diabetes and exercise€¦ · checking your blood glucose before, during and after exercise will...

Diabetes and ExerciseMarcey Robinson, MS, RD, CSSD, BC-ADMRegistered Dietitian / Diabetes Educator

Sports Nutrition & Exercise Physiologist

Peter Gottlieb, MDProfessor Of Pediatrics And Medicine

Barbara Davis Center

2018 ATDC Conference:

Conflict of Interest

Marcey

I do not have any Conflicts of Interest to report.

I will not be speaking on off-label topics.

Peter

I do not have any Conflicts of Interest to report.

I will not be speaking on off-label topics.

Objectives:

The Science of Exercise

Incorporating Exercise Motivators/ Goals into Diabetes Management

Gone with Glucocentric Thinking

The Role of Record Keeping

Exercise vs. Physical Activity:

Physical Activity – an increase in metabolic activity beyond that at rest

Exercise – performing regular physical activity for the purpose of improving fitness and/or performance

BOTH can have an effect on glycemic control due to the effect on glucose metabolism.

The Science

Increased demand for glucose to fuel the working muscles

Blood Glucose

Energy Stores

Glycogen (highly variable, limited supply in liver/muscle)

FFA/Glycerol (almost limitless supply in fat)

Carbohydrate Intake

The body tries to adjust to fuel this demand

Hormones

i Insulin

h Glucagon

h Stress Hormones

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A BIT OF PHYSIOLOGY

Glucose control during aerobic exercise in Type 1 diabetes

ADRENALS

MUSCLE

LIVER

PANCREAS

↑ glucagon

↑ Stress hormones

BLOOD

Subcutaneous insulin - level dependent on what is given

Food maybe needed

The impact of Type 1 Diabetes on the physiological responses to exercise. Chapter 2 in Type 1 diabetes (2012), Clinical Management of the Athlete. Editor Ian Gallen.

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A BIT OF PHYSIOLOGY

Glucose control during anaerobic exercise in Type 1 diabetes

ADRENALS

MUSCLE

LIVER

PANCREAS↑↑↑↑↑↑↑

Stress hormones

BLOOD

↑ glucagon

Subcutaneous insulin - level dependent on what is given

May finish with high blood glucose

The impact of Type 1 Diabetes on the physiological responses to exercise. Chapter 2 in Type 1 diabetes (2012), Clinical Management of the Athlete. Editor Ian Gallen.

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During aerobic exercise:

Blood glucose tends to fall (unless insulin dose reduction is perfect – difficult to do)

During anaerobic exercise:

Blood glucose tends to rise (unless insulin has been increased by correct amount)

During mixed exercise:

Blood glucose levels can go or

8

A BIT OF PHYSIOLOGY

Exercise on glucose control and Type 1 diabetes

Checking your blood glucose before, during and after exercise will enable you to see your own response to

different sports

Universal Goals for Exercise &

Diabetes Management

Prevent hypo/hyperglycemia during and after exercise

Achieve adequate fueling/hydration

Optimize performance

“Perform” activity/exercise successfully: avoid early

cessation due to hypo/hyper, feel strong, increase fitness,

finish or win an event

Normal Blood Glucose AND

Performance

Exercise Motivators

Why do you participate in PA/Exercise?

#1 Weight

Loss/Health

Stress Relief

Bone Health

#2

Improve

Fitness/Sport

PerformanceIncreased Energy

I Was Told I Have To

Improve Diabetes Management

Goals for Diabetes Management

Physical Activity/Exercise:

Weight loss or Health

Minimize Extra Fuel

Burn more stored calories

Efficiency (Prius)

Planned Exercise is Best

Prioritize Medication /Insulin Reduction

Reduce need to eat to maintain BG control

Goals for Diabetes Management

Exercise: Fitness/Sport Performance

“Athlete” in Training

Maximize Extra Fuel

Allow for high energy turnover

Fuel Hog (Toyota Tundra V8)

Prioritize Fuel with Medication/Insulin to Match Needs

May not need to reduce meds/insulin but instead allow for increased carb intake

Use a “Working Plan” individualized for each workout

Goals for Blood Glucose

Blood Glucose Glucose + Insulin Performance

(mg/dl) Metabolism Impact

< 70 BG too low Fatigue

for cell fuel needs i Performance

70-180 Efficient fuel use Optimal

Performance

> 180 BG will i if i Performance

Insulin levels OK

> 250 BG may h or i Fatigue

i Performance

Jimenez C, J Athletic Training 2007; 42:536-45

Blood Glucose Monitoring Guidelines

Before Exercise

Measure BG 2-3 times 30 minutes apart to determine trend

During Exercise

Measure BG every 30 minutes, if possible.

