Managing Diabetes In Athletes
Medical Advances Aside, Treatment Still A Balancing Act
By Scott Robertson

Bob Clarke endured all manner of battles during a 15-year career in the National Hockey League. Ron Santo faced similar battles during a 15-year major league baseball career with the Chicago Cubs and Chicago White Sox.

Their toughest battles, though, were off the field. Both Clarke, a Hall of Fame center with the Flyers, and Santo, a standout third baseman with the Cubs, battled diabetes in addition to opposing goaltenders and pitchers. They have seen great advancements in diabetic care for athletes, many of which are occurring in Pittsburgh.

They both have seen Dan Stephens, a defensive lineman with the University of Pittsburgh football team, who regularly checks his blood sugar levels on the sidelines during games using a small monitor that, in seconds, tells him whether his sugar count is above or below normal levels.

"It's amazing the things they can do now," said Clarke, now general manger of the Flyers. "Back when I was playing, you tested your sugars with a stick by urinating on the stick. The change of color told you if you were high or low.

"Nowadays, they have all different types of insulins that can bring the sugar level down quickly. You've got the monitors that tell you immediately what the levels are. Back when I played, you pretty much had to go by how you felt."

The Illness

Diabetes is a dangerous illness that, according to the American Diabetes Association, affects some 17 million Americans. The disease occurs when the body does not produce enough insulin or cannot use it properly. Insulin helps the body conduct glucose into the body's cells.

If glucose, or sugar, cannot enter the cells, the glucose level in the bloodstream increases. Over time, the increased sugar levels in the blood can lead to damage of the heart, blood vessels, kidneys, eyes and nerves.

The disease has no cure, but early diagnosis, combined with proper treatment and good control, can prevent or at least delay the complications of diabetes, which is the fifth-leading cause of death by disease in the U.S. The disease kills more than 210,000 Americans per year, according to the ADA, and can lead to heart attack, stroke, blindness, kidney failure and amputations.

Santo, now a broadcaster of Cubs games on Chicago's WGN, has lost both legs to the disease. He played 2,243 games in the majors between 1960 and 1974, hitting .277 with 342 home runs and 1,331 RBI. He notes that athletes such as himself and Clarke faced the problem of increased activity which meant their blood sugar levels would be too low. They thus had to keep on hand a ready supply of candy bars or soft drinks, things that could put sugar into their bodies quickly.

"I was diagnosed in 1959 when I was 18-years old," Santo said. "No one knew what it was all about back then. I don't even know if any players had it. Jackie Robinson died (from complications of diabetes), but that was after his playing career. It was a tough thing to deal with."

Santo spent a month in the hospital after his initial diagnosis.

"It was like going to school from 8 in the morning until 4 in the afternoon," he said. "I tried to learn all there was to learn. But back then, they didn't have the technology they do now. You had to go by how you felt and if you were working out and felt low, you knew you needed to get some sugar into yourself."

Today, the situation is much different for athletes like Clarke, Santo, Portland Trail Blazers forward Chris Dudley, LPGA golfer Kelli Kuehne, PGA Tour star Scott Verplank and Jonathan Hayes, the South Fayette High School grad and former NFL tight end with the Kansas City Chiefs and the Steelers.

Dr. Wayne Evron, associate medical director of the Joslin Diabetes Center at West Penn-Allegheny Health System here in Pittsburgh, said most Americans with diabetes can help themselves greatly by exercising and keeping weight off. He said elite athletes, because of the demands of their sports, more often face the problem of hypoglycemia, or low blood sugar because of their high level of exercise.

"They use up so much sugar because of the level of activity they are involved in that it presents a unique challenge," Evron said. "A healthy lifestyle is the most important thing you can do to control diabetes. Most of the athletes are in good control of their sugars, so they are at no increased risk of injury—they can do anything anyone else can do. But they do have to be careful to watch problems with their feet—turf toe can be a big problem for a football player with diabetes, for example."

Blood circulation problems develop in many diabetics, such as Santo. The circulation problems prevent good blood flow to the lower extremities, leading to potential foot and ankle problems or, in Santo's case, the risk of leg amputations.

The Treatment

Evron, who worked with Clarke while he was a medical student at the University of Pennsylvania in the 1970s, says treatment and control options have improved greatly.

"The meters alone have come a long way," he said. "Now you have meters that can tell you your sugar level in 5 seconds. It used to take a minimum of 2 to 3 minutes. The meters are much faster and more accurate."

Insulin pumps, which automatically inject insulin into the bloodstream, are another advancement. The pumps are about the size of a cell phone and are ideal for athletes involved in non-contact sports such as golf; both Verplank and Kuehne use them.

"We've got new insulins that work much faster and new ways of monitoring sugars that give a more accurate reading," Evron said. "With the pumps, athletes can adjust their dosages more often."

Evron pointed out that there are two different types of diabetes—Type I, or insulin-dependent diabetes and Type II, in which people are not insulin-dependent. He said advances in eyelet cell transplants have been a major step forward in treatment of Type I diabetics. The transplants in many cases have been shown to work almost as well as an artificial pancreas. "It's not a cure by any stretch of the imagination, but it is a significant new treatment," he said. "We have seen no complications from that treatment—it's an important advancement."

Evron said exercise and lifestyle, specifically eating properly and working out, are the main courses of treatment for those with Type II diabetes.

"The big difference now compared to years ago is money," Evron said. "There are so many people in America with diabetes that a lot of money has been devoted to researching ways to treat it. We estimate that 8 percent of the (U.S.) population has diabetes—the numbers in Pennsylvania are higher because the population here is elderly. More people are being diagnosed.

"One of the problems now is that people are exercising less. People are going to the drive-through windows or sitting on their couches and using the remotes to change the channels on the television. Activity levels on the whole have gone down. People need to exercise more. That would be an important step in the right direction."

It is a step Clarke and Santo take regularly.

"I still work out every day," said Clarke, who scored 358 goals and added 852 assists for 1,210 points in 1,144 career games with the Flyers and won Stanley Cups as the team's captain in 1974 and 1975. "I do weights and aerobic training—you have to. When you are involved in professional sports, there is so much that you do naturally that it's beneficial to your health.

"When you leave the game, if you don't exercise, you are going to have big problems. The best thing you can do is to maintain an active training program."

Santo does the same despite the loss of his legs. He lost his right leg in December, 2001 and decided to have his left leg amputated in December, 2002 even though doctors told him the leg had a better than even chance of healing. He now walks using a cane and two prosthetics—one wrapped in the colors of the Cubs home uniforms, the other in the colors of the road uniforms.

"I remember when I was first diagnosed, I went into a gym and (worked out) and kept testing my symptoms," he said. "My doctor kept track of everything —he told me to tell him everything as it happened—I started out with a cold sweat, I got hungry and as I went on with the workout, my nose got numb and my eyesight was not so good. He wrote everything down.

"After about 15 minutes, I was white as a sheet. I couldn't understand what was happening. Finally, they took my sugar and then I knew, because it was so low. They told me that with travel, and with playing, I would have to be very careful. It really took me about four years to acclimate myself.

"The big thing was learning how to regulate the insulin along with exercise. I always had a Coke or a candy bar in the dugout with me in case I needed it. I was fortunate playing for the Cubs because we played most of our games during the day, and that made it easier to regulate with eating and lifestyle than it might have been if we played at night.

"Now the thing for me to do is keep a close eye on things and keep exercising. I've never stopped exercising. When I retired, I kept on going with the workouts. To me, that's the real key to managing diabetes."

Scott Robertson is an Associate Editor of the Pittsburgh Sports Report.