Type 1 and Exercise Management

Rick Philbin, MBA, M.Ed., ATC

I Am Not An Athlete…

"Everyone is an athlete. The only difference is that some of us are in training, and some are not."

Dr. George Sheehan

Goals of Exercise Management

Optimize exercise performance Prevent hypoglycemia during

and after any physical activity Rapidly manage hypoglycemia

caused by or following exercise Prevent hyperglycemia and

DKA

Pre Exercise Medical Evaluation

Assess patients for conditions that might contraindicate certain types of exercise such as: Uncontrolled hypertension Severe autonomic neuropathy or

peripheral neuropathy History of foot lesions Unstable proliferative retinopathy Patient’s age and previous physical

activity level should be considered

Encourage patient to start with short periods of low-intensity exercise and slowly increase intensity and duration

DM 2012 Standards of Medical Care Physical Activity

Advise people with diabetes to perform: At least 150 min/week of moderate-

intensity aerobic physical activity▪ 50–70% of maximum heart rate▪ Spread over at least 3 days per week

with▪ No more than 2 consecutive days

without exercise

DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012, www.care.diabetesjournals.org

BLOOD GLUCOSE

Time

Type

Amount

Time

Type

Amount

Time

Type

Amount

STRESS

ALCOHOL/drugs

ILLNESS

INSULIN

FOOD EXERCISE

EXERCISE & BLOOD

GLUCOSE

Farquar, A July 17, 2008 DESA International Toronto, Canada

Factors That Affect Blood Glucose Levels

Hypoglycemia

Hyperglycemia

ANAEROBICShort durationHigh-intensity

AEROBICLonger durationLower Intensity

Types of Exercise Effect on BG Weightlifting, Power lifting

Track (sprinting/field events), Diving (Platform & springboard)

American football, Swimming (sprints), Gymnastics, Fencing

Wrestling, Volleyball, Ice hockey, Track cycling

Basketball, Soccer, Tennis, Lacrosse

Speed skating (500-1000m)

Skiing (slalom & downhill), Field hockey

Rowing (middle distance)

Running (middle distance), Speed skating (>1500m)

Road cycling

In-line skating

Cross country skiing

Race walking

Marathon running

Iron Man triathlon

Ultra-marathon running

The rate at which subcutaneously injected insulin is absorbed increases with exercise due to increases in body temperature and in subcutaneous and skeletal muscle blood flow

Exogenously administered insulin

levels do not decrease during exercise

Zinman B, Murray FT, Vranic M, et al. Glucoregulation during moderateexercise in insulin treated diabetics. J Clin Endocrinol Metab. 1977;45:641–652.

Absorption Rate

Profiles of Human & Analog Insulins

Diabetes Core Curriculum Workshop

0 2 4 6 8 10 12 14 16 18 20 22 24

Pla

sma

Insu

lin L

evel

s

Regular (6–10 hours)

NPH (12–20 hours)

Hours

Glargine (20–26 hours)

Humalog, Novolog, Apidra (4–6 hours)

Detemir (Up to 24 hours)

Adapted from American Diabetes Association. Diabetes in the Latino Population.

Available at: http://www.diabetes.org/uedocuments/LatinoSlidesAugust05.ppt.

Weekend warriors or untrained person

Increased duration, intensity and/or frequency

New activity

Hypoglycemia unawareness

Recent physical activity or hypoglycemia within last 24 hours

Alcohol use

Hypoglycemia Risk

Alcohol Use -Temporary Basal Rates

Duration Adjustment Notes

2 hrs per drink

-50% Begin after drinking

*Alcohol will stop liver from releasing glycogen

“THE DAY AFTER”

Frequently, strenuous exercise causes an increase in insulin sensitivity as well as the restoration in muscle glycogen storage May need insulin level adjustment to avoid frequent carbohydrate correction

More frequent glucose monitoring

Decrease Chances of Hypoglycemia

Frequent monitoring Consume extra carbohydrates when

necessary Keep accurate records of duration,

intensity, and frequency Reduce insulin that is active at time

of exercise

Decrease Chances of Hypoglycemia

Check BG often during exercise and in the following 24 to 36 hours (look for patterns)

Begin Temp rate before exercise begins

May need to lower boluses before exer. ~50% less as a starting point

May need lower bolus to correct high BG before or during longer periods of exer.

Disconnect can be an option up to one hour Or 0% Temp rate

Smart Pumping, Howard Wolpert, MD

Strategies for Avoiding Hypoglycemia

Pre, During & Post Exercise Exercise 2 to 3 hours after eating Know your individual glucose response to

exercise (determined from pre/post BG checks)

Check you glucose levels before you exercise (30 minutes apart – Why?)

