Type I Diabetes Mellitus, also known as insulin-dependent diabetes, is a condition where the pancreas does not produce any or enough insulin.  Insulin is a hormone that lets glucose (sugar) enter cells to be used for energy. Type II Diabetes Mellitus occurs when the body becomes resistant to the effects of insulin or doesn’t make enough insulin to handle all the glucose in the blood.  Type II Diabetes usually begins with insulin resistance.  The pancreas can keep up with the resistance by producing more insulin, but in time will lose the ability to secrete insulin in effective doses.

  • Hypoglycemia, (low blood glucose, <70 mg/dL) can have a rapid onset and is dangerous if not handled appropriately.
  • Hyperglycemia, (high blood glucose, >180 mg/dL), does not typically have an acute risk of death, however it does carry long term consequences.


  • Athletes should wear medical identification bracelets at all times
  • Take medications in appropriate doses at recommended times
  • Eat regular meals and snacks
  • Establish and follow diabetes care plan
  • For sports and exercise
  • Check blood glucose before activity
    • Avoid exercise if glucose level:
      • <100 mg/dL
      • >250 mg/dL with ketones present
      • >300 mg/dL regardless of ketone presence
  • Plan meals/snacks to be eaten before and after activity
    • Should contain carbohydrate and protein
  • Consult physician on altering insulin dosages before activity
    • Special considerations: insulin delivery via pump
      • Pump should be disconnected for collision sports
        • Athlete should monitor blood glucose carefully during participation when pump is disconnected
      • Pumps do not need to be disconnected for non-collision sports, however:
        • Exercise facilitates glucose uptake by muscle
        • Not as much insulin will be necessary
        • Type of exercise affects glucose levels differently
      • Experiment with exercise type and pump use while carefully monitoring blood glucose to determine individual recommendations for exercise
  • Adjust medication before activity
  • Check blood glucose during and after activity
  • Type I diabetic athletes can experience late hypoglycemia after exercise.  These athletes should consume carbohydrate before bed to prevent hypoglycemia while sleeping

Insulin Pump

Predisposing Factors

Type I Diabetes

  • Genetics
  • Autoimmune
  • Environmental
  • No known way of preventing Type I diabetes

Type II Diabetes

  • Older age
  • Family History
  • Overweight
  • Inactivity
  • Impaired glucose metabolism
  • History of Gestational diabetes (diabetes associated with pregnancy)
  • Race/Ethnicity: African American, Alaska Native, American Indian, Asian American, Pacific Islander, Hispanic/Latino
  • Type II Diabetes may be prevented or delayed by maintaining a healthy, active lifestyle.


  • Normal blood glucose is 72-100 mg/dL (Table 1)


Table 1. Recognition of Hypoglycemia and Hyperglycemia Causes and Signs and Symptoms.

Hypoglycemia (<70 mg/dL) Hyperglycemia (>180 mg/dL)
Signs and Symptoms Causes Signs and Symptoms Causes
Hunger Missed meal/snack Gradual onset Insulin not taken
Shakiness Delayed meal/snack Flushed, warm skin Miscalculated insulin dosage
Nervousness Not eating enough Frequent urination Pump malfunction
Pallor Physical activity Irregular breathing Consumed more than planned
Cool, clammy skin Alcohol Fruity/acidic breath Exercise less than planned
Dizziness/light headed Environmental heat stress Nausea Emotional stress
Sleepiness Drowsiness
Confusion Disorientation
Difficulty speaking


  • Signs and symptoms (Table 1)
  • Time of last meal/insulin dosage
  • Finger stick to measure blood glucose level
  • Urine testing for ketosis


Ketones are produced through a process called ketogenesis.   When there’s not enough insulin in the blood, glucose builds up because it can’t be used for energy.  Without glucose, the body breaks down fat for energy, and the byproducts are ketones.  Ketones are not harmful if blood glucose is not high.  It just means that your body is using fat for energy.  However, if blood glucose is high and left untreated, a condition called diabetic ketoacidosis may develop, which is life threatening.

