"everyone is an athlete. the only difference is that some of us are in training, and some are...
TRANSCRIPT
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Type 1 and Exercise Management
Rick Philbin, MBA, M.Ed., ATC
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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Alcohol Use -Temporary Basal Rates
Duration Adjustment Notes
2 hrs per drink
-50% Begin after drinking
*Alcohol will stop liver from releasing glycogen
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“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
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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
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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
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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
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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
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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
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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
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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
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Temporary Basal Rates
Prevention ofDelayed-Onset Hypoglycemia
Duration Adjustment Notes
6-10 hours -50% Base timing on experience
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Temporary Basal Rates
Prolonged Activity
Duration Adjustment Notes
Minimum 2 hrs.
-50% Start 1-2 hours prior
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The 30% Rule – How it Started
Pumping Insulin, Walsh J, Roberts R
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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
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Wear It! (Sport Pack, Bum Bag, Backpack Harness)
Re-Connect hourly & bolus 50% of missed basal rate
Alternatives to Disconnection:
Physical Activities
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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%
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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
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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.
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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
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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.
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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
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GETncm/justsaycust-recrate-itemcommunittg/stores/dtg/stores/d-favorite-listruejust-say-no
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Thank You From The Bottom of My Pancreas!
That means from the bottom of my heart but only deeper