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Injury Prevention

Insulin Problems

Dr Larry W. McDaniel and Sara Olson review the issues related to insulin problems for student-athletes competing in sports.

Overview of Diabetes

According to Wishnietsky (2004)[9] the education coordinator for the diabetes care centre at the Wake Forest University, "diabetes is on the rise in the United States costing us more than $132 billion in healthcare costs and lost wages." The increase in the number of cases of diabetes includes surrounding countries and other parts of the world. This paper will focus on the United States. "There are approximately 125,000 students under the age of 19 with diabetes in the United States."

Almost all students in high school participate in some kind of sport or required physical activity classes and need to know the necessities when taking care of diabetes while exercising. Students with diabetes are more likely to have Type I diabetes. "Students with Type I Diabetes will have to receive exogenous insulin for the rest of their lives unless a cure is found." One of the most critical health concerns for student-athletes with diabetes is low blood sugar or hypoglycemia. Low blood sugar results from having too much insulin for the amount of glucose in the blood which may be caused by ingesting poor food choices or attempting to plan insulin adjustments related to physical activity.

The segments of our population that exercise less than three times a week have a high risk of developing type two diabetes. People who do not exercise as children have a low chance of developing exercise habits as an adult. Parents who exercise may serve as a model for exercise and influence children to participate in physical activity. Knowledge related to symptoms of insulin fluctuation is a crucial aspect of one's health and continued participation in physical activities. (Wishnietsky 2004)[9].

The Symptoms of Diabetes

According to Berkowitz (2008)[6], "there are many symptoms concerning diabetes that is noticeable in daily living that should get attention from a physician." One of the symptoms includes constant thirst and frequent urination. "When your kidneys cannot filter and absorb excess blood sugar, you become dehydrated, so you drink more (and urinate more). Drinking a lot and still being thirsty are pretty big signs." Other symptoms of diabetes include weight loss and fatigue. Berkowitz (2008)[6] stated that "Without insulin, sugar from food cannot reach cells, so muscle and fat stores shrink. That can make you tired and irritable. If you are not performing at your peak, something is wrong."

Berkowitz (2008)[6] stated the blurred vision and tingling sensations in the limbs might be signs of diabetes. Later stages of Diabetes may cause the loss of limbs. "High glucose levels in the blood can damage the blood vessels in the retina. If left untreated, this can cause dark spots, flashing lights, and eventually, blindness. High blood sugar damages capillaries that nourish nerves, especially in the feet, hands, and penis. The poor blood flow causes a tingling sensation."

Blood Lipids Symptoms that occur during physical activity are dizziness, light-headed feeling, and shaking. These are warnings that are telling the athlete to get some insulin in their body and take a rest. (Berkowitz 2008)[6].

Figure 1, designed by Lesley Kirkwood (Kirkwood et al. 2007)[5], explains the effects of advice on dietary intake and/or physical activity on body composition, blood lipids, and insulin resistance following a low-fat, sucrose-containing, high-carbohydrate, energy-restricted diet. All of these factors have significant importance to diabetes.

Controlling Blood Sugar Levels

There are numerous ways to prevent fluctuations in insulin levels. Rest may be the most important. Knowing how much time to rest is difficult to determine but keeping blood sugars regulated is crucial. Waiting a few minutes after levels are back to normal is essential to facilitate insulin stability. For teams that include athletes with diabetes glucose tablets and PowerAde should be available at athletic events. Diabetic athletes will most likely have decreased insulin levels from physical activity; which causes a demand for PowerAde and glucose tablets. The glucose tablets and PowerAde will assist in the process of normalizing insulin levels. Ingesting large quantities of fluids may change insulin levels for some. Fixing insulin fluctuations due to physical activity takes time and patience. As an Athletic Trainer, staying calm and in control is positive reinforcement. When insulin fluctuations occur, the athlete with diabetes is usually uptight and nervous. Being around someone reassuring and positive will assist the athlete with diabetes with the needed adjustments to insulin.


Fig. 2, designed by Julian Aucouturier (Aucouturier et al. 2008)[1], includes the factors influencing the relative contribution of carbohydrate and fat to energy expenditure. Some factors increase CHO and decrease fat contribution to energy expenditure. In addition to the factors that reduce CHO and increase fat contribution to energy expenditure, having diabetes may cause a fluctuation in blood sugar percentages. It could affect one's duration of exercise and diet.

