Professional Development
Exercising with Type
1 Diabetes (T1D) and
hypoglycaemiAa
H
ypoglycaemia is a condition that
occurs when BGL (blood glucose
level) falls below normal. It is
commonly referred to as a hypo, insulin
reaction or low blood glucose. A BGL less
than 4mmol/L is getting low and 3.5mmol/L
needs to be treated quickly to prevent it
dropping lower.
Having a hypo can be serious because the
brain needs constant glucose; without it brain
function can be impaired, which can reduce
performance at school, reduce confidence
and participation and pose a safety risk to self
and others. If not detected early and treated,
a person can lose consciousness from low
blood glucose.
Imagine for a moment you are leading a
group of year 7 students on a PE (physical
education) activity, for example, touch
football. One student approaches you before
the first game explaining he has T1D. Would
you know what to ask him or how to help him
manage his blood sugars to help make his
touch footy experience a positive, rather than
negative, experience?
This scenario is quite possible. An
estimated ten to fifteen per cent of the 1.7
million Australians with diabetes have T1D
(previously called insulin-dependent or
juvenile-onset diabetes), the majority of
which are diagnosed during childhood or
adolescence. T1D is an environmentally
triggered autoimmune process that destroys
the body’s insulin-producing pancreatic
beta cells, rendering the body unable to
manufacture insulin which is the hormone
essential for uptake of glucose from the
bloodstream into the body’s tissue and cells.
To treat T1D and provide energy-giving
blood glucose to body cells, people with T1D
inject or pump synthetically made insulin
subcutaneously (that is, under the skin) on
a daily basis. Although understanding of
diabetes and the technology supporting it
has advanced significantly, doctors are still
a long way off from replicating the body’s
subtle moment-to-moment looping feedback
systems that regulate BGL (blood glucose
level) in people without diabetes.
What is Different for People with T1D?
Management of T1D is not a set-and-forget
proposition; rather,
it requires 24/7
monitoring. The key hurdle to managing it
during exercise, is that people with T1D do
not have the normal physiological responses
that occur in non-diabetic persons, whereby
the pancreas decreases insulin secretion
during exercise to help prevent blood glucose
from dropping too low. In T1D, higher injected
insulin levels combined with exercise can
cause glucose to be taken up quickly into the
muscles; at the same time, the liver reduces
the amount of glucose it adds to the blood,
and when more glucose is leaving blood than
is being delivered, blood glucose is likely to
drop to low levels. This situation can lead
to the most common acute complication of
diabetes – hypoglycaemia, commonly known
in the world of diabetes as a ‘hypo’.
Exercise and BGLs
Although physical activity is
acknowledged as a
cornerstone of T1D
management,
many with
the condition

Timing of physical activity relative to a student’s last
insulin dose and its peak action phase is an important
receive minimal information on exercise-
related management from educators and
doctors. Sometimes, exercise may even be
discouraged due to the complexities involved
with maintaining normal BGLs during any
physical activity; however, in the majority of
cases this is not justified.
This lack of knowledge about the effects of
exercise can make blood glucose management
even more difficult for diabetic children and
adolescents when they participate in normal
physical activities such as physical education
classes, recess activities, or sports.
Exercise lowers blood glucose in three ways:
1. The blood glucose contribution to the
direct energy cost of exercise. This is a
function of exercise type, intensity and
duration.
2. Exercise increases insulin sensitivity,
therefore magnifying insulin’s effect on
glucose uptake into muscle, that is, one
unit of insulin under exercise stress will
have much greater effect than the same
unit at rest.
3. Muscular contraction increases glucose
uptake into muscle independent of
insulin’s effect.
So, exercising when insulin is at its
peak can have a triple, additive affect on
lowering BGLs.
Key Causes of Exercise-related
Hypoglycaemia
Given that school timetables, and therefore
PE classes, are set and students with T1D
need to inject set doses of insulin to manage
rises in BGL after meals, it is easy for students
with T1D to be caught-out with higher levels
of circulating insulin than is desired for
physical activity. This is especially so when
exercise is performed soon after a main meal,
for example, a PE class directly after lunch
consideration for reducing hypo risk.
break. Timing of physical activity relative to
a student’s last insulin dose and its peak
action phase is an important consideration
for reducing hypo risk.
Diagram 1: Insulin behaviour
Two basic categories of insulin are available:
1. Basal insulin: this is used to replace the
body’s normal physiological resting insulin.
These insulins have a flat, relatively peakless
20- to 24-hour profile.
2. Bolus insulin: these insulins are used to
manage fluctuations in BGLs resulting from
carbohydrates consumed in meals and
snacks. Bolus insulin doses are the most
relevant to PE teachers.
Different types of insulins vary in the time
they take to have a peak effect and in the total
duration of their effects. Exercising during
the peak of any insulin usually increases the
risk for hypoglycaemia. However, rather than
avoiding physical activity during peak insulin
times, advice should be sought from the
student’s diabetes health care team about
making compensatory changes to insulin
doses, carbohydrate intake, or both.
