Basic Hydration Tips for Youth Athletes with Cystic Fibrosis and Diabetes

with  Shaun Grammer, MSPA, PA-C

While all children and adolescents have hydration needs - especially in hot and humid conditions - those with cystic fibrosis or diabetes need to pay extra care and attention to hydration.

Exercise protocols for CF

Cystic fibrosis (CF) is a genetic disorder that can affect all races but is most common in Caucasians, affecting approximately 1 out of 3200 children. It is often diagnosed at birth during newborn screening testing. However, if not detected during the screening, most cases are diagnosed by the age of 2 years.

The genetic mutation affects chloride and water transport. As a result, a person with CF will have thick mucus affecting several glands in the body. This can cause a chronic cough, recurrent lung infections, sinus infections, and nasal polyps. There will also be nutritional deficiencies due to blockage of pancreatic enzymes, which may present as fatty stools and poor growth and development.

One part of the treatment for cystic fibrosis is clearance of lower airway secretions. Current evidence suggests that people with CF may benefit from both aerobic and strength training exercises. In addition to the improved lung function, aerobic training may improve recovery following lung infections and improve clearance of lower airway secretions.

However, it is important to consider each person individually when developing an exercise protocol. Furthermore, cystic fibrosis requires an increased caloric and nutritional diet, which also must be considered in any exercise protocol.

Exercise and Type 1 diabetes

Diabetes mellitus type 1 is the form most often seen in children. It is often caused by the destruction of the insulin-producing cells of the pancreas resulting in an insulin deficiency. Without insulin, glucose (sugar) cannot move from the blood into the tissues that need it for energy.

The most common ages of diagnosis are between 4 to 6 years or 10 to 14 years. Children or teens with diabetes often present with an increased thirst, increased urination, and weight loss. Occasionally, they may present with a serious complication called ketoacidosis. Once diagnosed, insulin injections can maintain glucose levels successfully in the blood.

Exercise can have a major effect on the glucose levels of diabetics. It can lead to:

• increased absorption of insulin injections;
• decreased blood glucose due to increased energy demands; and 
• increased sensitivity to insulin.

As a result, the diabetic athlete may easily become hypoglycemic (low sugar) during exercise, and for up to 12 hours after finishing sports. With proper monitoring and medications, the diabetic athlete should not be restricted from participating in sports.

CF and Hydration

When young athletes with CF perspire during exercise, the sweat their bodies produce has a higher salt concentration. As a result, athletes with CF:

• Lose more sodium: When an athlete with CF finishes sports or recreational activity, they have lost more sodium from their body than the average athlete;
• Feel less thirsty: The thirst sensation in athletes with CF does not turn on as quickly as for other athletes, or may not be triggered at all. Experts speculate that this may be due to the excess sodium loss through sweat, but such a connection has not yet been established definitively through research. [Note: As far as we know, no new research has been conducted in active youth with CF looking into hydration concerns and solutions since 1999];
• Voluntarily drink less: Research shows that youth with CF drink 50% less than healthy counterparts when given water;
• Are more prone to dehydration: Youth with CF tend to become dehydrated even when given a typical flavored sports drink containing carbohydrate and sodium; and
• Don't find high sodium sports drinks "palatable." Youth with CF, when given a high sodium sports drink, drink more than when given a sports drink containing regular amounts of sodium, but don't like the taste.

Hydration Tips for CF Youth

• Flavored, high sodium sports drinks. Give CF athletes commercially available, flavored sports drinks containing carbohydrates and higher levels of sodium (see table below)
• Add salt to regular sports drinks. As an alternative, add ¼ teaspoon of salt to one quart of a regular sport drink (although, as noted above, the athlete may not like the taste).
• Be careful about pushing consumption beyond thirst. Don't necessarily push a child with CF to drink beyond thirst, but be aware of estimated fluid losses during a practice/game and replace as needed instead.

Hydration Tips for Diabetic Youth

While there is a notable lack of research on the hydration needs of active youth with diabetes (as far as we are aware), here are some general hydration tips:

• Same hydration advice as for typical child or teen: There is no research to suggest that youth with diabetes need to drink more or less than the typical healthy child. Simply address fluids lost during the practice, game, or recreational play
• No need for extra salt: Unlike youth with CF, youth with diabetes do not need to consume fluids with a higher salt content
• Watch out for hypoglycemia: Youth with diabetes can become hypoglycemic during, immediately after, or even hours after, exercise. 
• Sports drinks as needed: Youth with diabetes do need to consume fluids with the appropriate calories and sugar/carbohydrate ratios in order to regulate glycemic responses during exercise. This is dependent upon the youth's metabolic control and the intensity and duration of play.

Composition of Popular Hydration Beverages

Dr. Yeargin is Assistant Professor and Graduate Program Director in the Athletic Training Department at Indiana State University and MomsTeam's hydration expert.  Shaun Grammer is an Assistant Professor in the Department of Applied Medicine and Rehabilitation - Physician Assistant at Indiana State University working in family practice and pediatrics and as a Physician Assistant.

Sources:

1. Doorn NV. Exercise programs for children with cystic fibrosis: A systematic review
of randomized controlled trials. Disability and Rehabilitation. 2010; 32(1): 41-49.

2. www.cff.org

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4. Baker RD, Coburn-Miller C, Baker SS. Cystic fibrosis: Nutritional issues. UpToDate. 2010. http://www.uptodate.com/contents/cystic-fibrosis-nutritional-issues?sour.... Accessed June 18, 2011.

5. Levitsky LL, Madhusmita M. Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children and adolescents. UpToDate. 2011. http://www.uptodate.com/contents/epidemiology-presentation-and-diagnosis.... Accessed June 18, 2011.

6. Levitsky LL, Madhusmita M. Complications and screening in children and adolescents with type 1 diabetes mellitus. UpToDate. 2011. http://www.uptodate.com/contents/complications-and-screening-in-children.... Accessed June 18, 2011.

7. Bar-Or O, Blimkie CJ, et al. Voluntary dehydration and heat tolerance in cyctic fibrosis. Lancet 1992; 339:696-699.
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9. Zinman B, Ruderman N, et al. Diabetes Mellitus and Exercise. Med Sci Sport Ex 1997; 29(12): 1-6.