After Exercise

Measure BG 2 hr and 4 hr post-exercise for those who experience post-exercise late-onset hypoglycemia and at night for who experience nighttime hypoglycemia

CGM Changes Paradigm

► Before exercise can adjust basal and bolus insulin as well

as food intake to optimize pre-exercise BS.

► During exercise, can help to pick up trends and adjust

basal and food intake to avoid lows and highs.

► After exercise, can help with adjustments for post-

exercise BS excursions in either direction.

Factors That Effect BG During

Exercise

Active Insulin / Medication

Nutritional State (Fasted vs. Fed, High Carb vs. Low Carb Diet)

Intensity/Type (Aerobic vs. Anaerobic)

Duration

Fuel & Hydration

Level of Training

Effect of Stress (Heat, Competition)

BG History/Recent Hypoglycemic Event

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BLOOD GLUCOSE CONTROL DURING EXERCISE

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John decides to run 1 hour after lunch

His starting blood glucose levels are between 126-162 mg/dL

He consumes 80g of carbohydrates for lunch and takes 8 units of insulin

During the run his blood glucose falls

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CASE #1 – BLOOD GLUCOSE CONTROL DURING EXERCISE

John

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CASE #1 – BLOOD GLUCOSE CONTROL DURING EXERCISE

John’s training day blood glucose levels

Lunch +8 units insulin

Start of exercise

108

144

180

216

7236

12:0011:30 12:30 13:00 13:30 14:00

Time of day

SMB

G (

mg

/dL)

SMBG, self-monitoring blood glucose

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Three ways to manage drop in blood glucose

Adapt exerciseregime

3

Take carbs

1

Reduce insulin

2

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Basic ExCarb estimate:

15g carbohydrate per 30 minutes of exercise

Example:

John exercises for 60 minutes

= 15g at start and 15g at 30 minutes

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Extra carbs for exercise (ExCarbs)

Semi-quantitative estimate:

Takes into account body weight

1g carbohydrate/kg/hr exercise

Example:

John weighs 90 kg (198.4 lb) and exercises for 60 minutes

= 30g at start, 30g at 30 minutes and 30g at finish

Basic rule:

30g of carbohydrate per hour of exercise

Weight calculated 1g/kg/hr

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Simple algorithm for carbohydrate replacement

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Have you had a severe hypo in the past 24 hrs?

Do not exerciseCheck BG

No*Yes

<63mg/dL

63-90 mg/dL

>270 mg/dL91.8-144mg/dL

145.8-270 mg/dL Ketones: +’ve

CorrectiondoseKetones: -’ve

30%Correctiondose

Proceed to exercise

Additional10g Carb

20gCarb

Re-checkat 15 minto ensureBG rises

Wait 45 min beforeexercising

20gCarb

Wait15 min

*If you have had a hypo in the last 24 hours but not severe, risk of hypo is higher. Be sure to:- Take extra precautions- Do not do lone events on this day**Other ways of calculating glucose can be used:- Based on weight 1g/kg/hr- Based on tables for sport

!

Before exercise:Consume meal with normal insulin at least 2 hours prior

During exercise: 15g carb per 30 min exercise**

After exercise (if > 1 hour): 1g carb/kg + 20-25g protein

BG, blood glucose; hypo, hypoglycemia; Carb, carbohydrate

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Continous Glucose Monitoring (CGM) and carbohydrate intake algorithm to reduce/avoid hypoglycemia while exercising

CGM Glucose level Trend arrow(s) Action Comments

<90 mg/dL(5.0 mmol/L)

None or downward trending

16-20g CHO

Stop exercise if blood glucose

≤ 70 mg/dL(3.9 mmol/L)

91-110 mg/dL(5.0-6.1 mmol/L)

MedtronicDexcom

16g CHO

91-110 mg/dL(5.0-6.1 mmol/L)

MedtronicDexcom

20g CHO

110-124 mg/dL(6.1-6.9 mmol/L)