Managing Blood Sugar Problems

Stewart & Getsinger (2008)[8], and Exercise Physiologist from the Decatur Memorial Hospital Wellness Centre, emphasized that "cardiovascular and resistance training goes hand in hand, and those with diabetes can reap benefits such as weight control, heart health, and improved blood sugar when they participate in an exercise program with doctor's approval." "The heart is a muscle, and like all muscles, if we don't train it or if we do not use it, it will become weak," Stewart & Getsinger (2008)[8] said, emphasizing the importance of cardiovascular health in diabetes control.

Paying attention to one's feet is essential and in addition to wearing some type of medical identification. Maintaining fluid balance is an important element in controlling diabetes.

One of the keys related to diabetes control and physical activity is to make sure the body's systems have adequate levels of fluid. Those with insulin problems must be able to control levels of fluid and insulin and develop an awareness of fluctuating insulin level. Planning regular meals is a critical element in the process of managing blood sugar levels. According to Beaser & Hill (1995)[2], "meal planning consists of the proper balance of foods and nutrients that you need to maintain good health and manage your blood sugar levels." If meals are planned regularly and have nutritious value, maintaining blood sugar levels will be easier to control. Planning meals that are high in nutrition will hopefully eliminate a portion of fast food eating, which is not healthy for those with diabetes.

Beaser & Hill (1995)[2] stated that planning meals "will also help you manage the level of fats or "lipids" in your blood, which is frequently too high in people with diabetes." Becoming familiar with nutrition values for various types of foods may make it easier for some athletes to keep insulin levels normal. "Your meal plan will also take into consideration the timing of your meals in conjunction with your daily diabetes medications, goals you may have for weight loss, and the types of foods you like or dislike." When all of these considerations are put together correctly and used efficiently, insulin testing will be easier.


The model in Fig 3, designed by Carol Horowitz (Horowitz et al. 2008)[3], represents individual factors that relate to your health. When looking into most of these factors, such as your nutrition, physical activity, education, social factors, and food marketing your chances of being diagnosed with diabetes are at a higher risk when considering these factors.

Insulin Pumps

Athletes that have been diagnosed with diabetes may have dilemmas where their blood sugar level fluctuates during practices and games. Considerations for athletes with insulin concerns range from exercise rehabilitation to the use of an automatic insulin pump. The automatic insulin pump is a small battery-operated device about the size of a pager. The pump continuously delivers small doses of insulin into the body and can be conveniently clipped to a belt, waistband, or carried in a pocket. Many athletes have taken advantage of using this device to assist with insulin control. Sherr & William (2008)[7] at Yale University believes that using the pump may improve insulin control. Using the insulin pump during rough physical activity, such as playing football is not safe considering that a needle is stuck in the side of your abdomen. The insulin pump assists in the process of insulin regulation before and after practices to maintain desired insulin levels. Frequently checking insulin levels while the athlete is participating in practice or games is a requirement to prevent further injuries. The automatic insulin pump has many features and positive aspects that would benefit most diabetics. Below are some of the conditions where an insulin pump should be used, according to Sherr & William (2008)[7].

  • Recurrent severe hypoglycemia
  • Wide fluctuations in blood glucose levels regardless of A1C
  • Suboptimal diabetes control (i.e. A1C exceeds target range for age)
  • Microvascular complications and/or risk factors for Macrovascular complications
  • Good metabolic control but insulin regimen that compromises lifestyle

Sherr & William (2008)[7] also recognizes and shares ways where the insulin pump would be beneficial.

  • Young children and especially infants and Neonates
  • Adolescents with eating disorders
  • Children and adolescents with a pronounced dawn phenomenon
  • Children with needle phobia
  • Pregnant adolescents, ideally before Conception
  • Ketosis-prone individuals
  • Competitive athletes

Athletic Trainers Perspective

Before an athlete participates in a sport, a physical and physicians' approval is required. If the athlete has been diagnosed with diabetes, the physician will review numerous symptoms and facts with the patient. The Athletic Trainer working with the athlete is notified and has been prepared for various types of emergencies. According to Jimenez et al. (2007)[4] "Athletic Trainers constantly deal with Type I diabetes". Jimenez is a member of the National Athletic Trainers Association. "In managing diabetes, the most important goal is to keep blood glucose levels at or as close to normal levels as possible without causing hypoglycemia." If levels fluctuate, it is important to normalize the blood sugar content. Checking levels with a Blood glucose meter before and after meals should be performed. "This goal requires the maintenance of a delicate balance among hypoglycemia, euglycemia, and hyperglycemia, which is often more challenging in the athlete due to the demands of physical activity and competition."

