Rugby

By Rod Kafer (Australia and Leicester Tigers)

I have been an insulin Dependant diabetic for  17 years (I was diagnosed at the age of 15), throughout that period I have played rugby at a variety of levels including school, senior and Internationally culminating in being part of Australia's World Cup Winning team in 1999.  Over the last two years I have been playing for the Leicester Tigers Rugby club.  I use a combination of Actrapid Insulin 3 times a day between 2 and 8 units before meals, as well as Insultard at night, usually about 30-34 units.

Diabetic lifestyles that involve high levels of exercise are thought to assist with controlling long term blood sugars, maximising your health.  However, as every diabetic sports person knows, this balance can in the short term, be extremely difficult.  Most doctors suggest that having hypo's should be avoided if possible, however if I am not careful I cannot go a day or so without ending up low on sugar at some point.  Without careful control I have found it virtually impossible to be active and not end up with low blood sugars.  However if you are active and wish to manage your diabetes successfully and reach your highest potential as a sports person, I have suggested a couple of methods and areas you should pay particular attention to in your overall health management.  The challenge for all diabetics is to be consistent with their blood sugars, for sports people this means that a juggling act of enough food to prepare and replenish the body for exercise and the balance of the appropriate level of insulin to ensure that your BSL's stay within a healthy range. 

Diet

One of the recent discoveries I have made in relation to my diet is that by limiting carbohydrates, particuarily short acting carbohydrates I am able to control my diabetes far easier.  Combined with this has been a decrease in body fat (always an issue for me!) that a high protein low carbohydrate diet has led to.  The benefit in eating a limited amount of carbohydrates has been that I require only a small amount of insulin at any time, which limits the fluctuations in blood sugar.  Generally I can run my blood sugar levels (BSL's) between 3.5 and 7  rarely going outside of this range, with this eating regime.  Previously where I may have had between 12 and 16 units of bedim acting (Actrapid) insulin before a breakfast of cereal and toast, now I only require between 2 and 4 units of the same insulin whilst enjoying bacon and eggs every morning.  I no longer suffer from the spike in blood sugar following a high carbohydrate meal and the subsequent crash before I eat again  Arguments of lack of energy for training, high fat levels, high cholesterol levels and soon, which are associated with high protein intakes have not been an issue for me, and I have been using this regime for nearly 3 years.  Whilst this diet may not be for everyone, as some will suggest it may have other health issues associated with it, however when your diabetic control can potentially have life altering consequences it is worth considering if you struggle with your long term control.  As a sports person and a diabetic you are already constantly modifying your food intake, this method has been successful for me for a variety of reasons.

Blood Testing

Like most things in life preparation is the key to staying healthy as a diabetic.  Blood testing should form the corner stone to your preparation for activity.  When I was first diagnosed I did not take good control of my diabetes because I refused to blood test.  This provided me with a haphazard method of management and I never really new what my levels were leading into exercise and was vulnerable to way too many hypo's.  However my routine now is to test at least 8 times a day, sometimes more on game days, so that I always know where my sugar levels are and so I can modify my food are insulin accordingly.

My Experiences

Professional rugby players train between 7 and 14 sessions per week. Some activities are more physiologically taxing than others, but in general a combination of non rugby actives such as: weight training, speed and agility training, anaerobic and aerobic exercise is performed on a weekly basis; as well as rugby specific training such as: scrummaging, line out work, defense, attack, kicking, contact skills (being tackled) and back-line play are all fitted into the training week at some point. With the variety of physiologically taxing activities it is again important to monitor blood sugar levels and adjust accordingly.

Game Day

Normally on the day of a game, I would have my normal breakfast of bacon and eggs and 2 cups of coffee, and my normal dose of insulin, 2-4 units of Actrapid. Then I would generally not require any more food until we played, at around 3pm. I would monitor my blood sugar levels throughout the day. I would blood test when I arrived at the ground, before I warm up (30 minutes prior to kick off), before I run out and again at half time. I like to ensure my sugar levels are stable, as adrenalin and exercise can obviously affect your blood sugar levels.

