Athletes With Type 1 Diabetes Ignore Hypoglycemia Warnings

CHICAGO –American adults with type 1 diabetes who regularly engage in aerobic exercise often ignore the risk for hypoglycemia linked to their activity and the recommended precautions that could minimize that risk, based on a survey of about 100 US adults with type 1 diabetes recruited on social media websites geared to runners and other athletes.

A striking finding was that 46% of respondents said that they learned the most about managing their type 1 diabetes and exercise from social media, compared with 32% who cited their medical team.

People with type 1 diabetes "often feel that the information they get from online sources is as good or better than what they get from physicians. That can be a problem," said Joseph A. Henske, MD, and it may stem from inadequate attention paid to exercise safety by clinicians who manage people with type 1 diabetes, he suggested.

The most common source of learning was by trial and error during self-management, cited by 80% of survey respondents as a major source of their information.

Henske cited this pattern as something that needs to be fixed. "People with type 1 diabetes should get advice primarily from their doctors," he said during a press briefing at ENDO 2023: The Endocrine Society Annual Meeting, where he also presented the results of the survey.

Diabetes clinicians "have the guidelines, the context, and the understanding to know what's safe and what's not safe" when it comes to people with type 1 diabetes engaging in regular, strenuous exercise, added Henske, who himself has type 1 diabetes and is a marathon runner.

Nevertheless, "greater efforts are needed to make sure that both US diabetes clinicians as well as patients are up to speed on what published guidelines and statements say about best practices for people with type 1 diabetes who exercise," added Henske who is director of the diabetes program at the University of Arkansas for Medical Sciences in Little Rock.

Few Fear Hypoglycemia

The 96-question survey drew 102 complete responses following placement of links to it on social media sites designed for those with type 1 diabetes who are runners, ultra-endurance athletes, or other athletes.

Respondents averaged 42 years old (range, 18-70 years old), 69% were women, 94% were White, and 78% were US residents. Their average duration of type 1 diabetes was 20 years. Just over two thirds performed aerobic exercise (walking, jogging, or running) at least four times a week, and their average weekly exercise distance was 23 miles.

Almost all used a continuous glucose monitor (97%). Three quarters used a wearable insulin pump, and within this subgroup, 76% used a hybrid closed-loop system.

Just over a third (36%) of respondents said that exercise increased their glucose fluctuations, and 86% said that they had times when they had to stop exercising because of hypoglycemia. However, just 27% said they had a "fear of hypoglycemia" that posed a barrier to more frequent exercise.

Overnight episodes of hypoglycemia following exercise occurred in 41% of respondents, and 18% said they had a history of at least one severe hypoglycemic episode during exercise that forced them to seek help.

In total, 19% of respondents reported having hypoglycemia unawareness.

Just 11% could discern hypoglycemia while in normal blood glucose range when levels were > 70 mg/dL, 21% said they could feel the first hypoglycemia symptoms when blood glucose was < 50 mg/dL, 26% at 50-60 mg/dL, and 40% at 60-70 mg/dL.

And 3% said they never had hypoglycemic symptoms regardless of how low their blood glucose fell (percentages totaled 101% due to rounding).

"Managing high and low blood sugar levels before, during, and after aerobic exercise remains one of the greatest challenges for people living with type 1 diabetes," noted Henske.

Lack of Awareness of Guidelines Is a "Problem"

Henske highlighted several common examples of misguided self-management from the survey that contradict recommendations in guidelines and statements:

73% of respondents said they had exercised within 24 hours of having experienced a severe hypoglycemic event during which their blood glucose fell below 50 mg/dL.
74% said they did not check their ketone level even after measuring an unexplained episode of hyperglycemia (blood glucose level > 250 mg/dL) prior to exercise.
11% said they proceeded with their planned exercise even when they identified ketones in their blood or urine.
10% reported developing diabetic ketoacidosis after exercise.
49% admitted to not wearing a type 1 diabetes identification bracelet when they exercised.

"This study provides a number of key insights into the degree to which published guidelines and recommendations surrounding exercise with type 1 diabetes are understood and implemented in the real world," noted Henske. "Awareness of current guidelines is clearly a problem."

He cited as authoritative sources an expert-panel consensus review published in 2017 in The Lancet Diabetes & Endocrinology; another expert-panel consensus published in 2020 in Diabetologia that specifically addressed safety for competitive athletes with type 1 diabetes; and a position statement on glucose management in people with type 1 diabetes who exercise from the European Association for the Study of Diabetes (EASD) and the International Society for Pediatric and Adolescent Diabetes, also published in 2020 in Diabetologia.

In addition to advocating for improved patient education by diabetes clinicians, Henske cited further advances in management technology, advances in sports-oriented nutrition for people with type 1 diabetes, and broader use of glucagon as a hypoglycemia-rescue treatment as potentially useful strategies for improving hypoglycemia avoidance during and after exercise.

"This survey demonstrated that many people who live with type 1 diabetes, despite being tech savvy and engaged, passionate about exercise, and seemingly well-controlled based on A1c, are still struggling to exercise safely without high and low blood sugar," Henske said. "We hope to increase awareness of published guidelines regarding exercising with diabetes and help create better practical educational tools."

The study received no commercial funding. Henske has reported no relevant financial relationships.

ENDO 2023. Abstract THU-281. Presented June 15, 2023.

Mitchel L. Zoler is a reporter for Medscape and MDedge based in the Philadelphia area. @mitchelzoler

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