Any downward trending arrows

(both manufacturers)8g CHO

Note: Treatment of hypo or hyperglycemia should not be based solely on CGM. Self monitoring of blood glucose level is recommended. Carbohydrate (CHO) intake is generally recommended for long duration aerobic exercise for performance reasons (~1g/kg body mass per hour). 70.2 mg/dL = 3.9 mmol/L; 90 mg/dL = 5 mmol/L; 109.8 mg/dL = 6.1 mmol/L; 124.2 mg/dL = 6.9 mmol/L

or

Medtronic Guardian® Real-time CONTINUOUS GLUCOSE MONITORING SYSTEM User Guide, ©2006, Medtronic MiniMed, Inc.Dexcom G5™ Mobile CONTINUOUS GLUCOSE MONITORING SYSTEM Quick Start Guide, © 2015 Dexcom, Inc

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INSULIN MANAGEMENT AND EXERCISE

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Effect of reducing bolus insulin dose on liver glucose production when exercising

Normal insulin dose

Reduced insulin doseR

elat

ive

insu

lin

effe

ct

Time (h)

2 hourspost-meal

Less glucose from liver

More glucose from liver

Adapted from: Lumb AN & Gallen IW. Curr Opin Endocrinol Diabetes Obes. 2009 Apr;16(2):150-5.

Suggest reducing bolus (fast acting) insulin by 50% if exercising within 2 hours

of meal.

Adjust future reduction for exercise based on response.

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Simple algorithm for insulin adjustment

Have you had a severe hypo in the past 24 hours?

Do not exercise

Check BG

No* Yes

63-90 mg/dL

>270 mg/dL

145.8-270

mg/dL

Ketones: +’veCorrectiondose

Ketones: -’ve30%Correctiondose

Proceed to exercise

20gCarb

20gCarb

Wait15 min After exercise:

− 50% normal insulin ratio for meal− 50% normal correction dose

− 20% reduction in night time long-acting insulin

Before exercise:− Consume meal with 50% less insulin**

− Start exercise within 1 ½ hours of meal (best to start 30 min after)

*If you have had a hypo in the last 24 hours but not severe, risk of hypo is higher. Be sure to:- Take extra precautions- Do not do lone events on this day** Other ways of calculating insulin reduction:- Based on intensity of exercise- Based on carb ratio

!

Additional10g Carb



26BG, blood glucose; hypo, hypoglycemia; Carb, carbohydrate

<63 mg/dL

91.8-144

mg/dL

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Reducing pre-meal bolus insulin before exercise

Riddell MC, et al. Lancet Diabetes Endocrinol 2017 Published Online January 23, 2017 http://dx.doi.org/10.1016/S2213-8587(17)30014-1

Exercise intensity (% VO2max)

% Dose reduction

30 min of exercise 60 min of exercise

25 25 50

50 50 75

75 75 100

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Blood glucose Action

Low blood sugars during exercise • Temporarily lower basal rate starting 1 hour before by 50% • If eating within 2 hours before exercise also reduce bolus by 50% • Adjustments for future exercise will depend on result

High blood sugar post-exercise

(this is rare, but can happen with weight programs or stop-start events like tennis and squash)

• Temporary higher basal rate just before and during• Be sure to reduce once nearing end of event

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Options for pump users during exercise

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Simple algorithm for changes to pump with exercise

Have you had a severe hypo in the past 24 hours?

Do not exerciseNo* Yes

Ketones: +’veCorrectiondose

Ketones: -’ve30%Correctiondose

20gCarb

20gCarb

Wait15 min

After Exercise:− Use 50% of correction and bolus for first 6 hrs after exercise− If exercising after 4pm reduce basal insulin by 10% for first 4

hours (or for entire night after high intensity anaerobic exercise)

Before exercise:− Reduce fast acting insulin by 50% if within 1-2 hours of exercise

− Reduce basal insulin by 50% from 60 minutes prior until to end of exercise

*If you have had a hypo in the last 24 hours but not severe, risk of hypo is higher. Be sure to:- Take extra precautions- Do not do lone events on

this day**Other ways of calculating glucose can be used based on tables for sport

!

