managing glucose before, during and after exercise in type 1 diabetes rob andrews university of...
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Managing glucose before, during and after exercise in type 1 diabetes
Rob Andrews
University of Bristol/
Taunton and Somerset Foundation Trust
Fitness
Insulin requirement
Lipids
Endothelial function
Mortality
Blood pressure
Beta cell function
Glycaemic control
Fitness
Insulin requirement
Lipids
Endothelial function
Mortality
Insulin resistance
CVD
Wellbeing (only children)
Microvascular
complications
Osteoporosis
Cancer
CVD
Wellbeing
Microvascular
complications
Osteoporosis
Cancer
Beta cell function
Blood pressure
Glycaemic control
Beneficial
Uncertain/ Limited data
Physical activity
Type 2 diabetes
Type 1 diabetes
Beneficial
Uncertain/ Limited data
So what do Specialist in Diabetes know about exercise and diabetes?
The va
lue o
f exe
rcise
Types
of ex
ercise
Exerci
se in
tensit
y and
durat
ion
Effect
of ex
ercise
on bl
ood g
luco
se
Whe
n it i
s safe
to ex
ercise
Insu
lin ad
justm
ent f
or ex
ercise
Diet &
flui
d rep
lacem
ent f
or ex
ercise
Carboh
ydrat
e cou
ntin
g
0
10
20
30
40
50
60
70
Very confidentBroadly confidentNot so confidentNot confident at all
Result of survey of diabetes HCP – No 138
Exercise and blood sugar
HCP knowledge on what to do with high BG (>13), and slightly low 3.6 was good but
• 75% HCP did not know what to do with patients who had has severe hypo night before
• 50% HCP did not know what to do with BG of 5.5• 75% did not know what to do with blood sugar of
1.8
Doctors no better than nurses or dietitians.
Exercise and insulin
Fast acting insulin• 1/3 of HCP not clear as what should be done with fast
acting insulin if exercising 2 hours after a meal• 55% HCP not sure what should be done with fast
acting insulin if exercise before breakfast
Long acting insulin• 50-80% HCP (dependent on time of day) not knowing
what to do with background when exercising
Doctors significantly worse than nurses or dietitians.
Exercise and injection sites
Where to inject• 1/3 of HCP did not know the injection sites that
should be avoided when cycling or lifting weights.
Doctors no better than nurses or dietitians.
What you need to know
• Type of exercise
Aerobic exercise
Aerobic exercise
is physical exercise of relatively low intensity that depends primarily on the aerobic energy-generating process.
Aerobic
• Hiking • Golf • Road cycling • Cycle tour • Mountain biking • Distance running • Distance swimming • Triathlon, etc
Anaerobic exercise
Anaerobic exercise is exercise intense enough to trigger use of non oxygen using metabolism. It normally last less than 2 minutes
Anaerobic exercises
• Weight lifting• Body Building• Dressage• Fencing• Track and field events
(Javelin, Shot put, Long jump, Pole-vault, High jump, Sprinting)
• Archery• Wrestling
Hormonal response to exercise - 1
40 80 120
160
RecoveryExercise
Horm
on
e c
on
cen
trati
on
GHCortisol
GlucagonTestosterone
NoradrenalineAdrenaline
Time (min)Baseline 0 20 40 60
Gro
wth
Ho
rmo
ne C
on
cen
trati
on
(
g.l-
1 )
0
10
20
30Exercise
or
Rest
#
#
caa
Time (min)Baseline 0 20 40 60
Gro
wth
Ho
rmo
ne C
on
cen
trati
on
(
g.l-
1 )
0
10
20
30Exercise
or
Rest
#
#
ca
Time (min)Baseline 0 20 40 60
Gro
wth
Ho
rmo
ne C
on
cen
trati
on
(
g.l-
1 )
0
10
20
30Exercise
or
Rest
#
#
caa
Hormonal response to exercise - 2
RestResistance
Sprint
Endurance
Kate L. Gilbert et al 2008
Hormonal response to exercise - 3
Aerobic
Anaerobic
Summary 1
• With Aerobic exercises blood sugars will tend to fall.
