Diabetes Mellitus Cases on the Rise

November is Diabetes Awareness month and the Centers for Disease Control and Prevention has published its most recent findings on the prevalence of Diabetes Mellitus in the United States.  Currently it is estimate that 25.8 million people (children and adults) suffer from diabetes here in the United States.  The number of diagnosed cases of diabetes has increased in all fifty states from 1995 – 2010.  More specifically, there was a 50% or more increase in diabetes cases in 42 of 50 states during that 15-year span with 18 states experiencing a 100% or more increase.  Type 2 Diabetes has accounted for 90% – 95% of the increase in diabetes cases in the United States.  A further breakdown of the results can be found HERE.  If you would like specific data for your state and/or county check out the CDC Diabetes Interactive Atlases. 

There are three types of diabetes mellitus:  type 1, type 2 and gestational.  For the purpose of this post I will focus on comparing type 1 and type 2 diabetes mellitus.  The following table highlights key information as available from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the National Diabetes Information Clearinghouse.

	Type 1	Type 2
Definition	The body makes little to no insulin because the body destroys its own beta insulin cells in the pancreas	The body cannot utilize the insulin it produces because the insulin has become dysfunctional and does not remove sugar (glucose) from the blood
Diagnosis/Factors	Autoimmune condition; genetic and environmental factors could also play a role	Genetic, obesity, physical inactivity, metabolic syndrome
Onset	Rapid (within weeks)	Slow (years)
Warning signs	Increased thirst and urination, weight loss, extreme tiredness, constant hunger	Feeling tired or ill, frequent urination (especially at night), unusual thirst, frequent infections, slow wound healing, weight loss
Affected groups	Can affect any age, but most cases diagnosed between 5 – 25 years	Traditionally common in overweight, inactive adults, but as childhood obesity increases so have the cases of type 2 diabetes in young people
Dependency	Insulin dependent	Not insulin dependent
Cure	None	Physical exercise, healthy diet and weight loss
Treatment	Insulin injections, diet modifications, regular physical activity; key is controlling glucose levels	Diet, exercise, weight loss, medication (some cased do require insulin injections)

TYPE 2 DIABETES AND YOUTH OBESITY

Currently 1 in 400 children and adolescent have been diagnosed with diabetes (type 1 and type 2).  Historically, it was more common for youth and young adults to be diagnosed with type 1 diabetes and unlikely that they would be diagnosed with type 2, leading to type 1 diabetes initially being referred to as juvenile diabetes.  As the number of diabetes cases grows, cases of type 2 diabetes in young people are increasing.  Type 1 diabetes is still more prevalent, but the rate of type 2 diabetes is increasing.  It appears that as rates of pediatric obesity increases, cases of type 2 diabetes increase.  According to the 2011 Diabetes Fact Sheet:

• During 2002 – 2005 15,000 youth were diagnosed with type 1 annually and 3,600 youth were diagnosed with type 2 diabetes annually.
• Among youth aged <10 years, the rate of new cases was 19.7 per 100,000 each year for type 1 and 0.4 per 100,000 for type 2 diabetes.  Among youth aged 10 years or older, the rate of new cases was 18.6 per 100,000 each year for type 1 and 8.5 per 100,000 for type 2 diabetes.
• Type 2 diabetes was extremely rare among youth aged < 10 years; while still infrequent, rates were greater among youth aged 10 – 19 years than in younger children.
• For youth aged 10 – 19 race influences the frequency of type 1 and type 2 diabetes; for non-Hispanic white youth the rate of new cases was higher for type 1 than for type 2 diabetes; for non-Hispanic black and Hispanic youth had similar rates for both type 1 and type 2 diabetes; for Asian/Pacific Islander and American Indian youth the rates were higher for type 2 than type 1 diabetes.

DIABETES MELLITUS AND EXERCISE

It is important to understand the role of exercise in the treatment of both type 1 and type 2 diabetes.  Exercise can be a key factor in maintaining a healthy lifestyle for anyone who has diabetes, but understanding how exercise affects glucose and insulin levels is important to maximizing the positive role of exercise in overall health and proper management of diabetes.

