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Exercise and Endocrine Care
Eric Sherman
MAJ, USAF, MCPediatric Endocrine Fellow
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Objectives
Discuss the maintenance of euglycemia
Review some basics of exercise physiology
Review exercise physiology in type 1diabetes
Review the literature on exercising safely
with type 1 diabetes Review other endocrine disorders and any
exercise recommendations
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Fasting state
Reduced insulin secretion
Increased levels of cortisol, GH, glucagon
and epinephrine Glucose production enhanced
Mobilization of fatty acids for energy
Sperling Pediatric Endocrinology
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Fed state
Increased insulin secretion (w/in 20-30 min)and decreased glucagon secretion
Glycogen synthesis enhancedEnhanced glucose uptake in muscle
Suppression of gluconeogenesis
Lipid synthesis activated and lipolysissuppressed
Sperling Pediatric Endocrinology
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After exercise
Similar to fasting state
Goal to rebuild skeletal muscle glycogen
stores
Increased GLUT4 transport (insulin not initially
required)
Full replenishment of muscle stores requiresinsulin
PierceBr. J. Sports Med(1999)
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Counter regulatory hormones
Cortisol (adrenal cortex)
Enhances gluconeogenesis
Epinephrine (adrenal medulla)More potent than norepi
Inhibit insulin secretion
Increase glucose secretion from liver andlactate from muscle
Norepinephrine (same as epi)Sperling Pediatric Endocrinology
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Insulin regimens
Traditional
NPH + regular (now Novolog/Humalog) in AM
Novolog at dinner
NPH at bedtime
Basal-bolus
Lantus once daily + Novolog at meals
CSII (insulin pump)
Intensive treatment
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Diabetes and exercise
1. Exercise may decrease risk of diabetes
complications
2. Hypoglycemia
3. Increased risk of DKA
4. Unmasking CAD
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What is different in diabetes
Constant non-physiologic insulin supply
Variable insulin absorption
Suboptimal release of counter-regulatoryhormones (especially during sleep)
Increased skeletal muscle uptake following
exercise Increased insulin sensitivity after exercise
McMahonJCEM(2007)
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Exercise physiology in diabetes
Decline in serum glucose
Decreased plasma
insulin secretion
Increased glucagon
secretion
Muscular glucose production
+
Fatty acids mobilized from adipose tissue+
Gluconeogenesis from lactate (liver)
+
GLUT4 stimulated transport of glucose into muscle
Increased counter-
regulatory hormones
Hypoglycemia
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Hypoglycemia
Older data suggests that risk of hypoglycemia lasts
up to 31 hours after exercise MacdonaldDiabetes Care (2007)
2-4% of deaths in type 1 diabetes attributed tohypoglycemia CryerDiabetes Care (2003)
2 episodes per week of severe hypoglycemia in
well controlled diabetics CryerDiabetes Care (2003)
One episode of hypoglycemia blunts responses to
subsequent hypoglycemia for several daysHopkinsDiabRes Clin Prac (2004)
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And now for some real data
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McMahonJCEM(2007)
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McMahonJCEM(2007)
Early hypoglycemia
Lack of physiologic decrease in insulin
secretion
Late hypoglycemia (MN4AM)
Imbalance between glucose production and use
Need to replete glycogen storesBlunted counter-regulatory responses during
sleep
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McMahonJCEM(2007)
Lack of hypoglycemia from 5PMN
Elevated counter-regulatory hormones may
have increased fatty acid oxidation
Fatty Acids Cortisol Growth Hormone
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How many carbs before exercise?
9 adult subjects on NPH and Novolog exercisedfor 60 minutes (50% VO2 max) with euglycemicclamp3 hours post breakfast
Given 0, 15 & 30 g of carbs prior to exercise
Based on GIR and amount of pre-exercise carbs, aregression equation calculated
35 g of carbs prevents acute hypoglycemia 40 g of carbs prevents acute and late
hypoglycemia DubeMed & Sci in Sports & Exercise (2005)
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Reduction in pre-meal insulin
8 adult males in randomized crossover trial
Exercised at 25, 50 & 75% of VO2 max for 30
and 60 minutes (90 minutes after eating)Injected 25, 50 & 100% of typical Humalog
dose
100% of Humalog dose associated with
significantly reduced BG compared withdose reduction (all groups)
RabasaLhoretDiabetes Care (2001)
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Insulin pumps
Is suspending them an option?
50 patients aged 8-17 in random crossover trial
(on and off pump during 75 minutes of exerciseat 55% VO2 max)
DirecNetDiabetes Care (2006)
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Hypoglycemia 3 times morecommon in basal continued
group
Hyperglycemia 4.5 times
more common in basal stopped
group
DirecNetDiabetes Care (2006)
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Another pump study
10 patients exercised for 45 minutes (60%
VO2 max) with pump on and pump off
Wore CGMS for 24 hours after exercise
No difference in hypoglycemic events
during exercise (2 in each group)
All 10 had 1-3 hypoglycemic events (BG
50-70) from 2.5 to 12 hours after exerciseAdmonPediatrics (2005)
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Higher intensity exercise
7 adults
30 minutes of moderate exercise (40% VO2
max)30 minutes of intermittent high intensity
exercise (40% VO2 max + 4s sprints every 2minutes)
IHE felt to mimic typical toddler activityand adolescent sports
GuelfiDiabetes Care (2005)
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GuelfiDiabetes Care (2005)
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GuelfiDiabetes Care (2005)
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Why the difference?