If you can modify your behavior slightly perhaps changing your diet (in consultation with the relevant professionals) and maintain a strict testing routine, you should be able to enjoy a full and healthy life and maximize your sporting potential.

When I became a diabetic I resolved that I would achieve the highest sporting success attainable in rugby union, and that my diabetes was going to be my inspiration rather than my impediment. The plan worked and the goal was achieved.

Rugby

Laurence Marsh

Lawrence Marsh, is a 20 year old aspiring professional rugby player who is at University but also playing at Henley Hawks.   The problems that he has are absolutely typical of the Type I diabetic athlete, namely loss of performance during maximum effort, hypoglycaemia during training and sub-optomal glycaemic control.   Lawrence has had Type I diabetes for approximately 10 years.   He is not known to have any diabetic complications.   He has had 4-5 admissions to the hospital with hypoglycaemia.   His current insulin treatment is Novo Rapid 32 units 3 times daily and Glargine 20 units at night time.

Training

His training consists of practices for scrums, phases of rugby and line-outs.   These generally last about an hour and are relatively low intensity.   He then does intense weight training with bursts of 10 minutes of anaerobic exercise at 3 minute gaps.   It is during these efforts that he is finding difficulty with loss of power.   He also has a speed ball burst of 20 minutes and full rugby matches on Wednesdays and Saturdays.   He does not check his blood glucose prior to his different activities and has no idea whether his blood sugar rises or falls.

Diet

He has little idea of the amount of carbohydrate he takes, nor of the different types of carbohydrate that he takes.   He tends to load up extra carbohydrate prior to an anticipated heavy sports day leading to marked hypoglycaemia.   His performance will be improved when he regularises his carbohydrate intake and eats the basic same quantity on each day.   He can, of course, vary his protein intake ad lib.  

Plan

He needs to adjust his meal related insulin doses to ensure normoglycaemia.   He needs to measure his blood glucose prior to starting his exercise, during and after, so that we can get a template of what the general effect of each different type of exercise is on his blood sugar.   Once we have this information, we can work out how to supplement glucose to avoid hypoglycaemia.   He should not do as he is currently doing, which is to go into his exercise with marked hyperglycaemia and avoiding hypoglycaemia by this means.   This will certainly impair his athletic performance.   He can remain on his Lantus treatment at present unless there is a significant effect of hypoglycaemia during his prolonged rugby matches.  

Did it Work?

At a recent review, Laurence tells us that his performance and energy levels had improved remarkably in the second half of his matches. he is controllong his carbs with the aim of getting down 10Kg so that he can be faster. England trials next?

Robert Green, Leicester Tigers 2nds

Robert, who plays front row, has had type 1 diabetes since 1995, treated. Robert’s diabetes treatment is Novorapid 12-16 units three times a day and Glargine approximately 30 units evenings. His diabetic control has been good.  He is not troubled by severe hypoglycaemic unawareness and he is not known to have any diabetic complications.  Robert wants to optimise his performance in the light of his promising sports career.

Training and Energy Requirement

Roberts sporting programme, is a match on Monday night, obviously lasting 80 minutes with a pre-match run (using approximately 2500 calories).  On Tuesday’s he has a heavy training day with 2 hours of contact training, using approximately 2000 calories.  He then does weights for 40 minutes, using approximately 1500 calories, he then does a 40 minutes intensive cardiovascular work using approximately 1350 calories. On Wednesday he has a shorter day with 2 hours of contact training sports, and on Thursday he has a slightly more intensive training day with an hour of contact training and time in the gym.  Friday is the same.  These 2 days both use approximately 3000 calories.  In addition to his basal requirement of 3000 calories, his daily energy take is somewhere between 6000-7000 calories. Given that 60% of this should be in the form of carbohydrate, he needs to be on the range of 700-900 grams of carbohydrate per day.  His current estimated food intake is very variable and he is taking between 500-900 grams of carbohydrate per day, and he is varying his carbohydrate intake according to his work intake.  He also takes a very small amount of glucose during his matches.  He notices that his blood sugars fall from 10 to 5 during a match, although doing short periods of exercise, his blood sugars may rise.