Maintaining insulin balance before, during, and after physical activity is important. The athlete, with the assistance of athletic training, will continue with insulin testing and regulating. If insulin levels do not return to normal, a physician must be seen as soon as possible. Some of the items for athletic trainers to keep on hand during practices and games include glucose tablets, PowerAde, and water. Being aware of the symptoms of insulin fluctuation in the athlete is important to prevent further damage to the athletes' body. Athletic Trainers should be present during games and practices. They will be aware of the symptoms and know what to do if blood sugar levels fluctuate. (Jimenez et al. 2007)[4].

Coaches Perspective

In some settings, Athletic Trainers may not always be available for practices. When this occurs, the coach is responsible and must be prepared if insulin problems arise. Sometimes athletes with blood sugar problems need additional rest. Knowing how much time to rest when suffering from insulin problems during physical activities is important. Allowing the athlete with insulin to return to the game or practice too early could cause further damage and make it challenging to bring insulin levels to normal. Keeping blood sugars regulated on the side during timeouts or breaks will assist with the consistent regulation of stabilizing glucose levels. In addition to the head coach, assistant coaches should be well educated in this area. During a competition, the head coach will be more concerned with the game and what is happening on the field, placing more responsibility in this area on the assistant coach. The assistant coaches will be able to tend to athletes and monitoring them during the competition. All coaches should be required to have enrolled in and passed course content related to diabetes.


Most athletes with diabetes are capable of competing. How well the athlete monitors insulin levels will affect the time needed to rest during games and practices to regain normal blood sugar levels. Managing insulin levels takes time. Regardless of the type of athletic participation, investing in an automatic insulin pump may be an excellent choice. Insulin management may be improved for athletes who study and research information related to diabetes and physical activity.


  1. AUCOUTURIER, J. et al. (2008) Fat and Carbohydrate Metabolism during Submaximal Exercise in Children. Sports Medicine, 38 (3), p. 213
  2. BEASER, R. and HILL, J. (1995) A Program for Managing your Treatment: The Joslin Guide to Diabetes. New York: A Fireside Book: By Simon and Schuster
  3. HOROWITZ, C.R. et al. (2008) A Model for Using Community-Based Participatory Research to Address the Diabetes Epidemic in East Harlem. Mount Sinai Journal of Medicine, 75 (1), p. 13-21
  4. JIMENEZ, C. et al. (2007) National Athletic Trainers' Association Position Statement: Management of the Athlete With Type 1 Diabetes Mellitus. Journal of Athletic Training, 42 (4), p. 536-545
  5. KIRKWOOD, L. et al. (2007) Effects of advice on dietary intake and/or physical activity on body composition, blood lipids and insulin resistance following a low-fat, sucrose-containing, high-carbohydrate, energy-restricted diet. International Journal of Food Sciences & Nutrition, 58 (5), p. 383-397
  6. BERKOWITZ, K. (2008) COULD DIABETES SIDELINE YOU? Men's Health (10544836) 23 (7), p. 60
  7. SHERR, J. and WILLIAM, V. (2008) Past, Present, and Future of Insulin Pump Therapy: Better Shot At Diabetes Control." Mount Sinai Journal of Medicine, 75 (4), p. 352-361
  8. STEWART, M. and GWTSINGER, A. (2008) Exercise can help control diabetes. Herald & Review (Decatur, IL) (27 Feb. 2008)
  9. WISHNIETSKY, D. (2004) Helping Students with Diabetes Management. Bloomington, Indiana: Phi Delta Kappa Educational Foundation

Page Reference

If you quote information from this page in your work, then the reference for this page is:

  • McDANIEL, L. and OLSEN, S. (2009) Insulin Problems [WWW] Available from: [Accessed

About the Authors

Dr Larry McDaniel is an associate professor and advisor for the Exercise Science program at Dakota State University, Madison SD USA. He is a former All-American in football (USA) and Hall of Fame athlete & coach.

Sara Olson is an outstanding student enrolled in Exercise Science and student athletic trainer at Dakota State University, Madison, SD USA.