For athletes and others who are living with type 1 diabetes it is important to work with their health care provider and/or diabetes educator to develop a treatment plan specific to exercise.  Understanding how exercise specifically affects insulin and glucose levels will help participants understand what sort of nutrition is required before, during and after exercise.  It also helps participants understand what adjustments to insulin dosages are required before, during and after exercise.  Each person responds differently to exercise so the nutrition/insulin-exercise plan must be individualized.  Recent research shows that resistance and aerobic exercise improves glucose control in those with type 1 diabetes.  This means exercise can be an important key in managing type 1 diabetes consistently.  Resources that can help give some basic information on exercising with type 1 diabetes include the following:

National Athletic Trainers’ Association Position Statement:  Management of the Athlete with Type 1 Diabetes Mellitus

Care of Children and Adolescents with Type 1 Diabetes (American Diabetes Association)

Physical Activity/Exercise and Diabetes (American Diabetes Association)

For those living with type 2 diabetes exercise is very important because it is a key component of the overall treatment plan.  Exercise combined with a well managed diet is the best combination for those who need to control their weight in an effort to manage (and potentially eliminate) type 2 diabetes.  There has been increasing attention paid to management of this condition as its prevalence continues to grow.  For recommendations on safely exercising with type 2 diabetes review the following resources:

Physical Activity/Exercise and Diabetes (American Diabetes Association)

Exercise and Type 2 Diabetes American College of Sports Medicine and American Diabetes Association:  Joint Position Statement

As the obesity epidemic continues to grow, so will the number of diagnosed diabetes cases (particularly type 2).  Exercise plays an important role in decreasing the likelihood (or delaying onset) of type 2 diabetes and improving the glucose response of those living with type 1 diabetes.  It is important to take an educated approach to exercise and management of diabetes.  Living with diabetes doesn't keep you from participating in your favorite sports; your favorite sport could help you improve your overall health.

Submitted by Heather L. Clemons, MS, MBA, ATC

Environmental Cold Injuries: Specific Injuries

Last week’s entry discussed general keys to preventing environmental cold injuries by having an emergency action plan in place, having appropriately trained personnel available, learning to layer correctly to minimize heat loss and knowing who may be most susceptible.  Specific injuries or conditions may require specific prevention steps, but proper recognition and initial first aid are also important.  I will focus primarily on hypothermia and frostbite since they happen most often, but there are other conditions to be aware of.  Recognizing the signs and symptoms an athlete shows when presenting with an injury such as frostbite or hypothermia is critical.  Taking the appropriate steps to minimize the severity of the injury and getting appropriate treatment are also important.

HYPOTHERMIA:

Hypothermia, defined as a core temperature of 95^o F or lower, affects a variety of body systems, getting more severe as the core temperature continues to drop.  Sometimes hypothermia is referred to as accidental hypothermia in the literature to differentiate it from the therapeutically induced hypothermia utilized by medical professionals.  The severity of injury is described as mild, moderate, and severe and each stage presents with specific signs and symptoms.  The ability to recognize these signs and symptoms can help you understand the severity of hypothermia without assessing core temperature.  Assessing core temperature requires the use a specifically designed thermometer and most typical clinical thermometers are inaccurate at temperatures below 95^oF.  Seeking immediately medical treatment for someone suffering from hypothermia is critical, especially as the condition becomes progressively worse.

Signs and symptoms of mild hypothermia include a core temperature between 98.6^oF and 95^oF, vigorous shivering, lethargy, loss of fine motor control among others.  As the patient progresses to mild hypothermia the core temperature is between 90^oF and 94^oF, respirations and pulse slow, cyanosis (blue hue to skin) is present and shivering ceases.  As the patient reaches severe hypothermia the core temperature is below 90^oF and may even be comatose.  The complete list of signs and symptoms are available by clicking the “Cheat Sheet” link at the bottom of this post.  I have simply tried to highlight some of the signs and symptoms here. 

Athletes most likely to suffer from hypothermia are those who experience prolonged exposure to cold, wet, or windy conditions, or some combinations of these.  This means those soccer and football games in the late fall could put your athlete at risk if not properly prepared.  The easiest way to prevent hypothermia is to properly layer under (and over) the uniform to maintain warmth and to stay properly hydrated.  Most athletes do not remember to drink when it is cold since the thirst mechanism is not as obvious.