Plan

• He needs to regularise his carbohydrate intake so that he is taking approximately the same amount and the same glycaemic index of carbohydrate each day.  Fractionated into appropriate meal and snack portions.  He should not adjust his carbohydrate intake according to his anticipated level of exercise.  His stores will buffer this for him adequately.
• He should increase his carbohydrate intake to avoid hypoglycaemia whilst training (30-60 grams every half hour).  This can be taken in form of Lucozade Sport or PPSS2 an isotonic glucose polymer drink, which can be made up to his own requirements.  Typically for a 10% solution, he will need to take 300 ml per half hour.  He should dribble in his glucose steadily rather than taking it all as boluses and aim to start his match with a sugar somewhere between 8-10.
• Although, he has improved greatly since starting on Glargine treatment, I wonder whether in fact this is the best form of therapy for him.  High background levels of insulin impair the mobilisation of oxidative fuel sources such as ketone bodies and free fatty acids.  Although his blood glucose may appear to be well controlled.  It is likely that he is losing the major portion of stored sources coming from his stores, and this might impair his aerobic performance substantially.  Detemir in this particular instance may be more helpful. 
• There is a specific issue about glucose storage in type 1 diabetes as the muscles tend to get a disproportionate amount of post-meal glucose absorption.  There is a helpful trick in that if you give a carbohydrate bolus with an injection of insulin immediately in the post exercising state, the relative insulin resistance can promote liver glucose storage.  Suggest that he gives himself 60 grams of carbohydrate immediately after training with a bolus of insulin, perhaps 4-6 units.
• He needs to be scrupulous about his glycaemic control on days following a hypoglycaemic episode.  His ability to recognise low blood sugar following a previous hypoglycaemic episode during training is much impaired and he should consider carefully if he has a bad hypoglycaemic episode, whether he does any training at all.

Robert's Experience

I have been diabetic since I was 10 years old, always extremely well controlled, highest Hba1c in the last 6 years or so has been 8.4.  Recently I had a bad hypoglycaemic attack which required the help of paramedics.  I went to see my consultant about my apparent lack of control, having been on a Mixtard regime consisting of two injections a day, the decision was made to change on to a Basal Bolus routine with Glargine and Actrapid being the two constituent insulins. 

Playing rugby in the Leicester Tigers set-up means that I have a relatively good awareness about my body.  My somatotype is closer to a mesomorph than an endomorph meaning that I do not seem to have to work as hard at weights as I do at cardiovascular (CV) training.  I have always struggled to maintain my CV ability.

Having been on the Mixtard regime for about 9 years I had got used to controlling my body with that form of insulin intake.  For the last couple of years I had been on approximately 50 units of Mixtard before breakfast and 50 units before my evening meal.  I was controlling my blood sugar levels with food, eating whenever I felt my sugar level was dipping.  As a result of this method it was extremely easy to gain weight but very difficult to loose weight as I had to eat in order to maintain an acceptable blood sugar level.  I tended to put unwanted weight on around the stomach and hip area which was hard to get rid of, I was therefore partaking in many fat burning sessions in the gym at Tigers.  After my hypoglycaemic incident I lowered my insulin intake, still on 2 injections a day but only at 38 units per injection, I was surprised to find that I could maintain a good blood sugar level with this amount of insulin.

Prior to rugby matches or training I would have a decent snack and many Lucozade tablets to increase my blood sugar level so when it fell during training or matches it would not fall far enough in order to cause a hypo.  This sometimes meant that I would be lethargic and feel tired during training.  I seemed to be controlling my diabetes with food intake rather than controlling it with insulin.

Changing onto the Basal Bolus regime has caused some remarkable improvements.  I am currently on 34 units of Glargine (Basal) taken in the evening and 6 – 14 units of Actrapid taken before meals or snacks depending on the size and / or consistency of the food stuff.  This regime has allowed me to loose unwanted weight and control my weight a lot better.  I am able to control my blood sugar levels with insulin intake as opposed to food intake.