Daily Insulin Regimes
Many insulin regimes exist and due to
differences in relative circulating insulin
levels, all can have a major effect on individual
blood glucose responses to exercise. Most
individuals use a combination of short-acting
(bolus) and longer-acting (basal) insulins,
requiring insulin injections two or more times
a day. Diagram 2 illustrates an example of
a multiple daily injection regime using four
injections, that is, one basal at 10pm (shown
By Allan Bolton
in red) and three bolus injections at meals
(shown in blue).
Diagram 2: Example insulin
treatment regime
In this example, touch footy is scheduled
to start at 1:30pm. This would have the
student exercising smack in the middle of his
lunchtime insulin’s peak, increasing hypo risk.
Exercising at different times of the day makes
a big difference to the effects of insulin and
hypo risk. Here, the student would be at less
risk of hypoglycaemia at 10:30am or 2:30pm,
when insulin levels are lower.
How to Avoid Hypos
The most effective way for people with
T1D to avoid hypoglycaemia is with close
monitoring BGLs in combination with a solid
understanding of their individual insulin
regime and its related peak actions. This
can pose a problem for PE teachers because
children and adolescents are often not the
best at monitoring and self-managing their
condition. Hypos can also sneak up and catch
people unaware, that is why it is important for
all concerned to be aware of hypo symptoms
so that they know when it is time to act.
The key to avoiding hypoglycaemia is for
individuals to check BGLs before, during
and after exercise to help them decide when
extra carbohydrate is needed. In the majority
of situations, the diabetic student will need to
eat additional carbohydrate or reduce insulin
to counter exercise effects. Such actions
should be based on advice from the student’s
diabetes health care team.
If a PE teacher, or student with T1D,
active education 71
Professional Development
notices any of the following symptoms,
it is important to act immediately; hypos are
not a condition that can wait until the
game is over.
Hypo symptoms
It is important not to become complacent
when it comes to treating hypos. Putting
off treatment at first signs can turn a minor
inconvenience into a major problem –
severe hypoglycaemia, which can cause
unconsciousness, extreme disorientation,
fitting and convulsions. Every hypo should be
treated as an emergency.
Early warning signs: Trembling/shaking,
sweating, hunger, heart pounding, dizziness,
fast pulse, changes in body temperature,
tingling around mouth, paleness, heavy
breathing
Late warning signs: headache, slow
thinking, blurred vision, slurred speech, unusual
behaviour, trouble concentrating, confusion,
numbness, drowsiness, disorientation.
A 5-step Approach to Treating
Hypoglycaemia
The good news is that treating a hypo is
relatively simple. It is hard to believe something
that can be potentially life threatening can
be stopped in its tracks with six or seven
jelly beans!
Step 1- Be prepared: Always have some easily
absorbed carbohydrate available, it should
contain 15g of fast-acting carbohydrate.
72 active education
This should be something that can be eaten
or drunk quickly.
Step 2 - Be sure: If a student with T1D
experiences hypo symptoms, they should
perform a finger prick BGL check whenever
possible if they are hypoglycaemic. If this
is not possible, always treat symptoms as a
hypo regardless.
Step 3 - Do not wait: If a student experiences
hypo symptoms or a BGL is 4mmol/L or lower,
they should eat or drink 15g of fast-acting
carbohydrate like glucose or non-diet soft
drink. Examples are: six to seven normal size
jelly beans, half a can of non-diet soft drink,
half a glass of fruit juice.
Note: Avoid over-treating and swinging from
hypo (low) to hyper (high) by not eating more
than is recommended above.
Step 4 - Follow-up: Fifteen minutes after the
initial Step 1, perform a second finger prick
blood glucose test to determine if further
treatment is needed. If blood glucose is still
low, repeat Step 3, regardless if symptoms are
present or not.
If the student is feeling better and BGL is
rising, he/she should have 15g of slower acting
carbohydrate, unless intending to have a meal
containing carbohydrates within the next
twenty minutes. Examples are: one glass of
milk, one slice of bread, one piece of fruit.
Step 5 - Get specialist help: If BGL does not
rise after two lots of glucose, be ready to seek
medical help. If a student is having a hypo
and is too drowsy or disoriented to respond
to simple questions, they should not be given
anything by mouth; this goes without saying
for anyone who is unconscious. This is when
an injection of Glucagon is required, which
should only be administered by someone
trained to do so.
References
Ambler G., Barron V., May C., Ambler E.,
and Cameron, F. (2001) Caring for Diabetes
in Children and Adolescents: A Parent’s
Manual. Combined Children’s Diabetes
Services of NSW.
Colberg, S. (2001) The Diabetic Athlete
– prescriptions for exercise and sports.
Human Kinetics
Nagi, D. (2005) Exercise and Sport in
Diabetes: Second Edition. John Wiley &
Sons. England.
Mr. Allan Bolton B.H.M.S. (Hons)
MAAESS AEP SP has lived with type 1
diabetes for thirty years and, with hundreds
of alpine, water and road-based endurance
events under his belt, it is fair to say that
he has taken diabetes for some seriously
hard ‘science to practice’ test drives. This
experience has given him great insight into
functional diabetes management, both during
exercise, sport and day-to-day living. Mr.
Bolton is the creator of www.ext1d.com.au,
an e-learning website dedicated to teaching
people how to exercise successfully with type
1 diabetes – check it out to learn more!