Decrease the insulin dose that is working while you are exercising (consult healthcare team first)

Pt. may need extra food or basal insulin adjustments up to 24hrs after exercising depending on the length/intensity of the exercise

Exercise Induced Hyperglycemia Anaerobic Exercise

Hyperglycemia◦Counter regulatory hormones are released: cortisol, glucagon, growth hormone, adrenalin

◦Glucose can increase during exercise

Delay exercise if ketotic

Diabetes Core Curriculum Workshop

ADA Guidelines Hyperglycemia & Exercise

GLUCOSE LEVEL

» Fasting* blood glucose

level is 250 mg/dL (13.9 mmol/L)**

Blood glucose value is 300 mg/dl (16.7 mmol/L) and without ketones**

» COMMENT

Test urine and/or blood for ketones - If ketones present, exercise is contraindicated**

Exercise with caution, and continue to monitor blood glucose levels**

*Fasting is defined as 4 h or more after eating a meal.**Zinman B, Ruderman N, Campaigne BN, Devlin JT, Schneider SH. Physical activity/exercise and diabetes. Diabetes Care. 2004

Insulin Pump Therapy & Exercise

Allows greater flexibility

Decide whether it is best to disconnect or not

May program the pump to accommodate exercise (temporary basal or separate basal program)

Diabetes Core Curriculum Workshop

The Pump Club Insulin Pump

When to Use Temporary BasalExercise - decrease

Start Temp Basal ~ 1 ½ to 3+ hours prior to exercise

End Temp Basal ~ 30 minutes to as much as 24hrs after exercise

Less Activity - increase Long meetings All day seminars Long car rides

The Pump Club Insulin Pump

Temporary Basal Rates

Prevention ofDelayed-Onset Hypoglycemia

Duration Adjustment Notes

6-10 hours -50% Base timing on experience

Temporary Basal Rates

Prolonged Activity

Duration Adjustment Notes

Minimum 2 hrs.

-50% Start 1-2 hours prior

The 30% Rule – How it Started

Pumping Insulin, Walsh J, Roberts R

Benefits of Insulin On Board(IOB)

Decreased risk of stacking insulin Less chance of hypoglycemia

Decreased risk of intentionally running high due to fear of hypoglycemia May improve A1c

Wear It! (Sport Pack, Bum Bag, Backpack Harness)

Re-Connect hourly & bolus 50% of missed basal rate

Alternatives to Disconnection:

Physical Activities

Borg Scale - 15 Point Rate of Perceived Exertion - Scale from 6 to 20

6 - 20% effort 7 - 30% effort - Very, very light (Rest) 8 - 40% effort 9 - 50% effort - Very light - gentle walking 10 - 55% effort 11 - 60% effort - Fairly light 12 - 65% effort 13 - 70% effort - Somewhat hard - steady pace 14 - 75% effort 15 - 80% effort - Hard 16 - 85% effort 17 - 90% effort - Very hard 18 - 95% effort 19 - 100% effort - Very, very hard 20 - Exhaustion

Borg, G, "Perceived Exertion as an indicator of somatic stress",Scandinavian journal of Rehabilitation Medicine 1970, 2(2), 92-98

Moderate 12-13

Very light < 10

Hard 14-16

Heart Rate 70-89%

Muscle Glycogen

Muscle glycogen contains 300-400 grams of glycogen

▪ 1200-1600 calories Liver glycogen contains

75-100 grams of glycogen▪ 300-400 calories

Blood glucose contains 25 grams of glucose

▪ 100 calories

Recovery Nutrition

Normally takes 24 to 36 hours to replace muscle energy (glycogen)

Consuming carbohydrates immediately post exercise (w/n 15 minutes) can reload the muscles in 12 to 16 hours

Snack should be mostly carbohydrates and some protein (4 parts CHO’s and 1 part Pro)

Added protein does not help with glycogen reloading but may repair and help with protein synthesis after exercise

Nutrition shake, smoothie, peanut butter sandwich, energy bar, yogurt, turkey sandwich, string cheese and crackers

Clark N, et al., “Sports Nutrition”, 124-28, 2003.

Serious & Recreational Athletes are Returning to a Childhood Favorite –

Chocolate Milk • In place of more common sports drinks• When pitted against commercial sports recovery drinks, several new studies have found that chocolate milk is the superior beverage when it comes to post-exercise recovery and fluid replacement

• Chocolate milk is 90 percent water, so it’s ideal for rehydration

• It has the perfect combination of carbohydrates and protein to refuel a tired athlete’s body, and it’s packed with many other nutrients including calcium and vitamins A and D (4 grams of carbs to 1 gram of protein)

Applied Physiology, Nutrition, and Metabolism, Sept 2010

Challenges

One size doesn’t fit all Variability

intraindividual ▪ ~10 - 20%

Variability interindividual▪ ~20 - 35%

Heinemann L, Weyer C, Rauhaus M, Heinrichs S, Heise et all, ”Variability of the Metabolic Effect of Soluble Insulin and the Rapid-Acting Insulin analog Insulin Aspart”, 2003.

Exercise Using CGM 40 mins on Stairmaster Level 10 Intensity

197 mg/dl - start

81

117 – ate 15 grams of carbs

170

Minutes 20 30 40

188 at 7am 15 grams of carbs/protein50% decrease in basal 8hrs

GETncm/justsaycust-recrate-itemcommunittg/stores/dtg/stores/d-favorite-listruejust-say-no

Thank You From The Bottom of My Pancreas!

That means from the bottom of my heart but only deeper