensity activity typically lowers blood glucose levels

■ Studies have shown that intense activity, such as a burst-style sport like wrestling, can actually lead to an increase in blood sugar– Body goes into a “fight or flight mode”– “Activates the sympathetic nervous system” –

diabeteshealth.com– Forces the liver to release its stored emergency

glucose

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Hyperglycemia Prior to Practice

■ Glucose levels above 240 mg/dl– Check for Ketones in urine– Administer insulin

■ Lower dosage than normal

■ Do not exercise until blood sugar is below 240 mg/dl– Glucose levels can elevate even higher – diabetes.org

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How would you ensure proper blood sugars prior and during wrestling practice?

■ Test, test, and more blood testing– 1 hour before– 30 minutes before– Immediately before practice begins

■ Allows individual to notice blood glucose trends

■ Test blood sugar 1-2 times during practice– Test when feeling irregular

■ Trial and Error

■ Make sure blood sugar is slightly elevated prior to practice– 150 – 200 mg/dl

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■ 3 out of 4 interviewees stated their blood sugars would drop dramatically during practice

– Length of practice– Intensity of practice

■ Sip small amounts of sports drink during practice– Don’t over-drink– Keep fast-acting carbohydrates near by

How would your blood sugar typically respond from activity from practice?

KS – “One of the most important things is having your wrestling coach understand the signs of a low or a high. This way he can see if you’re starting to get sluggish, you need to check your sugar. “

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Hyperglycemia During Practice■ Uncommon

■ Administer insulin with syringes/pens– Pump takes longer– Lessen dosage

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Weigh-Ins

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Did you have a dedicated “after-weigh-in” meal?

■ ROUTINE

■ Eat the SAME meal every time after weigh-ins for better insulin/glucose estimation

CL – “I did have a dedicated after weigh-in meal that I ate after every single weigh-in.”

TP – “Yes, every meal after weigh-ins was the same.”

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Weigh-Ins

■ Eat as much of post weigh-in meal prior if weight permits– Takes approximately 2 hours after meal for glucose

to stabilize■ Only one hour in between weigh-ins and match start

time

■ Administer insulin as early as possible– Take a lower dose of insulin as compared to normal– High is better than low

KS – “You still need to take insulin to cover the food you’re eating, but you don’t want to take too much and risk a low while wrestling.”

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Competition Day(s)

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Competition Day(s)■ Nerves, anxiety, and stress

– Difficult to control– Contribute to higher blood sugars

■ Epinephrine - stress hormone increases blood glucose – Webmd.com

■ TEST , TEST, TEST– Bring extra test strips

■ Test blood sugar 15-25 times on competition day

CL – “I would say I would at least check it 20-25 times the day of a tournament.”

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Competition vs Practice

■ Blood sugar would typically increase from matches– Adrenaline– Nerves/anxietyOR– Liver releasing stored glucose because “fight of

flight” mode■ 7 minute matches compared to hour long practices

– INTENSE

CL – “I have noticed that during matches my blood sugar would normally increase. Most of the time I would go into my matches around 160 mg/dl and when I would check after my matches it could be up to 230 mg/dl.”

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■ Minimal Carbohydrate Intake on Competition Day(s)– Prevents glucose spiking

Competition Day(s)

JP – “I try to eat minimum amount of carbohydrates during meals because I have determined that by consuming more carbohydrates, you have a bigger scale of sky-rocketing up or going low with more insulin-intake.”

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Once Wrestling has Concluded■ Delayed Onset Hypoglycemia/ Post-Exercise Hypoglycemia

– Activity causes the body to be more sensitive to insulin up to 48 hours after exercise – diabetes.com.uk

■ “Heavy exercise can have increased risk of middle-of-the-night hypo’s unless you eat a big bedtime snack” – healthcentral.com

■ Preventing a Delayed Low Blood Sugar– Large bedtime snack– Reduced basal (long-acting) insulin– More blood glucose testing than normal

CL – “Normally I would just set my temporary basal rate a 0% for a few hours when I went to bed to keep it from dropping when I first went to sleep. “

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Conclusion■ Don’t wrestle through the extreme “highs”

or “lows”– Hypoglycemia unawareness

■No “best method”

■ Make sure someone knows how to treat you in case of an emergency

■ Find what works for YOU– Trial and Error

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Moving Forward…

■ “Artificial Pancreas could be ready in 2017 for Diabetics” –CNBC– Annetta Miller

■ Closed loop system that runs continuous algorithms– Continuous glucose monitoring– Insulin secretion– Glucagon

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Questions?

