John is a 25 year old man who has had diabetes for three years duration. You with no diabetic complications but you do have lots of high levels of blood sugar and lots of low levels of blood sugar. He is a keen sportsman playing polo professionally for the Maltese national team.
John's training programme was as follows. On three days per week he trains for polo. This involves high intensity exercise for an hour and a half, mostly in the evening. His blood glucose falls very rapidly from 20 down to 3 – 5 over a period of time. This was in spite of taking extra glucose in the form of glucose syrup in a sachet form. This particularly at the end of the period of the match that you lose performance and find it difficult to complete. On a match day which occurs at weekends, there is a similar fall in blood glucose. Food intake consists of cereals with breakfast, a lunch of pasta and again pasta as evening meal.
Suggested Management Plan1. Continue on isophane insulin but reduce the morning isophane insulin down significantly to 8 – 10 units and increase evening isophane insulin when you come after training up to 18 – 20 units. Titrate the evening dose by aiming to get yorning blood glucose somewhere in the range of 4.5 – 6.5 mmols.
2. Start taking prandial insulin in the form of either Novo Rapid or Humalog insulin. This should be given at the rate of 1 unit per 10gm of carbohydrate.
3. Regularise your carbohydrate intake. Work out how much carbohydrate in each meal and try to keep the amount the same each day and keep it at the same general glycaemic index type.
4. Take extra glucose with matches and training. Typically the weight is 1gm per kg per hour, so may need to take 60gm. This can be taken in the form of Lucozade, Dextrosol tablets, jelly babies or Gatorade. The glucose should be taken in 20gm boluses when your blood glucose starts to fall below 7 rather than all at the start. If blood glucose falls during training or during the match, take a higher dose of glucose, or if it is elevated, take less. Balancing blood glucose in this way will certainly improve performance towards the end the match. Use the opportunity to refuel liver glucose by taking 30gm of glucose immediately after the match with 2 – 3 units of quick acting insulin, ie Novo Rapid or Humalog.