During matches or training I use a quick release glucose source (Lucozade tablets) to maintain my blood sugar level which means I do not have to become hyperglycaemic prior to the exercise in order to maintain homeostasis.  Also having recently discovered a carbohydrate drink which I can use during training and matches called PSP22 my blood sugar levels remain within <0.5< mm of my initial blood sugar level taken before the session.  PSP22 is a maltodextrin based drink with a higher glycaemic index than glucose, this means that the release of sugar into the blood stream and consequently the muscles is quicker than glucose.  The PSP22 drink is a light drink and therefore does not sit in the stomach.  I use a 10% mix of the drink 50g of PSP22 to 500ml of water and consume approximately 500ml every 30 – 45 mins relative to the training intensity.

Preceding training I take blood sugar readings so I know exactly what my body is doing, this enables me to be at optimal levels for training.  I personally hated taking blood sugar levels, as a result of this I rarely took my blood sugar level, however, I could determine my blood sugar level within 2 mm by the feeling of my body.  Now I take the readings because I need to know exactly what my body is doing, leading up to a match I will take a reading every half an hour in order to start a match at the optimum level; I usually start matches with my blood sugar between 8 – 10 mm, however, I would like to reduce this to between 6 – 8 which I now feel I could do, as I can maintain my blood sugar level during the exercise using the carbohydrate drink.

Recently I have liased with a sports nutritionist who was happy with my diet which consists of approximately 50% carbohydrate, 30% protein and 20% fat.  Due to the intensity of training I find myself consuming around 6000 calories a day in order to maintain energy levels.  Having seen the sports nutritionist I acquired a conversion chart which allows me to weigh the food I am eating and cross reference the chart to gain the quantity of carbohydrate in the food stuff, this helps me to regularise my intake. During the meeting I was privy to a glycaemic index chart which was very interesting as it shows which food stuffs release sugars into the blood stream the quickest and the slowest.  This is useful as if the food stuff being consumed has a low glycaemic index value the injection of Actrapid I find should be taken after the food is consumed to avoid a hypo.  Information such as this is useful for match day nutrition.

Immediately after partaking in a match or training session I find it useful to have a shot of about 6 units of Actrapid along with a carbohydrate source with a relatively high glycaemic index value, such as PSP22, sandwiches, some fruits, Lucozade sport.  This action imitates the body of a non diabetic as when the body stops exercising it releases a burst of insulin to replenish stores of energy such as glycogen in the liver.  Therefore by having a shot of insulin with a carbohydrate source I recover quicker.

When transferred onto the Basal Bolus regime I was made aware that Glargine the Basal insulin I am currently using can inhibit the bodies metabolism of free fatty acids which are an important energy source when glucose supplies are limited.  However, I find that my aerobic capacity is good and has improved noticeably since beginning on the Basal Bolus regime.  I was advised that there is a different form of Basal insulin which does not inhibit the bodies metabolism of free fatty acids this insulin is called Determire and works for a limited period, whilst one is asleep, therefore the insulin is not in ones system whilst active during the day.  As things stand I do not feel it necessary to change to Determire as my body is coping well with Glargine, possibly in the future it may be necessary to change.

Since I begun on the Basal Bolus regime I have lost a fair bit of weight, this was unwanted weight however, currently I am attempting to regain the weight but in lean body mass as opposed to fat.  In order to do this I am consuming a greater amount of protein in my diet and also before weight training sessions I am taking half a pint of milk or instant skimmed milk powder which contains amino acids, these amino acids are used to manufacture new proteins which can be used to generate muscle.  Amino acids can also be used in the TCA cycle (Tricarboxylic acid cycle) in order to generate ATP (Adenosine tri phosphate) the particle which is broken down in order to create energy.  The amino acid supplement is also taken after the weight session along with the insulin shot and carbohydrate intake.