Additional10g Carb



29

During exercise: 15g carb per 30 min exercise**

BG, blood glucose; hypo, hypoglycemia; Carb, carbohydrate

<63 mg/dL

63-90 mg/dL

91.8-144

mg/dL145.8-

270 mg/dL

>270 mg/dL

Check BG

Proceed to exercise

Insulin – Too High

If Insulin levels are too

high………

(Over-insulinized)

Blood glucose levels can

drop too low

Symptoms

Early, rapid-onset fatigue

Potential loss of coordination

Reduced strength and endurance

Suboptimal performance

May/may not feel like typical hypoglycemic symptoms.

Blood

Glucose

Levels

Insulin – Too High

Causes:

Oral Medication (Glyburide, Glipizide,

Amaryl, Starlix, Prandin)

Bolus Insulin (2-4 points/min)

Basal Insulin (.5-1.5 points/min)

Inadequate Fueling

Hx of Hypoglycemia

Blood

Glucose

Levels

Insulin – Too Low

If Insulin levels are too

low………

(Under-insulinized)

Blood glucose levels can

rise too high

Symptoms

Fatigue (“Heavy legs”,

“Hitting the Wall”)

Headache

Nausea/Cramping

“Just not right”

BG’s may be moderately

high, but could be

normalInsulin Deficiency / DKA

Blood

Glucose

Levels

Insulin – Too Low

Causes:

Large Basal reduction (unintentional/intentional)

Bolus avoidance

Inappropriate Fueling

Timing/amt of carb intake in relation to glucose

utilization

Psychological Stress/Fear

Blood

Glucose

Levels

Tips for Bolus Insulin Adjustments: (Not to replace consultation with full healthcare team)

Pay attention to IOB (greatest contributor to BG within 1st hr of exercise)

Pre-Exercise Meal Boluses:

Short/intense, 0% - 25%

up to 25%, ~3+ hrs after meal

up to 50%, ~2 hrs after meal

75 - 100%, < 1 hr after meal

During Exercise bolusing:

Not preferred

Mini-boluses

Technology Considerations:

Avoid uncovered carbs with Auto Mode - Medtronic 670G

Tips for Basal Insulin Adjustments: (Not to replace consultation with full healthcare team)

For Exercise >90 min:

Pump: basal rate up to 50% starting ~ 90 min prior and ending with end of exercise/~ within last 90 min

Evaluate need to extend temp basal for up to 24 hrs post endurance exercise

For Auto Mode – Medtronic 670G, increase temp target ~90 min prior and consider brief suspend if needed; can extend temp target overnight

Lantus/Levemir: Prior to prolonged exercise, injected basal up to ~25%

Nutritional State

Fasted vs. Fed State

Impact of Time Interval from the Last Meal on Glucose

Response to Exercise in Subjects with Type 2 Diabetes*

PAUL POIRIER†, ANGELO TREMBLAY, CLAUDE CATELLIER, GILLES TANCRE` DE,

CAROLINE GARNEAU, AND ANDRE´ NADEAU. The Journal of Clinical

Endocrinology & Metabolism Vol. 85, No. 8

19 Men with Type 2 diabetes treated with diet and oral

hypoglycemic agents

Copyright ©2000 The Endocrine Society

Glucose levels before and after 1 h of ergocycling at 60% of VO2peak based on the time interval from the last meal .

Poirier, P. et al. J Clin Endocrinol Metab 2000

Nutritional State

Nutritional Status

Low Carb Diet

Lower glycogen stores

If also using Auto Mode – Medtronic 670G, will likely

have more aggressive basal insulin delivery and

require greater reliance on carbohydrate intake

during moderate/intense exercisePotential for increased risk of Hypoglycemia during moderate intensity / longer duration exercise

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CASE #2 – BLOOD GLUCOSE CONTROL IMMEDIATELY AFTER EXERCISE

Option 1: Exercise

Weightlifting, Tag

Sprinting, Diving, Swimming, Gymnastics,

Wrestling, Dodge ball, Volleyball, Ice hockey, Track cycling

Basketball, Football, Tennis, Lacrosse

Skating

Skiing (slalom & downhill), Field hockey

Rowing (middle distance)

Running (middle distance)

In-line skating

Cross country skiing

Brisk Walking

Jogging

Cycling

Warm down

hypoglycemia

hyperglycemia

ANAEROBIC

Short duration

High-intensity

AEROBIC

Longer duration

Lower Intensity

Duration –

Tips for Exercise < 60 min

Minimal basal insulin adjustment is necessary at moderate intensity

Ideally, exercise >3 hrs after a bolus, may need to decrease bolus amount

Test blood sugar before/during/after exercise (more important if exercise is “new”)

