By Sam Scott, PhD.

In this blog post, I summarise a recent invited presentation that I delivered at the 50th Annual Conference of the International Society for Paediatric and Adolescent Diabetes (ISPAD) Lisbon, Portugal, on the 19th October 2024. Given the presentation’s time constraints, this is not an extensive review article. Please note also that my focus here is on individuals aspiring to compete at an elite level in their chosen sport. This level of ambition necessitates a high degree of motivation, dedication, and meticulous attention to detail in terms of training, recovery, and nutrition.

Many children dream of being athletes when they grow up

Inspired by their favourite sporting heroes and the thrill of competition, they envision themselves scoring the winning goal, crossing the finish line first, or making the game-winning shot.

This aspiration is fuelled by the excitement and camaraderie of sports, as well as the desire to achieve greatness and make their mark in the world. For these young dreamers, the journey towards becoming an athlete is not just about physical prowess but also about cultivating discipline, teamwork, and resilience.

Dreaming of greatness. Type 1 diabetes should not have to prevent you from reaching your goals in sport.

But exercise is challenging after a type 1 diabetes diagnosis

A child diagnosed with type 1 diabetes may face significant challenges in pursuing their dream of becoming a top athlete. Managing blood glucose levels during intense physical activity can be complex, requiring constant monitoring and adjustments. Access to advanced technology, such as continuous glucose monitors (CGM) and insulin pumps, is important but not always readily available or affordable. Additionally, a lack of understanding and support from teachers and parents can make the journey even more daunting. The feeling of embarrassment associated with managing diabetes in public, especially among peers, can also be a significant barrier.

Young athletes with type 1 diabetes must consider additional factors during their sport that their peers do not, such as calculating insulin needs and managing hydration and nutrition more meticulously. Despite these hurdles, with the right support and resources, children with type 1 diabetes can still achieve their athletic aspirations.

Competing at the highest level in sports is definitely possible!

In recent years, we have seen a number of people living with type 1 diabetes competing and succeeding in various professional sports. This can be attributed to a combination of factors, including personal commitment, dedication, and careful glucose management strategies, as well as significant advancements in diabetes technologies and care.

However, can we confidently say that we are at a stage where we can assist the majority of people with type 1 diabetes in achieving their exercise goals? What more could and should we be doing to support individuals pursuing sport, both at elite and recreational levels?

My presentation addressed the following question: "How can we support children with type 1 diabetes in achieving their dreams of becoming athletes?"

The primary objectives were:

To identify areas for improvement in our current support systems for young athletes with type 1 diabetes, enabling more individuals to realise their athletic aspirations.

Areas of focus included:

• The power of role models

• Community and support networks

• Educating and supporting teachers and parents

• Sports nutrition tailored to type 1 diabetes

• Diabetes technology, particularly its application in sports and competition

Substantial progress has been made in supporting glucose management and exercise for people with type 1 diabetes

Participating in exercise and physical activity is associated with a variety of health benefits for individuals with diabetes. However, physical activity presents many challenges for managing glucose concentrations during and following exercise. Today thanks to research and development going on around the world we have a number of resources:

• Comprehensive guideline papers consolidating the latest research findings and clinical experiences.

• Tailored educational materials and courses specifically designed to help people living with type 1 diabetes manage their glucose levels around sport.

• Increasingly, we are seeing community support, including type 1 diabetes-specific sports teams and groups.

• Significant advancements in diabetes technology, such as innovative hardware, insulins, insulin pumps, and automated insulin delivery (AID) systems.

But are we maximising these resources to their full potential when it comes to exercise? What other aspects are important when it comes to helping people develop in sport?

In the following sections, I explore key factors that can help individuals with type 1 diabetes excel in competitive sports.

1. The Power of Role Models in Sport

Role models serve as inspiration and motivation, demonstrating what is achievable and breaking down barriers.

