Tennis

Tennis is very popular and safe for people with diabetes, here are 2 great examples

John Gleddon, Senior Tennis Circuit

John who is a tennis professional and who now plans to enter the over 45 tennis circuit over the next couple of years. He is a type 1 diabetic of 23 years duration and is currently on Novorapid approximately 20 units 3 times a day with insulin Glargine at night time. This is giving him a reasonable although not perfect degree of control with an HbA1c of 7.9%. He is a tennis professional who owns a tennis court and coaches in the afternoon. His exercise programme currently is quite modest. He runs 3 mornings a week for about half an hour, on alternate days he swims. In the afternoon he either plays tennis or coaches, again to not any great intensity.
He has identified several problems with his diabetes that he wanted to address. The first is that his morning blood glucoses are rather high. The second is that his blood glucose falls very rapidly whilst he is running and the third being that he notices marked loss of energy and stamina during his tennis matches. Lastly, he has unexplained hypoglycaemia in some circumstances.

Going through John’s diabetic management, one can make the following suggestions or recommendations:

The first is that his fasting blood glucoses are routinely too high and he needs to increase his Glargine at night time to bring his fasting blood sugars down to a more acceptable range. He is using his morning Novorapid to deal with a part of his basal insulin requirement. It is arguable whether in fact he may be better on Detemir, as he is doing most of his exercises in the afternoon, and the differences between Detemir and Glargine means that he may have slightly less basal insulin around which may help with his falling blood glucose.

He is really not concentrating on his carbohydrate intake and he needs to regularise his daily carbohydrate intake and understands how much is in each meal. He is pre-loading with a variety of sugary containing foods before exercise and noticing on the background of a high level of sugar it is raising his blood sugar to the mid-teens. This is certainly causing him loss of performance. He does this to avoid hypoglycaemia. His falls in blood sugars are quite sharp, typically 5-7 mmols over ½ an hour to ¾ of an hour. He might check his blood glucose before he starts his sport. If it is higher than 10, he should not take any extra food. If it is lower than 10 he can take a banana which seems to be his preferred food type.

Once he does his sport, he should be checking his blood glucose for the first 20 minutes and then perhaps every 50 minutes thereafter. If he finds his blood sugar is falling, he should give himself 10-20 grams of glucose in the form of either Dextrosol tablets or more preferably in a self-made 10% glucose containing drink. 100 ml equal to 10 grams. Typically he will need 30-60 grams of glucose depending on rapidly his blood glucoses falls.

He should to use his heart rate monitor. If his heart rate monitor is in the range of 70-85% of the maximum predicted heart rate, he could expect his blood glucose to fall very steadily. If however it is above 85%, then he could expect his blood glucose to rise during shorter burst of exercise. If he sees his heart rate is in the aerobic range he knows that he will need to give glucose in advance. If he finds that his heart rate is above that range, he knows that he will not need to give himself any glucose.

After very prolonged periods of training he can give himself 30 grams of glucose as a bolus with 4 units of Novorapid in addition to whatever he would normally eat later. This will replenish his hepatic glucose stores and reduce the chance of hypoglycaemia. It would also augment his performance.

John's Experience

I came to see Dr Gallen on 7th July 06 and really benefited from our meeting. Although there was initially an awful lot to take in, I went away feeling for the first time in my life I understood my diabetes and how exercise impacted on my body.
I also realised that although being a diabetic of 20 years, I still had a lot to learn, but decided it was never too late to learn. I decided that there were two main issues for me to deal with, exercise and carbohydrate intake and I set about tackling both.
The exercise ( due to your advice, was an instant success, and the quest for knowledge on carbs took longer, but I’m getting there…

Exercise.

I fully understood what you told me about how to control my sugar levels while exercising and immediately changed from my old theory of loading with sugar ( levels of 15+ mmol ) before I exercised to the new regime of starting exercise at a level of 4 – 6 mmols and ‘topping up’ my levels during exercise.The benefits were immediate, and I was able to double the distance I ran immediately as I didn’t feel lethargic as I exercised, as I used to. The first few runs I did, I found it difficult to ‘trust’ that I could run without going hypo, starting at such a low level, and I ran for an hour, but stopped every 15 minutes and did a blood test, until I had the proof I was ok and then learnt gradually how much sugar I needed per 15 minutes, to run 10k in less than an hour. As I realised, that to keep my body at a steady 4- 7 mmol, I needed 2 glucose tablets per 15 minutes, I became more confident and now I only do a test before I start and when I finish and am very rarely anything but spot on at the end. I am now running 10k three times a week, all in under an hour, (which although it won’t get me into the ext Olympics ) is a great improvement for me as a 42 year old, who hasn’t exercised regularly for 10 years. One thing I found strange, was that normally I get plenty of physical signs, when my sugar levels drop to 2-4mmol, but when running I have checked my levels after say 30 minutes and have had levels of 2.5, without a single physical sign ???? This concerned me at first, but now I have learnt what I need to keep my levels nearer 5 or 6, I have relaxed more..