If you believe someone may be suffering from mild hypothermia it is important to remove them from the weather conditions and remove any wet clothing.  Using blankets to warm them is also appropriate.  Providing warm food and fluids are also acceptable.  Do not rub hands and fingers to warm them as this could cause further tissue damage if frostbite is also present.  Immediate referral and transport to a hospital is important for anyone suffering from hypothermia, no matter the stage.

FROSTBITE:

Frostbite is the actual freezing of body tissues and often happens to the face and extremities. Frostbite can happen in cold, dry conditions while wet conditions can exacerbate the condition and is a result of the body shunting blood to the core to keep vital organs warm.  Coming into contact with cold objects (such as a lacrosse stick) can also result in frostbite.  The stages are frostnip (precursor to frostbite), mild frostbite and severe frostbite.

Frostnip is freezing of the most superficial layers of the skin as a result of cold, windy conditions or coming in contact with a cold object (typically metal).  Mild frostbite results in freezing of the skin and subcutaneous tissues, while severe frostbite is freezing of the skin, subcutaneous tissues and other tissues below that including muscle and bone.  Signs and symptoms include “waxy,” pale skin initially and can progress to a mottled skin, edema and/or transient numbness and tingling.  See “Cheat Sheet” for a complete list.

If you believe someone may be suffering from frostbite it is important to know that you should not rub the injury to warm it, it causes further tissue damage.  If blisters are present, do not break them open as it increases the risk of infection.  Finally, if you decide to re-warm (slowly) the extremity make sure there will not be an opportunity for the tissues to refreeze making the tissue damage more severe.  While frostnip may not require further referral, mild and severe frostbite are likely to need immediate referral for further medical treatment.

CHILBLAINS/PERNIO:

Chilblains (pernio) results from extended exposure (1 – 5 hours) to cold, wet conditions and most often affects the hands and feet.  Can occur in similar conditions as trench foot, but is typically a more superficial and less severe injury.  Signs and symptoms often include red or cyanotic skin, numbness and tingling, swelling and tenderness among others (see “Cheat Sheet”).

If you believe someone is suffering from chilblains remove the wet and constrictive clothing.  As with frostbite do not rub skin or break open any blisters that may be present.  The patient should also be non-weight bearing if it is the lower extremity that is affected.  Immediate referral may be necessary depending on the severity of the condition.

IMMERSION (TRENCH) FOOT:

Immersion (trench) foot is similar to chilblains, in that it occurs with prolonged exposure to cold and wet.  Exposure typically ranges from 12 hours to 4 days and often results from wearing continually wet boots and socks.  Signs and symptoms include cyanotic skin, numbness and tingling, or skin fissures and macerations.

RAYNAUD’S SYNDROME:

Raynaud’s syndrome (or phenomenon) is the result of constriction of blood vessels in the fingers (most often) that leads to a white, pale appearance.  Raynaud’s is aggravated by cold conditions.  Often times, avoidance of cold conditions is recommended for managing this poorly understood condition.

COLD URTICARIA:

Cold urticaria is an allergy to cold temperatures.  Exposure to cold will cause redness, itching, and hives on the exposed skin.  Avoidance of cold conditions is recommended for people with this condition.

Signs and symptoms “cheat sheet”

NATA prevention recommendations

ACSM preventions recommendations

REFERENCES:

Baumhakel, M. & Bohm, M. (2010). Recent achievements in the management of Raynaud’s phenomenon.  Vascular Health and Risk Management, 6:  207 – 214.  Available at:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856576/pdf/vhrm-6-207.pdf

Biem, J., Koehncke, N., Classen, D., & Dosman, J. (2003).  A the bedside:  Management of hypothermia and frostbite.  Canadian Medical Association Journal, 168(3):  305 – 311.  Available at:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC140473/pdf/20030204s00018p305.pdf

Cappaert, T.A., Stone, J.A.,Castellani, J.W., Krause, B.A., Smith, D. & Stephens, B.A. (2008).  National Athletic Trainers’ Association position statement:  Environmental cold injuries.  Journal of Athletic Training, 43(6):  640 – 658.  Available at:  http://www.nata.org/sites/default/files/EnvironmentalColdInjuries.pdf

Castellani, J.W., Young, A.J., Ducharme, M.B., Giesbrecht, G.G., Glickman, E., and Sallis, R.E.  (2006).  Prevention of cold injuries during exercise.  Medicine and Science in Sports and Exercise, 38 (11):  2012 – 2029.  Available at:  http://journals.lww.com/acsm-msse/Fulltext/2006/11000/Prevention_of_Cold_Injuries_during_Exercise.19.aspx#

