Page 103 - JSOM Summer 2023

Exercise for all people with diabetes is recommended due to required. Exercise and return to activity recommendations
improved morbidity and mortality benefits associated with for Type 3c DM are not defined as Type 1 and Type 2 DM,
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regular, moderate-intensity physical activity. This case is an and more research is required. This case report applied the
index case of an elite athlete with Type 3c DM; as such, there only existing clinical management guidelines for elite athletes
is a paucity of literature to guide return to physical activity that require insulin to include individualized, tailored aerobic
with pancreatogenic diabetes. Type 3c DM is similar to Type exercise, resistance training, and HITT workouts with use of
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1 DM in terms of insulin deficiency. Therefore, a strategy may continuous glucose monitoring to guide insulin adjustments.
be extrapolated utilizing Type 1 DM treatment recommen- Unfortunately, the diagnosis and treatment requirements have
dations from the 2022 American Medical Society for Sports precluded his return to full duty in the military and profoundly
Medicine (AMSSM) position statement on diabetic athletes impacted his quality of life.
and the American Diabetes Association (ADA) clinical prac-
tice guidelines. Disclosure
The authors have no financial disclosures.
Resistance training may reduce the acute risk of exercise-
related hypoglycemia and improves muscular strength and Disclaimer
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functional status. High-intensity interval training (HIIT) The views expressed in this article are those of the authors and
benefits both Type 1 and Type 2 diabetics, specifically regard- do not reflect the official policy or position of the Department
ing glycemic management, insulin sensitivity, and minimizing of the Army, Department of Defense, or the United States Gov-
hypoglycemic episodes. Prolonged aerobic exercise, such as ernment. All authors are military Servicemembers. This work
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marathon running, is possible in athletes with Type 1 diabetes was prepared as part of their official duties. Title 17 U.S.C.
but requires adjustments to pre-run insulin requirements. 6 105 provides that ‘Copyright protection under this title is
not available for any work of the United States Government.’
Most hypoglycemic events occur during, immediately after, or Title 17 U.S.C. 110 defines the United States Government
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up to 48 hours post-exercise. Hyperglycemia may also occur work as a part of work prepared by a military Servicemember
due to overconsumption of carbohydrates before or during ex- or employee of the United States Government as part of that
ercise, relative insulin deficiency, and intense exercise, such as person’s official duties.
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resistance training, due to a sudden release of catecholamine.
Hypoglycemic episodes following short-term hyperglycemic Author Contributions
episodes after exercise generally do not occur but are still a JA was the treating SOF medic and CR was the primary care
risk that requires monitoring. With Type 1 DM, utilizing HIIT physician coordinating the medical care described in this case
or resistance training for 30 minutes prior to an extended aer- report. All authors contributed to the development of this
obic exercise for up to 45 minutes may decrease the risk of a written case report with patient consent.
hypoglycemic event. 6
References
Due to the variability of Type 3c DM, it is critical to consider 1. Panchapakesan U, Pegg K, Gross S, et al. Effects of SGLT2 inhibi-
the patient’s current glycemic status as the patient performs tion in human kidney proximal tubular cells—renoprotection in
different exercises. As such, close monitoring of glucose levels diabetic nephropathy? PLoS One. 2013;8(2):e54442.
before, during, and after exercise is critical. Workouts should 2. Hart PA, Bellin MD, Andersen DK, et al. Type 3c (pancreatogenic)
diabetes mellitus secondary to chronic pancreatitis and pancreatic
occur in the morning to prevent episodes of overnight hypo- cancer. Lancet Gastroenterol Hepatol. 2016;1(3):226–237.
glycemia commonly seen after aerobic exercises later in the 3. Makuc J. Management of pancreatogenic diabetes: challenges and
day. Finally, athletes should have oral glucose and an emer- solutions. Diabetes Metab Syndr Obes. 2016;9:311–315.
gency glucagon pen while conducting aerobic exercises. 4. Hirsch IB, Gaudiani LM. A new look at brittle diabetes. J Diabetes
Complications. 2021;35(1):107646.
5. Army Regulation 40-501. Standards of Medical Fitness. 27 June
Conclusion 2019. https://armypubs.army.mil/ProductMaps/PubForm/Details.
aspx?PUB_ID=1004688. Accessed 10 May 2023.
This case describes the first case involving an elite athlete with 6. Trojian T, Colberg S, Harris G, et al. American Medical Society for
frequent fluctuations in insulin secretion and exertion-related Sports Medicine position statement on the care of the athlete and
hypoglycemic events, leading to a diagnosis of Type 3c DM athletic person with Diabetes. Clin J Sport Med. 2022;32(1):8–20.
secondary to an episode of acute necrotizing pancreatitis. Ad-
ditionally, this is the first case involving brittle diabetes asso- PMID: 37224391; DOI: 10.55460/XTQ3-78WA
ciated with Type 3c DM. Initial medical treatment for Type
3c DM includes oral glycemic control followed by insulin as

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