Consider, for instance, Roger Bannister breaking the four-minute mile record. While not directly related to type 1 diabetes, this example illustrates the impact of role models:

Roger Bannister first to run 4 minute mile. A feat thought impossible. (Associated Press)

Runners had been chasing the 4-minute mile goal seriously since at least 1886, with the challenge attracting the most brilliant coaches and gifted athletes worldwide.

But the elusive 4-minute barrier had always beaten them. It had become as much a psychological barrier as a physical one. Like an unconquerable mountain, the closer it was approached, the more daunting it seemed.

Then, on May 6, 1954, Roger Bannister broke the 4-minute barrier, clocking a time of 3 minutes and 59.4 seconds.

In the wake of Bannister's achievement, the floodgates opened:

• Just 46 days later, Australian runner John Landy also broke the barrier, with a time of 3 minutes and 58 seconds.

• A year later, three runners surpassed the four-minute mark in a single race.

• Over the past half-century, more than a thousand runners have conquered a barrier once deemed hopelessly out of reach.

This example underscores the power of role models in sports. Achievements inspire others and illustrate what is possible when boundaries are broken, whether it's:

• Nacho Fernández winning the Champions League,

• Alexander Zverev securing Olympic gold, or

• Noortje De Brouwer claiming bronze for Synchronized Swimming at the 2024 Olympic Games.

At Enhance-d, we are building new ways through our app to showcase what is possible in exercise for people living with type 1 diabetes. For the first time, users can explore examples of hundreds or thousands of people with type 1 diabetes achieving a wide variety of sporting accomplishments. This includes not only ultra-endurance events or scaling the highest mountains but also gym sessions, taking your dog for a walk, or completing a first 5k run.

It’s a unique way for people to find examples of people in their chosen sport living with T1D reaching a goal that appeals to them. Adding inspiration on an achievable level.

2. Communities and Sports Teams

Allow people to feel better supported and learn from each other

Living with type 1 diabetes can be challenging and oftentimes isolating, but engaging in community and sport can significantly improve both physical and mental well-being. Regular exercise through sports helps manage blood glucose levels, improves insulin sensitivity, and reduces the risk of complications. Additionally, being part of a community, whether it's a local diabetes support group or a sports team, offers a sense of belonging and understanding.

These networks provide practical advice, emotional support, and motivation, making the daily management of type 1 diabetes feel less daunting. The combination of community and sport creates a positive and empowering environment, encouraging individuals to lead active, healthy lives while effectively managing their condition.

Additionally, a diabetes community offers a space where others understand your experiences. Today, numerous type 1 diabetes-specific teams exist worldwide.

The Power of Enhance-d, the exercise app for the diabetes community

At Enhance-d we are creating a way to connect these teams and help you to identify or build a team in your local area depending on your favourite sport.

1. Supporting Parents, Teachers and Sports Coaches

Support from parents, teachers, and coaches is vital for children pursuing athletic dreams, especially those with type 1 diabetes.

Parents or other caregivers play a crucial role by providing logistical and emotional support, such as ensuring their children attend regular practice sessions. For instance, if a child shows interest in swimming, parents may need to commit to early morning training sessions, providing transportation, and adjusting family schedules.

Teachers and coaches also take on significant responsibilities, often going beyond teaching skills and strategies to mentor and guide young athletes. Consistent, positive reinforcement from both parents and teachers can greatly influence a child's commitment and passion for sports, helping them develop into well-rounded athletes and individuals.

Managing type 1 diabetes adds an extra layer of complexity to a child's athletic journey, requiring additional vigilance and cooperation from both parents and teachers. Teachers and coaches take on the added responsibility of understanding and monitoring the child's condition during practices and games. They need to be educated about the signs of hypoglycaemia (low blood glucose) and hyperglycaemia (high blood glucose), and they should know the appropriate actions to take in case of an emergency. This may involve ensuring the child has access to quick-acting carbohydrates, monitoring blood sugar levels, and administering medication as needed.