Submitted by Heather L. Clemons, MS, MBA, ATC

Environmental Cold Injuries: Prevention

PREVENTING ENVIRONMENTAL COLD INJURIES

The late fall is upon us and in some places signs of winter have arrived with snow and cold temperatures.  While environmental cold injuries can happen any time of year in the right conditions the likelihood of these injuries increases as the ambient temperature drops, the snow falls and the ski or snowboarding trips are planned.  While those competing in traditional winter sports or wildernesses activities can be particularly at risk for environmental cold injuries, so can athletes who are participating in traditional fall sports in cold conditions.  Participation in a football or soccer game or even a cross country race in cold weather can potentially lead to frostbite or hypothermia with the right combination of conditions.  The important thing to understand is that these types of injuries can be prevented with appropriate precautions.

ENVIRONMENTAL RISK FACTORS:

In order to understand how to prevent environmental cold injuries you must first understand cold stress and your body’s response.  As an equation, cold stress can be described as follows:

LOW TEMPERATURES + WIND SPEED + WETNESS = INJURIES & ILLNESS

As the temperatures become lower and wind speeds rise the likelihood of environmental cold injuries increase.  The likelihood increases even further if a person is outside in cold temperatures with high wind speeds and is wet (perhaps from sweating or even immersion in cold water).  Heat transfer in the water is 70 times greater than in the air.  Heat loss increases two times when someone is wet and cold as compared to dry and cold.  Additionally, the insulating properties of clothing are decreased up to 90% when wet.  The NOAA windchill chart can give you an idea of the increasing injury potential as temperatures drop and wind speeds increase.

NON-ENVIRONMENTAL RISK FACTORS:

Several non-environmental risk factors or certain medical conditions can increase the potential for environmental cold injuries.  Those who have suffered previous environmental cold injuries are 2 – 4 times more likely to suffer another injury.  Females are also 2 times more likely to suffer from environmental cold injuries.  Wearing the appropriate clothing (check insulation rating) is a particular focus on prevention, being unprepared increases injury risk.  Youth athletes are at increased risk of injury because of higher surface area to mass ratio and lower adipose deposits.  This means young athletes can suffer from an injury in conditions that would not normally impact adults.  Also, if your child suffers from exercise-induced bronchospasm or asthma, Raynaud’s syndrome or cold urticaria the risk of environmental cold injury increases.

PREVENTION RECOMMENDATIONS:

The National Athletic Trainers’ Association Position Statement:  Environmental Cold Injuries (2008) delineates several recommendations in order to prevent cold injuries.  Those recommendations are as follows:

• Have trained personnel available that are specifically trained in cold injury prevention, recognition, and treatment; athletic trainers are among these.
• Identify those participants that are increased risk and monitor them closely; in certain situations they may need to be withheld from participation.
• Have a clear event or practice guideline on assessing weather conditions and making decisions about event postponement or cancellation.
• Know how to properly layer clothing with an inner wicking layer, middle insulation layer and wind and water resistant external layer; click HERE for a video and HERE for an article on how to layer properly.
• For young athletes more frequent breaks and opportunities to warm are necessary.

Next post:  Recognizing common environmental cold injuries

REFERENCES:

Cappaert, T.A., Stone, J.A., Castellani, J.W., Krause, B.A., Smith, D., and Stephens, B.A. (2008).  National Athletic Trainers’ Association position statement:  Environmental cold injuries.  Journal of Athletic Training; 43(6): 640–658.  Available at http://www.nata.org/sites/default/files/EnvironmentalColdInjuries.pdf

National Weather Service. Windchill Chart.  Accessed at http://www.nws.noaa.gov/om/windchill/

Occupational Safety and Health Administration.  Cold Stress  Accessed at http://www.osha.gov/SLTC/emergencypreparedness/guides/cold.html