I have to be careful if I run in the evening, as I tend to keep dropping low slightly quicker overnight if I have exercised after 7.30pm and I have found my ideal time to run ( for my body ) is around 3 – 5 in the afternoon. I tried the sugar top up with jelly babies, but to be honest they didn’t seem to touch the sides and I was falling low after 5 minutes, no matter how many I ate. I then tried the lucozade glucose tablets and they work much better for me. The only issue I have is that I have to have one tablet, every 7½ minutes to keep my level stable and when huffing and puffing hard, I find it easy to slightly choke on the dry powdery tablet, which has ended a couple of runs early !!

Apart from that I feel in full control !! - I am now considering trying to substitute the tablets with the glucose drink, but I’m not sure how much liquid glucose I will need to substitute the tablet for liquid, but will get to work on that soon !!!

Carbs

I realised as soon as I left your office, that my knowledge of carbs was VERY poor and set about trying to correct that, as I realised without that knowledge, I would never achieve the control I was after. In mid August I was able to secure a 90 minute appointment with one of the diabetic dieticians, (Carla Gianfrancesco) who help run the DAFNY courses in Sheffield and Carla started right from the beginning and educated me on what a carb was and the 3 basic types of carb and how I could adjust my diet. I have found this part more difficult, but I am now getting there and my overall diabetic control is getting better and I now understand how different foods affect my control. My last HbA1c in September 06, was down to 7.1% ( previous 7.9%) and expect the Dec 06 test to be improved some more. I have bought some electronic weighing scales and a palm top ( with diabetes pilot software ) to keep better records in the future.

Fasting Blood Glucoses.

My next challenge.. I decided to concentrate on the two main challenges I covered above to begin with, as I wanted to set goals that were achievable, but now I am comfortable with my daytime management, I am tackling the routinely high night time blood glucose levels. I have started by cutting out supper altogether ( I thought every diabetic had to have sugar every night before bed !! ). Now I am trying to juggle my glargine insulin up and down a bit to find the perfect balance. I am finding if I go to bed with a sugar level or 10, I go hypo at around 1am if I have glargine of 18 units, so I am trying to cut down to 16 or 14 units. I know that technically speaking, that the long lasting insulin shouldn’t substantially reduce the blood sugar levels in the night, but I find that some nights it does.. I believe that I will master this within a couple of weeks.

If you are near Sheffield, you can get coaching from John at http://www.abbeydaletennisclub.uk.com

Benjamin Archer-Clowes

Ben is a young man who developed type 1 diabetes in 2004. He is a highflying tennis player based in New Mexico and aims to become a professional tennis player ultimately, if possible to go to Wimbledon. He has no complications of diabetes and his current insulin treatment is18 units at night time and Novorapid 1 unit per 15 grams of carbohydrate during rest periods, and 1 unit per 10 grams of carbohydrate during sporting periods. He is concerned about are hypoglycaemia after training and limits to his performance particularly on multiple day events with slow recovery, and fatigue ability and cramps.

Training

His training schedule is as follows:

He normally wakes at about 8 o’clock in the morning and has breakfast at 8.15 with typically 6-8 units of insulin, and the breakfast consists of 80 grams of carbohydrate in the form of fruit, oatmeal and yoghurt. He goes to college in the morning and then has his lunch at 12 o’clock with a further 6-8 units of insulin consisting of 80 grams of carbohydrate in the form of a sandwich or and a yoghurt. He then trains in tennis from 1.30 to 5.30 pm. The first 4 hours are training matches, which are very variable. The last hour or thereabouts is in training using weights or running. He becomes very dehydrated and takes water. He does not check his blood glucose during this, but at the end of the event he notices that his blood sugar is stable and he very rarely has hypoglycaemia. However post-training his blood glucoses fall rapidly. He then eats his evening meal at approximately 5 o’clock and this is usually 100 grams of carbohydrate in the form of a pizza or pasta. He then studies and then goes to bed following a Lantus injection of approximately 10 units at 9 o’clock.

On rest days when he wakes, the pattern is largely similar, although he does something less energetic such as golf in the afternoon. On these days he has to take more insulin.

Match days are difficult. Matches are at no fixed time and are of variable length and it is difficult to predict in advance what is going to happen to his meal times on his insulin doses.