Parents, on the other hand, must ensure that their child is prepared for physical activities with the necessary supplies and that the coaching staff is well-informed about their child's condition. They also need to reassure their child (and themselves) that it is safe to participate in sports, as regular exercise can be highly beneficial for managing type 1 diabetes.

Open communication and coordination between parents, teachers, and healthcare providers are essential to create a safe and supportive environment that allows the child to fully participate and thrive in athletic activities.

4. Applying Sports Nutrition Practices to Athletes with Type 1 Diabetes

Athletes without T1D are able to take glucose levels for granted. They don’t need to balance the fine line between hyper- and hypoglycaemia, which can impact both health and sports performance.

An athlete without diabetes is much more free to experiment with their nutritional strategies in relation to their training and competition goals, without the risk of hypoglycaemia. Whereas, athletes with type 1 diabetes, must always prioritise glucose management.

While sports nutrition guidelines for athletes without diabetes are well-established and adaptable, athletes with type 1 diabetes face unique challenges:

• They must carefully monitor their glucose levels to prevent hypoglycaemia.

• They need to consider the impact of insulin therapy on their nutritional strategies.

• They should adapt guidelines to their individual needs and circumstances.

There’s still so much we don’t know about sports nutrition and type 1 diabetes!

In order to compete at the top, an athlete with type 1 diabetes needs to find a way to include a whole range of nutritional practices into their regimes, because their competitors without diabetes will certainly be optimising their nutrition. But depending on the sport, it’s important to align nutritional practices with competitive goals in order to compete at the top.

Research in this area is extremely limited and but we need to find a way to improve our understanding in this area. There's a significant gap in research specific to type 1 diabetes and sports nutrition, making it challenging to develop evidence-based guidelines.

We must advance our understanding by creating practical protocols for scenarios such as:

• Fed vs. fasted training

• Carbohydrate loading

• Fuelling throughout exercise

• Other specific scenarios such as cutting weight if you are competing in combat sports

5. Understanding the Challenges of Diabetes Technology in Sport and Competition

Advancements in diabetes technology have significantly improved the quality of life for individuals with type 1 diabetes and expanded the boundaries of what they can achieve, particularly in sports and competition. CGM, insulin pumps, and hybrid closed-loop systems have been instrumental in addressing some of the challenges associated with exercise.

CGM, insulin pumps and hybrid closed loops have played a pivotal role in alleviating some of the challenges around exercise.

Not the most scientific approach to this, I know, but if you just look at general trends, you can see that there are more athletes with type 1 diabetes achieving top of their chosen sport and this appears to align with developments in tech over the last 100 years.

Taking continuous glucose monitoring (CGM), as an example, this offers tremendous benefits for athletes living with type 1 diabetes:

Positives:

• A useful tool to learn about your individual responses to training and competition.

• Aids in determining carbohydrate and insulin requirements.

• CGM alarms can provide an extra level of assurance, especially overnight.

• Useful for post-exercise review and analysis.

• In certain sports you can easily see glucose during event and even use it for decision making as we have seen with pro cyclists that use it on their monitor while competing.

Challenges:

• Difficult to obtain real-time readings in certain sports due to prohibitions or signal interference, such as during contact sports like boxing or rugby.

• Lag time with CGM can be exaggerated during rapid glucose changes, as often happens during exercise.

• Accuracy may deteriorate significantly during exercise.

• Sensors may detach during contact or water-based sports.

At Enhance-d we are aiming to overcome some of these barriers by making CGM more actionable around sport and physical activity.

With the Enhance-d Clinician Dashboard, you can review your exercise sessions with greater context.

Conclusions

For individuals living with type 1 diabetes, exercise presents numerous challenges. Nevertheless, reaching an elite or professional level in sport is possible. Although, possible, it is essential to acknowledge the additional obstacles and identify ares for improvement and support to enhance the likelihood of success.