Ketone Testing:

  • You should test for ketones when you plan to exercise and blood glucose is >250 mg/dL.
  • Even if you don’t plan to exercise, you should test for ketones when blood glucose is >250 mg/dL for two tests in a row.

How to test:

Ketone testing kits are available at most pharmacies or drug stores.  They usually require you to urinate in a small cup, dip in a strip, then match the strip to the colors on the bottle.

Ketone Testing

If the test is positive:

  • Consult your physician, as you may need additional insulin.
  • Drink plenty of water or other non-calorie beverage (to wash-out the ketones).
  • Test blood glucose every 3-4 hours, and test for ketones if blood glucose remains >250 mg/dL.
  • Do not exercise if blood glucose is >250 mg/dL and ketones are present, as this may cause more ketones to be released.

Differential Diagnosis

  • Hypoglycemia
  • Hyperglycemia
  • Anaphylaxis
  • Exertional sickling
  • Cardiac pathology
  • Head injury
  • Heat illness
  • Stroke

Follow this algorithm to assess diagnosis and treatment options:

Diabetes Algorithm

TreatmentGlucose Sources

  • Check blood glucose levels
  • Hypoglycemia:
    • If conscious
      • 1 serving of a sugary snack or beverage
        • 3-4 glucose tablets
        • 1 serving of glucose gel
        • 1 Tbsp honey or sugar
        • 4 fl oz fruit juice or regular soda
        • 5-6 pieces of hard candy
      • If no improvement, call 911
      • If improvement, recheck blood glucose every 15 minutes
      • Administer additional carbohydrate if blood glucose remains <70mg/dL
      • Once blood glucose is within a normal range, athlete should consume a carbohydrate and protein snack
    • If unconscious
      • Call 911
      • Administer glucagon
      • Monitor vitals
  • Hyperglycemia:
    • If conscious
      • Assess urine for ketones
      • Administer water or other non-carbohydrate beverage
      • If ketones present, keep drinking and recheck in 15 minutes
      • If no ketones, exercise if blood glucose is <250mg/dL
    • If unconscious
      • Call 911
      • Monitor vitals


Return to Play

  • Athletes with mild hypoglycemia and hyperglycemia may return to activity when blood glucose is within a normal range without ketones.
  • Athletes with moderate hyperglycemia (<250 mg/dL) may continue with activity as long as no ketones are present in the urine and signs and symptoms do not increase.


Recommended Equipment List

  • Hypo/Hyperglycemia Care Kit
    • Diabetes Care Plan
    • Glucometer and test strips
    • Glucose tablets, glucose gel, sugary snack or beverage
    • Glucagon
    • Insulin and syringes
    • Alcohol swabs
    • Sharps container
    • Urine/blood ketone testing supplies (cup and strips)
    • Spare parts for insulin pump (batteries, tubes)

Hypoglycemia Care Kit


  1. Bernhardt DT, Roberts WO. Preparticipation Physical Evaluation. 5th ed. American Academy of Pediatrics. 2010.
  2. Centers for Disease Control and Prevention. Diabetes Public Health Resource. Available at: http://www.cdc.gov/diabetes/index.htm. Accessed on September 21, 2011.
  3. National Diabetes Information Clearinghouse (NDIC). Available at: http://diabetes.niddk.nih.gov/index.aspx. Accessed on September 20, 2011.
  4. Yeargin SW, Yeargin BE, Anderson JM. Anaphylactic Shock, Hypothermia, Diabetes, and Wilderness Medicine.  In: Casa DJ, ed. Preventing Sudden Death in Sport and Physical Activity. Sudbury, MA: Jones and Bartlett Learning. 2012: 201-231.
  5. American Diabetes Association. Diabetes Basics. Available at: http://www.diabetes.org. Accessed on September 20, 2011.
  6. Jimenez CC, Corcoran MH, Crawlay JT, Guyton Hornsby W, Peer KS, Ohilbin RD, Riddell MC. National Athletic Trainers’ Association position statement: management of the athlete with type I diabetes mellitus. J Athl Train. 2007;42(4):536-545.