• With anaerobic exercise blood sugars will tend to rise
What you need to know
• Type of exercise• Intensity of the exercise
Hormonal response to exercise - 4
Exercise intensity
0 20 40 60 80 100
V02 max
Hor
mon
e co
ncen
trat
ion
Dependent
• Exercise intensity• Type of exercise• Competition• Body temperature• Age• ? Blood glucose
Independent
• Circadian rhythm• Meal time• Menstrual cycle • Sex
Fuels used during exercise
Lactate during exercise
Insulin in response to different exercises
E F
0
2
4
6
8
10
12
14
16
18
20
-10 0 10 20 30 40 50 60
time (min)
seru
m insulin
(m
IU/l)
b
c
pre- end
SprintWeight trainingEndurance
Summary 2
As the intensity of exercise rises • Glucose becomes the major fuel• Lactate levels rise• Insulin levels rise to compensate for this
Cardiovascular response to exercise
120
140
160
180
200
60
80
100
120
140
160
Hea
rt r
ate
Sys
tolic
BP
Rest Exercise Recovery
Borg Scale
7 >1686 1311 15149 10 12
Under 6 = Rest
Over 16 = Very Heavy
Very Light Light Moderate Heavy
<90bpm ~100-110bpm ~120-130bpm 146-160bpm
Summary 3
• Exercise induced HR rise is Less in patients
with Type 1 Diabetes
• Thus using Predicted HR for training is not
very useful in patients with Type 1 Diabetes
• One helpful scale that can be used is the
borg scale
What you need to know
• Type of exercise• Intensity of the exercise• The length of the exercise
Normal response to exercise
GH and Cortisol rise
Activation of CNS
Insulin levels fall
Glucagon levels Rise
Adrenaline levels Rise
Prepares bodyInsulin resistance
Increased lipolysisIncreased glucoseOutput
Pre
Exercise
Hormones during exercise.
TG
FFA’sGlycerol
Glycogen
Glucose Glucose
CortisolAdrenaline
NoradrenalineGH
Amino acids
CortisolGlucagon
AdrenalineNoradrenaline
Glucagon
MuscleLiver
Glucose
Insulin
PyruvateCo2
T4T3
Summary 4
Fuel for exercise comes from three sources
• Muscle (few minutes)
• Liver (40 minutes)
• Fat breakdown
And is under the control of hormones
Response to exercise in diabetics
GH and Cortisol rise
Activation of CNS
Insulin levels fall
Glucagon levels Rise
Adrenaline levels Rise
Prepares bodyInsulin resistance
Reduced lipolysis and decreased glucose output
Pre
Exercise
Hormones during exercise in diabetes.
TG
FFA’sGlycerol
Glycogen
Glucose Glucose
CortisolAdrenaline
Noradrenaline
GHAmino acids
CortisolGlucagon
AdenalineNoradrenaline
Glucagon
MuscleLiver
Glucose
Insulin
PyruvateCo2
T4T3
Summary 5
• In patients with T1DM less fuel comes
from the liver and fat, with the fat more
effected than the liver.
• So glucose may be needed for short bouts
of exercise and definitely will be needed
for longer durations of exercise
What you need to know
• Type of exercise• Intensity of the exercise• The length of the exercise• When they are exercising in relation to
their fast acting insulin
Insulin Sensitivity: 1922 Lawrence
0
2
4
6
8
10
12
14
30 60 120 240
Time mins
Pla
sma
glu
cose
mm
ol.
l-1
No InsulinInsulin
Actrapid or Humulin S
Novorapid or Humalog
Different insulin regimes
0 2 h 4 h 6h
Hypo risk
Hypo
Summary 6
• Glucose falls quicker during exercise
when insulin is around.
• Adjustments in insulin or glucose intake
will thus need to be made if exercising
within 2-4 hours of taking insulin
What you need to know
• Type of exercise• Intensity of the exercise• The length of the exercise• When they are exercising in relation to their
fast acting insulin• What time of day they are exercising
Changes in insulin sensitivity with exercise
Changes in glucose with exercise
Summary 7
Insulin sensitivity increases
• During exercise
• For an hour after exercise
• At 6-8 hours post exercise
Glucose thus needs to be watched at 2
time points
How to do it!
Step 1: Dietary intake
Diet
33 yr female, diagnosed type 1 DM age 16
Training for a triathlon
Weight currently 63 kg, height 1.65 m
Her current problems – dips and highs in glucose levels and running out of energy in training.