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References■ http://www.athleticscholarships.net/history-of-wrestling.htm■ https://unitedworldwrestling.org/organization/history■ http://www.experimentsinmotion.com/motion-gallery/89/Egyptian+burial+chamber+mural/■ http://ic.galegroup.com/ic/whic/ReferenceDetailsPage/ReferenceDetailsWindow?

failOverType=&query=&prodId=WHIC&windowstate=normal&contentModules=&mode=view&displayGroupName=Reference&limiter=&currPage=&disableHighlighting=false&displayGroups=&sortBy=&search_within_results=&p=WHIC%3AUHIC&action=e&catId=&activityType=&scanId=&documentId=GALE%7CCX3205100359&source=Bookmark&u=mlin_s_orrjr&jsid=b456a358b12d7d06545df65c4445f44e

■ http://www.spokesman.com/stories/1998/feb/05/needles-and-pins-diabetes-no-match-for-determined/■ http://health.usnews.com/health-news/patient-advice/articles/2015/05/13/teens-with-type-1-diabetes-

how-to-cope-and-when-to-seek-help■ http://www.joslin.org/info/why_is_my_blood_glucose_sometimes_low_after_physical_activity.html■ http://www.healthcentral.com/diabetes/c/110/8630/delayed-exercise/■ http://integrateddiabetes.com/Articles/exer/delayed%20onset%20hypoglycemia%20article.pdf■ http://www.diabetes.co.uk/sport-and-hypoglycemia.html■ http://insulinnation.com/living/5-tips-to-better-exercise-with-type-1-diabetes/■ http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understanding-carbohydrates/glycemic-

index-and-diabetes.html?referrer=https://www.google.com/■ http://www.humankinetics.com/news-and-excerpts/news-and-excerpts/insulin-levels-during-exercise-

critical-to-performance■ https://www.bd.com/us/diabetes/page.aspx?cat=7001&id=7245■ http://www.everydayhealth.com/diabetes/understanding/diabetes-mellitus-through-time.aspx■ http://diabetes.diabetesjournals.org/content/50/2/217.full■ http://www.defeatdiabetes.org/diabetes-history/

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References■ http://www.healthline.com/diabetesmine/the-kerfuffle-over-new-names-for-type-1-and-type-2-

diabetes#1■ http://www.diabetes.org/diabetes-basics/type-1/■ https://www.nlm.nih.gov/medlineplus/ency/article/000305.htm■ http://www.diabetes.co.uk/blood-glucose/honeymoon-phase.html■ http://iuhoosiers.com/coaches.aspx?rc=1364&path=wrestling■ http://www.spokesman.com/stories/1998/feb/05/needles-and-pins-diabetes-no-match-for-

determined/■ http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/

hypoglycemia-low-blood.html■ https://nfb.org/images/nfb/publications/vodold/pancreas.htm■ http://www.endocrineweb.com/conditions/type-1-diabetes/type-1-diabetes-causes■ http://www.webmd.com/diabetes/features/type-1-diabetes-misconceptions■ http://www.mayoclinic.org/diseases-conditions/hyperglycemia/basics/causes/con-20034795■ http://www.mayoclinic.org/diseases-conditions/hyperglycemia/basics/complications/con-20034795■ http://www.diabetesnet.com/diabetes-control/low-blood-sugars/hypoglycemia-unawareness■ http://www.mayoclinic.org/diseases-conditions/hyperglycemia/basics/treatment/con-20034795■ https://www.youtube.com/watch?v=_OOWhuC_9Lw■ http://www.childrenwithdiabetes.com/sports/TravisPascoe.htm■ http://www.cnbc.com/2016/03/30/artifical-pancreas-could-be-ready-in-2017-for-type-1-

diabetics.html