Plan

He needs to give his Glargine insulin earlier. There is data to suggest that Glargine insulin is better given at 6 o’clock than 9 o’clock to reduce nocturnal hypoglycaemia.

He needs to check his blood glucose at 2-3 o’clock in the morning. If his blood sugar is less than 5 then he should reduce his Glargine substantially.

He should have some Lucozade in his bedroom.

Check blood glucose at hourly intervals during matches. It is likely that his blood glucose rises in the first hour or so, and then falls rapidly. This would be typically of the high counter regulatory response seen in upper limb exercise followed by the sustain fall induced by his aerobic exercise later on. If this is the situation, then he needs to take regular glucose drinks, 30-60 grams during the second and third hour. He should have a post-exercise refuelling as his colleague tennis players do. This should be in the form of a glucose containing drink 30-60 grams with 3-6 units of insulin. This is then followed by his regular meal an hour later with a regular amount of insulin. On days when he has been excessively energetic, he should reduce his insulin dose with his evening meal and reduce his Glargine dose by about 10%.

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On match days he will need to check his blood sugar as often as he can. Ideally hourly and take glucose in the form of an isotonic drink at the dose of 30-60 grams per hour throughout the event.

Did it Work? Letter From Ben

Hi Ian,
It has been hectic trying to combine school, tennis and diabetes.
I have been doing reasonably well this year and reached the semi finals at our home event and just got back from the all american where I was suffering from tendanitis in my wrist and therefore did not perform like I wanted to. The concept of drinking Gatorade after playing but also injecting Insulin has been working great and I feel that my second and third day performances have improved.
John who is a tennis professional and who now plans to enter the over 45 tennis circuit over the next couple of years. He is a type 1 diabetic of 23 years duration and is currently on Novorapid approximately 20 units 3 times a day with insulin Glargine at night time. This is giving him a reasonable although not perfect degree of control with an HbA1c of 7.9%. He is a tennis professional who owns a tennis court and coaches in the afternoon. His exercise programme currently is quite modest. He runs 3 mornings a week for about half an hour, on alternate days he swims. In the afternoon he either plays tennis or coaches, again to not any great intensity.
He has identified several problems with his diabetes that he wanted to address. The first is that his morning blood glucoses are rather high. The second is that his blood glucose falls very rapidly whilst he is running and the third being that he notices marked loss of energy and stamina during his tennis matches. Lastly, he has unexplained hypoglycaemia in some circumstances.

Going through John’s diabetic management, one can make the following suggestions or recommendations:

The first is that his fasting blood glucoses are routinely too high and he needs to increase his Glargine at night time to bring his fasting blood sugars down to a more acceptable range. He is using his morning Novorapid to deal with a part of his basal insulin requirement. It is arguable whether in fact he may be better on Detemir, as he is doing most of his exercises in the afternoon, and the differences between Detemir and Glargine means that he may have slightly less basal insulin around which may help with his falling blood glucose.

He is really not concentrating on his carbohydrate intake and he needs to regularise his daily carbohydrate intake and understands how much is in each meal. He is pre-loading with a variety of sugary containing foods before exercise and noticing on the background of a high level of sugar it is raising his blood sugar to the mid-teens. This is certainly causing him loss of performance. He does this to avoid hypoglycaemia. His falls in blood sugars are quite sharp, typically 5-7 mmols over ½ an hour to ¾ of an hour. He might check his blood glucose before he starts his sport. If it is higher than 10, he should not take any extra food. If it is lower than 10 he can take a banana which seems to be his preferred food type.

Once he does his sport, he should be checking his blood glucose for the first 20 minutes and then perhaps every 50 minutes thereafter. If he finds his blood sugar is falling, he should give himself 10-20 grams of glucose in the form of either Dextrosol tablets or more preferably in a self-made 10% glucose containing drink. 100 ml equal to 10 grams. Typically he will need 30-60 grams of glucose depending on rapidly his blood glucoses falls.

He should to use his heart rate monitor. If his heart rate monitor is in the range of 70-85% of the maximum predicted heart rate, he could expect his blood glucose to fall very steadily. If however it is above 85%, then he could expect his blood glucose to rise during shorter burst of exercise. If he sees his heart rate is in the aerobic range he knows that he will need to give glucose in advance. If he finds that his heart rate is above that range, he knows that he will not need to give himself any glucose.

After very prolonged periods of training he can give himself 30 grams of glucose as a bolus with 4 units of Novorapid in addition to whatever he would normally eat later. This will replenish his hepatic glucose stores and reduce the chance of hypoglycaemia. It would also augment his performance.