Submitted by Heather L. Clemons, MS, MBA, ATC

Preventing Overuse Injuries in Youth Athletes

OVERUSE INJURIES IN YOUTH SPORTS

Sports participants of any age can suffer acute or overuse (chronic) injuries.  Acute injuries are those that happen unexpectedly to an otherwise healthy participant; examples include muscle strains, joint sprains, and fractures.  Overuse injuries are those that develop over time because of repetitive stress; examples include tendinitis, stress fractures, and “shin splints.”  Pediatric/adolescent overuse injuries are those repetitive stress injuries that are happening in participants under the age of 18.  There are approximately 30 - 35 million sports participants between the age of 5 - 18 (Soprano & Fuchs, 2007), causing a significant increase in the number of pediatric overuse injuries.  Studies have reported that overuse injures account for an estimated 50% of all athletic injuries, requiring twice as many visits to sports medicine physicians as acute trauma (Cuff, et al., 2010; McLeod, et al., 2011). There are also approximately 2.6 million emergency department visits in the United States for sports-related injuries for those between age 5 -24 years old, with the highest percentage being in males 5 - 14 years old (Soprano & Fuchs, 2007).

There has been significant focus on the prevention of pediatric overuse injuries because of their increasing occurrence and the potential for long-term rehabilitation programs and significant missed participation time (McLeod, 2011).  Youth athletes are participating in sports with developing skeletons leading to the possibility of growth plate injuries such as Osgood-Schlatter’s, Sever’s disease and others (McLeod, 2011; Soprano & Fuchs, 2007).  These conditions can cause significant pain and disability and are best treated by preventing them in the first place.  The exact causes for such repetitive stress injuries are unknown due to lack of research, but suggestions are that injuries can be the result of improper technique, training errors, excessive sport training, and muscle imbalances or weakness (McLeod, 2011).

Focusing on the prevention of these overuse injuries the National Athletic Trainers’ Association issued a position statement (April 2011) in an effort document the best practice to date on the prevention of pediatric overuse injuries.  The position statement addresses the following areas as key steps in preventing overuse injuries:

• Injury surveillance research
• Pre-participation physical examination
• Identify risk factors
• Coach education and medical supervision
• Sport alteration
• Training and conditioning programs
• Sport specialization

Overuse injuries are not life-threatening events, but they can be very painful and debilitating.  It is just as important for parents to understand how to prevent overuse injuries as it is to be prepared for an emergency.  Parents are critical in making sure that their children are getting an appropriate amount of rest and limiting the number of months during a given calendar year that they participate.  The amount of time spent participating in sports in a given calendar year is the biggest controllable risk factor for injury based on available research (Cuff, Loud & O'Riodan, 2010).  Given the growing number of private leagues and the continued availability of school sport programs athletes may also be participating in two sports concurrently.  Appropriate rest is necessary for proper recovery.  Parents should be sure their youth athletes are getting the necessary rest in a given athletics season and calendar year.

While the information provided by the NATA is a good jumping off point for parents, its intended audience is athletic trainers and other health care providers.  This begs the question, what resources are out there for parents who want to learn more about overuse injuries?  STOP Sports Injuries is a campaign and website developed by a coalition of organizations and corporations invested in preventing overuse and traumatic injuries in kids.  I have focused on this particular campaign because of the resources it makes available to parents.  There are educational resources available about a variety of injuries, tip sheets for preventing overuse injuries, and sport specific tip sheets just for starters.  There is also a blog, media resources and a repository of key position statements regarding the care of young athletes.  Simply click on “STOP Sports Injuries” link and look around.

REFERENCES:

Cuff, S., Loud, K., and O'Riodan, M.A. (2010).  Overuse injuries in high school athletes.  Clinical Pediatrics, 49(8):  731 - 736.  Available at http://cpj.sagepub.com/content/49/8/731.

McLeod, T.C., Decoster, L.C., Loud, K.J., Micheli, L.J., Parker, J.T., Sandrey, M.A., and White, C.(2011).  National Athletic Trainers' Association position statement:  Preventing pediatric overuse injuries. Journal of Athletic Training, 46(2):  206-220. Available at http://www.nata.org/sites/default/files/Pediatric-Overuse-Injuries.pdf.

Soprano, J.V. and Fuchs, S.M. (2007).  Common overuse injuries in the pediatric and adolescent athlete.  Clinical Pediatric Emergency Medicine, 8(1):  7 - 14.  Available at http://www.clinpedemergencymed.com/article/S1522-8401(07)00010-9/fulltext.

Submitted by Heather L. Clemons, MS, MBA, ATC