3 February 2012 Janet Gorton Diabetes Specialist Dietitian Taunton & Somerset NHS Foundation Trust
Food diary
Breakfast - 40g (bowl) whole oats, 100 ml skimmed milk & water, small banana, actimel
1 hr training - refuel 350ml flavoured sk milk
Lunch - Egg s’wich, 1 slice toast , 200g baked beans
1 hr 45 training/yoga - refuel 200ml sk milk, 500ml water
Dinner - Liver, bubble & squeak, yoghurt, herbal tea3 February 2012 Janet Gorton Diabetes
Specialist Dietitian Taunton & Somerset NHS Foundation Trust
Energy Expenditure
• Most athletes expend
45-50 kcal/kg body weight
• 63kg 2835 – 3150• 90kg 4050 – 4500 kcals
• Other factors
3 February 2012 Janet Gorton Diabetes Specialist Dietitian Taunton & Somerset NHS Foundation Trust
3 February 2012 Janet Gorton Diabetes Specialist Dietitian Taunton & Somerset NHS Foundation Trust
14 -16 pints skimmed Milk63 kg
Carbohydrate requirements body mass, exercise intensity & duration
Training LoadCHO
Recommendations
Very light training
(low intensity exercise or skill-based exercise)3-5 g.kg-1.day-1
Moderate intensity exercise for 1 hr/day 5-7 g.kg-1.day-1
Moderate to high intensity exercise for 1-3 hrs/day 6-10 g.kg-1.day-1
Moderate to high intensity exercise for 4-5 hrs/day 8-12 g.kg-1.day-1
2010 International Olympic Committee (IOC) Concensus statement on Sports Nutrition
*Burke, L.M., (2010)
Hormones post exercise.
TG
FFA’sGlycerol
Glycogen
Glucose Glucose
Amino acids
MuscleLiver
Glucose
PyruvateCo2
Insulin
CortisolGH
Cortisol
Insulin
Recovery
• Protein and Carbohydrate together improve glycogen storage 2 hours post exercise
• 4 carb : 1 protein• 20-25 g protein optimal• Total 1.2g/kg
3 February 2012 Janet Gorton Diabetes Specialist Dietitian Taunton & Somerset NHS Foundation Trust
Step 2: Starting blood sugars
Case 1 - starting blood sugar
Rob is a keen runner
When he gets up for his morning run his blood sugar is 3.5. What would you advice?
If he had had hypo over night would this change your management?
Starting blood sugars
Has Blood sugar been <3.5 in last 24 hours?
Do not exerciseCheck BG
No Yes
<3.5 3.5-5.6 >145.7-6.9 7.0-14
20 gCarb
Wait45 min
Recheck BM
20 gCarb
Wait15 min
Ketone PosCorrectionDose
Ketone Neg30%CorrectionDose
Proceed to exercise
Additional15 gCarb
15g Carbohydrate
• 3 jelly babies• 160 ml fruit juice• 9 jelly beans• 5 fruit pastilles• 250 ml 6-8% carbohydrate sports drink• 2 wine gums• 1 mini can cola• 1 fruit lolly
3 February 2012 Janet Gorton Diabetes Specialist Dietitian Taunton & Somerset NHS Foundation Trust
Step 3: Starting advice
Case 2 -training for marathon
John is 26 and has had type 1 diabetes for 3 years and is on mixtard 30 22/24.
He does little exercise but is keen to do the london marathan in 6 months time.
What advice would you give him?
Options
Insulin regime
Injection sites
Size of needles
Overall diet
Carb loading
Carb replacement during exercise
10 Second Sprints
Replenishment post exercise
Alteration insulin dose pre exercise
Alteration insulin dose post exercise
Bolus insulinCarb during exercise
Case 2
Change insulin to QDS.
Access dietary needs.
Advice about starting glucoses
Advice about carb Ex
3 strategies
• Additional carbohydrate
• Insulin reduction
• Combination of both
Basic strategy Ex carb estimate
• 15g carbohydrate per 30 minutes exercise. • Add on half time exercise for recovery
Example – Mark exercises for 60 minutes. So takes 15g at start, 15g at 30 minutes and 15g at end
Semi -quantitative strategy for Ex carb estimate
• Takes into account body weight• 1g glucose/kg/hr exercise
Example – Mark weighs 90 kg and exercises for 60 minutes.
So takes 30g at start, 30g at 30 minutes and 30g at end
Quantitative strategy for Ex carb estimate
• Takes into account body weight and intensity of exercise
• Uses tables or CGM readings.
Example – Mark weighs 90 kg wants to cycle for 1 hour at average 18 miles per hr.
Semi -quantitative strategy for Ex carb estimate
Quantitative strategy for Ex carb estimate
• Takes into account body weight and intensity of exercise
• Uses tables or CGM readings.
Example – Mark weighs 90 kg wants to cycle for 1 hour at average 18 miles per hr.
Need 165 grams so 40 grams start, 40 grams 30 minutes and 85 grams at end
Simple startDo not exerciseCheck BG
<3.5 3.5-5.6 >145.7-6.9 7.0-14
20 gCarb
Wait45 min
Recheck BM
20 gCarb
Wait15 min
Ketone PosCorrectionDose
Ketone Neg30%CorrectionDose
Proceed to exercise
Additional15 gCarb
Post exercise if BG > 14 mmol/l give 30% usual correction and test 2 hours laterIf exercising evening reduce background by 10%
Replace Carb as perChoice of regime
Step 4: More complex advice
Case 2
John is now on a basal bolus regime of novorapid 6-10 TDS and Levemir BD 12/10. He has started to run 3 times a week but finds it difficult to run more than 30 minutes and is having frequent hypo during his runs.