Lactate
Inhibit glucose uptake within skeletal muscle
Stimulate hepatic gluconeogenesis Catecholamines
Inhibit insulin mediated glucose uptake
Stimulate hepatic gluconeogenesis
GH
Inhibit insulin mediated glucose uptakeGuelfiDiabetes Care (2005)
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A novel approach
7 adult males with type 1 diabetes in
random crossover trial
Exercised for 20 minutes at 40% VO2 max +/-a 10 s sprint at completion of exercise
Theorized that a short sprint would prevent
hypoglycemiaIncrease in lactate & catecholamines
BussauDiabetes Care (2006)
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BussauDiabetes Care (2006)
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Lactate
Epinephrine
Glucagon
Growth
hormone
Norepinephrine
Cortisol
Insulin
Fatty
acids
BussauDiabetes Care (2006)
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My recommendations
Avoid exercise if BG < 100 or > 300
Check ketones if BG > 250 and exercising
Take 15 g of carbohydrates for every 30minutes of exercise
Check BG every 30-60 minutes during
exercise and as needed Avoid using legs for injections p/t running
(increased absorption)abdomen better
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My recommendations
Check BG after exercise
Disconnect pump during moderate to high
intensity exercise, most sporting events andswimming
Check BG prior to bedtime and eat snack
with both carbohydrates and protein
Check BG at 2A on intense exercise days
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Insulin adjustment
Post exercise
Consider decrease in insulin dose of 25-50%
Elite athletes
50-75% reduction in total daily insulin dose
Hypoglycemia can occur up to 24-36 hours
after competition (restoring muscle glycogen)PierceBr J Sports Med(1999)
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Exercise & Hyperglycemia
Physiology
Insulin deficiency
Hepatic glucose production continues withoutglucose utilization (exaggerated
hyperglycemia)
Increased lipolysis leads to FA and ketone
production (exaggerated ketosis)
ZinkerClinics in Sports Med(1999)
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Preparticipation evaluation
Vital signs
Complete PE including monofilament evaluation
A1C Yearly eye exam
Microalbumin
Fasting lipid panel TFTs
Consider formal cardiac stress test
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Exercise & Retinopathy
ADA Position StatementDiabetes Care (2004)
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Exercise and Nephropathy
No specific recommendations
ADA says high intensity/strenuous exercise
should be avoided unless BP monitoringavailable
Treatment may limit exercise capacity
ADA Position StatementDiabetes Care (2004)
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Exercise and peripheral
neuropathy Loss of sensation in feet increases risk of
ulcers
Contraindicated AllowedTreadmill Swimming
Prolonged walking Biking
Jogging Rowing
Stairmaster Chair/armexercises
ADA Position StatementDiabetes Care (2004)
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Exercise & autonomic
dysfunction Difficult to diagnose
Resting HR > 100
Orthostasis
Delayed gastric emptying
Cardiac stress test
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Type 2 diabetes
Exercise benefits more clearly defined
HDL cholesterol, Total chol, LDL chol, TG
BP
insulin sensitivity
weight loss ( insulin resistance)
fatal cardiac events
Armen Clin Sports Med(2003)
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Type 2 Diabetes
Decreased risk of hypoglycemia whentaking oral agents
Insulin therapyIncidence of hypoglycemic events similar to
type 1 diabetics when patients matched forduration of insulin therapy HopkinsDiab Res Clin Prac (2004)
Increased carbohydrate intake and BGmonitoring prior to exercise recommendedDiabetes Care (2004)
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Hemodynamic changes in thyroid disease
Hyperthyroidism Hypothyroidism
Peripheral vascular resistance
Circulation time
Cardiac output
Stroke volume
Cardiac index
Arterial resistance
Venous resistance
Systolic/diastolic function
Systolic blood pressure
Pulse pressure widened narrow
Kahaly Thyroid(2002)
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Exercise and Hypothyroidism
No specific ATA recommendations
Limited data about exercise in treated
patients
Subclinical hypothyroidism
No change in exercise parameters after 1 year
of treatment (TSH 4.65 before treatment and1.28 after treatment)
CaraccioJCEM(2005)
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Exercise and Hyperthyroidism
No specific ATA recommendations
Increased metabolic state with increased O2
consumption
Increased risk of atrial fibrillation and
rhabdomyolysis
Kahaly Thyroid(2002)
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Exercise and Hyperthyroidism
What we recommend
Avoid exercise until T3 and T4 levels are
normalized (may take several weeks)TSH may remain suppressed for several months
(no impact on exercise tolerance)
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Brief case report
45 yo white male with sarcoidosis
Treated with prolonged steroid taper over 3
years (was on 2.5 mg/day at time of death)
On Atenolol for 1 year for HTN
Collapsed & died in June 1983 3.5 miles
into marathon in Sheffield, England
ParsonsBr J Sports Med(1984)
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Brief case report
Missed Prednisone 2 days prior to race and
on race day
Autopsy revealed cortical atrophy and lipiddepletion of adrenal glands (total weight 4
g)
ParsonsBr J Sports Med(1984)
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So what
LWPES and ESPE recommend that extra
steroid dosing be considered when
performing endurance sports
LWPES/ESPE Consensus Statement JCEM(2002)
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CAH and High Intensity Exercise
WeiseJCEM(2004)
Stress dose steroids??
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WeiseJCEM(2004)
Stress dose steroids??
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CAH and Prolonged Exercise
Green-GolanJCEM(2007)
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Review
Discussed the maintenance of euglycemia
Reviewed some basics of exercise physiology
Discussed exercise physiology in type 1 diabetes Reviewed the literature on exercising safely with
type 1 diabetes
Discussed other endocrine disorders and any
exercise recommendations
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Questions
Recommended