Consider pre-exercise snack based upon starting blood sugar and time since last meal

Duration –

Tips for Exercise > 60 min

Endurance Exercise – fueling is necessary

Be Proactive vs. Reactive

Make a plan (fuel & insulin) and then prepare for the unexpected

Ideally, exercise >3 hrs after a bolus, may need to decrease bolus amount

Test blood sugar before/during/after exercise

You may need extra food or basal insulin adjustments 24-36 hrs after exercising depending on duration

Fueling Exercise

Pre Exercise Ideally eat 3+ hrs pre-exercise, 50 gms carb for each hr (if early am, ~½

of liver glycogen is depleted)

During Exercise (< 60 min) None/minimal additional carbs

During Exercise (> 60 min) Start within the 1st 30-60 min of exercise, consuming 30-60 gms per hr

(0.7 g/kg)

Use carbohydrates to FUEL performance and avoid Bonking / Hitting the Wall AND hypoglycemia

For those with diabetes/untrained/new to exercise, carbs may

need to be consumed for ALL exercise regardless of duration.

Fueling Exercise

After Exercise > 90 min +

Early ingestion may decrease risk of hypos later on

(nocturnal hypoglycemia)

½ gm carb/lb body weight within 2 hrs (best if

consumed in a balanced meal, ~20-30 grams protein)

If exercising less than 90 min, eat adequate

carbohydrate at next meal

Must have adequate insulin

Consider referral to a sports dietitian

Hydration

Water aids digestion, lubricates joints, transports

nutrients to working muscles, removes waste

products (CO2, lactate), regulates body temp

Dehydration can raise blood glucose

(decreased blood volume)

Hydration

Pre Exercise

2 cups within 2 hrs of exercise

During Exercise

½ -1 cup every 15-20 min, a least 1 standard water bottle/hr

Water vs. Sports Drinks

Sodium helps to reduce diuresis that can occur with plain water

Sports drinks for exercise > 60 min or high intensity

After Exercise

Replace water lost through sweat

2 cups (16 oz) / pound

Additional Variables –

Training Level - less trained for the sport, greater effect on blood glucose

Effect of Stress (Heat, Competition)

Perception

Stress hormones will cause ↑ in BG

Insulin Sensitivity

Recent Hypoglycemic Event

Menstrual cycle

Alcohol intake

Individualized Exercise Response

Encourage BG testing every ~ 30 min starting 1 hrprior to exercise and throughout (for endurance, test frequently for 24-36 hrs)

CGM and/or Auto mode can be invaluable

Record Keeping

Evaluate and Re-evaluate: Meds, Basal Insulin, C:I ratios/CF, effect of time of day, effect of specific exercise, effect of stress hormones, fueling strategy

Each exercise session has different variables

Utilize software/CGM & Pump reports

GET HELP (CDE, Sports Dietitian)

Case Study

Suzy, 34 years old, type 1 diabetes for 13 years, on an insulin

pump for 6 years, CGM for 2 yrs, recent A1C = 7.1%

Goal = Performance (competitive Triathlete)

Well educated, counting carbs

Training 6-12 hrs/wk, 1-6 hrs per day, often 2/day

What do you think?

Time BG Exercise Insulin Food

5 am 76

7 am 73

8 am 1078:45 – 11

Bike

(2hr,15min)

10% Basal

8:30 – 10 am10 am 110

11 am 105 1 gu (25 g C)

Noon 107 12-12:50

Run

(50min)

1 pm 101

2 pm 105

3 pm 152

7 pm 74

11 pm 122

Practical take-Home Pearls

Goals for Diabetes & Exercise = BG control & Performance

If HEALTH is the motivator, encourage planned, regular

exercise, minimal IOB, reduce insulin/medication

If PERFORMANCE is the motivator, prioritize fueling and a

flexible plan for insulin adjustments to support it

Address changing exercise session variables to reduce

frustration

Practice for Progress not Perfection

Thank you!

FOR MORE INFORMATION ABOUT JDRF PEAK EXERCISE PROGRAM

HTTP://WWW.JDRF.ORG/T1D-RESOURCES/PEAK/

http://www.jdrf.org/t1d-resources/peak/

diabetes and exercise€¦ · checking your blood glucose before, during and after exercise will...

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