What advice would you give him?
Options
Insulin regime
Injection sites
Size of needles
Overall diet
Carb loading
Carb replacement during exercise
10 Second Sprints
Replenishment post exercise
Alteration insulin dose pre exercise
Alteration insulin dose post exercise
Bolus insulinCarb during exercise
Reducing pre-meal bolus insulin before exercise
Exercise intensity (% VO2max) % Dose reduction
30 min of exercise 60-min of exercise
25 25 50
50 50 75
75 75 -
Rémi Rabasa-Lhoret Diabetes Care 24: 625-630
More complex strategy for insulin
Working out how much need to reduce by - Work out how many grams you will burn - Decide how much carbs you will take- Divide difference by carb/insulin ratio to
calculate reduction in insulin required.- Then decide how you will make this reduction.
Can be done by- Reduction bolus- Reduction background- Combination
Example bolus reduction
Mark wants to cycle for one hour after breakfast. He normal takes insulin in ration 6:1. For breakfast he has 90 grams of carbohydrate. On his ride he will consume 60grams of carb.
• Difference is 90-60 – 30 grams• So needs to take insulin to cover 30 grams – 5
units, as opposed to his normal 15 units.
Example combined reduction
Mark plans to play golf 3 hours after breakfast. The calories he will burn on the round is 144 grams.
Whilst on the round he will take 30 grams every hour ( round takes 4 hours).
• Difference is 144-120 – 24 grams• Ratio 6-1.• So needs to reduce insulin by 24/6 =4 units less of
his am background• Normally takes 16 normally so reduce down to 12
Carb + insulin plan
Do not exerciseCheck BG
<4.5 (<5.6)*
>144.6 -5.6(5.7-7.0)*
5.7-14(7.0-14)*
30 gCarb
Wait15 min
Ketone PosCorrectionDose
Ketone Neg30%CorrectionDose
Proceed to exercise
Additional15 g Carb
Recheck BM
Pre breakfast no change insulin *1-2 after breakfast or lunch reduce pre dose by 50%
Before lunch & 2 hours after break no change*Before supper & 2 hours after lunch reduce morning background by 10%
Between supper & bed decrease pre by 50% and consider decreasing pm background by 10%
Replace Carb as perTable every hour
Step 5: Problems
Case 3
Robert is an elite athlete. He is gradually building up the length of his runs .
In spite of good carbohydrate intake and replacement during exercising and dose reduction of his insulin prior to his training he is having problems with hypos during training.
What advice would you give him?
Options
Insulin regime
Injection sites
Size of needles
Overall diet
Carb loading
Carb replacement during exercise
10 Second Sprints
Replenishment post exercise
Alteration insulin dose pre exercise
Alteration insulin dose post exercise
Bolus insulinCarb during exercise
Hormones post exercise in diabetes.
TG
FFA’sGlycerol
Glycogen
Glucose Glucose
Amino acids
MuscleLiver
Glucose
Insulin
CortisolGH
Cortisol
Insulin
Replenish stores
• Eat within one hour of exercise
• Take bolus with it
Case 4
Sally is a university runner. She use to do the bulk of her training in the afternoon. Recently she has had to change her training to the morning.
Prior to training she has breakfast and takes a reduced dose of her insulin. Whilst running she takes glucose regularly but finds it difficult to keep up with her requirements and often goes hypo.
What advice would you give her?
Options
Insulin regime
Injection sites
Size of needles
Overall diet
Carb loading
Carb replacement during exercise
10 Second Sprints
Replenishment post exercise
Alteration insulin dose pre exercise
Alteration insulin dose post exercise
Bolus insulinCarb during exercise
Hormones during exercise in diabetes.
TG
FFA’sGlycerol
Glycogen
Glucose Glucose
CortisolAdrenaline
Noradrenaline
GH
Amino acids
CortisolGlucagon
AdenalineNoradrenaline
Glucagon
MuscleLiver
Glucose
Insulin
Increasing noradrenaline
Short Sprints Caffeine drinks
Continuous vs continuous + intermittent
Riddell MC Diabetic Medicine 2011
Continuous vs continuous + intermittent
Riddell MC Diabetic Medicine 2011
Avoid glutamine
Summary
• Decide what type of sport it is
• Access and give advice on diet
• Simple advice about starting blood sugars
• Simple carb advice for during and after exercise
• Reassess
Conclusion
• With advice and support patient with Type 1 diabetes can exercise safely and compete at the highest level.
• In the future being able to give exercise advice may become more important
Contact details