Managing blood glucose and exercise in young people with ... · -Cardio and weights in the gym Sports Workshop 2018 Yardley et al (2012) Diabetes Care 35: 669-675 . ... •It is recommended

Managing blood glucose and exercise in

young people with Type 1 Diabetes

Dr Alistair Lumb Dr Taffy Makaya

Anne Marie Frohock RD

May 2018

www.ouh.nhs.uk/childrens-diabetes

Plan

• Why might exercise be a challenge in T1

• What strategies do we have for dealing with this? • Before • During • After

• Technology and the future

• What can be done with T1?

Sports Workshop 2018

Why is exercise a challenge in T1?



What is the body doing during exercise?


Which fuels?


How is this controlled?

• Variation in a number of hormones of which insulin is only one

• Other important hormones include adrenaline and noradrenaline (catecholamines) and glucagon

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=uTPmaLg9vu1YiM&tbnid=vJxuofs7h3ivfM:&ved=0CAUQjRw&url=http://www.cs.cf.ac.uk/Dave/Multimedia/node224.html&ei=qa56UqTWGsu10QXktIC4CA&bvm=bv.55980276,d.ZGU&psig=AFQjCNGvfp7wnFsevjXClcBATQc8spU2Kg&ust=1383858170682575

Sports Workshop

Different needs for different sports

Sprinting, swimming sprints Weightlifting, Climbing Gymnastics, Fencing Athletics Field events

Football, Rugby, Hockey, Lacrosse Tennis, Squash, Rounders Running (middle distance) Playground games Skiing, Ice skating

Jogging/cross country Brisk walking, long walks Cycling, Marathon running Triathlon Skateboarding

Main fuel is carbohydrate from muscle glycogen

Fuel can be fat from stores and carbohydrate from blood glucose and

muscle glycogen

Muscle glycogen is a limited pool. Which is why

sprint-speed is not sustainable

Burning fat needs oxygen and takes

longer. Endurance exercise allows this


Effect on BG of different sports

Graphic courtesy Professor Mike Riddell


Effect on BG of different sports

Graphic courtesy Professor Mike Riddell

Blood Glucose DURING Exercise -Cardio and weights in the gym


Yardley et al (2012) Diabetes Care 35: 669-675

Blood Glucose AFTER after exercise - Late hypoglycaemia


Yardley et al (2012) Diabetes Care 35: 669-675

Blood Glucose AFTER after exercise - The Double dip

McMahon et al (2007) JCEM 92(3):963-968

BGs may drop 1-4 hrs afterwards

BGs may drop again 7-11hrs afterwards

BGs may be high immediately after

BGs may drop 1-4 hrs after

BGs may drop again 7-11hrs after

Exercise hormones remain elevated – Insulin Resistance

Anaerobic, sprinting or intermittent exercise

Pump off

As muscle stores of glycogen replenish

Blood Glucose AFTER after exercise - The ‘Whip, Double Dip‘

Sensitivity to insulin

remains increased

The hormonal response to a

falling glucose is not as strong

Responses are individual


Management strategies for exercise with T1


• Check • Check • Check!!

There is no other way

Before, During, After

Master your own diabetes


Be prepared! • Practice your diabetes and exercise management plan

• Monitor glucose closely when you train and when you compete • Think about the intensity • Practice your refuelling plan • Learn your own patterns

• Make sure you are safe –

• if you have been hypo earlier in the day know the increased risk of hypo during training and consider going ahead.

• Be aware that things can change on “game day” (and practice dealing with this if you can)

• Expect the unexpected…


It’s a balancing act!!

Strategies for Managing Exercise.

• We don’t want to change the exercise, so we need to see

what we can do with the insulin and carbohydrate

We are balancing 3 things


BG level 5-8 when starting exercise and throughout exercise

Aims of strategies

• Prevent hypoglycaemia after exercise • Prevent high BGs during exercise and afterwards


5- 8mmol/l

Riddle and Pankowska Talk ISPAD 2012

Muscles work better, reactions are faster, you can train for longer and recover

quicker when BG levels are 5-8mmol/l

http://www.yorku.ca/mriddell/documents/ISPADRiddell2012oct10.pdf




• Before, During, After

A number of factors which will affect the right management strategy:

• What is your BG now? Do you know what direction it is going in?

• When did you last eat? What did you last eat?

• What insulin do you have on board?

• What sort of exercise are you going to do? How long for?

Things to consider


Before and During Exercise


Before During After

BG below 4 Treat the hypo Only exercise when BG has recovered to above 5 mmol/l.

If you have been hypo earlier during the day be aware you are more likely to hypo during exercise

BG 4-7 Consider 10-15g extra carbs without insulin

BG 8-14 No extra carbs Drink plenty of water. Start low intensity exercise

BG over 8 Do not correct immediately after exercise After 2hrs, consider giving a small correction (half usual)

BG over 14 – CHECK KETONES Ketones over 1 mmol/l, do not exercise

Give a correction dose. Wait until ketones under 0.5 to exercise

Ketones less than 1 mmol/l, start low intensity exercise but drink plenty of water. For high intensity consider a correction dose (less than usual)

BG readings


• Do not exercise at peak insulin action – (with significant Insulin on Board)

For aerobic exercise: • Reduce IoB by reducing bolus insulin if taken in the 2hrs

before exercise • Reduce basal insulin 90mins before if able

For anaerobic exercise: • No bolus reduction may be needed

Insulin


Normal dose

Insu

lin le

vel

Time (h)

Effect of lowering insulin by 50%

1 2 3

Reduced dose

Fast acting insulin

Basal insulin


Bolus insulin before aerobic exercise

Basal insulin – aerobic activity

MDI • Generally not advised to reduce basal insulin prior to activity • Would only recommend this for extended periods of aerobic activity

(e.g. activity weekends, skiing holidays)

Insulin pump • Ideally reduce basal rate 60-90 minutes before exercise • Best reduction will be individual, starting point reduction by 50-

80% • Can remove pump, but think about reconnecting approximately

every hour to replace missed basal


Before During After

Bo

lus

Reduce insulin for food eaten within 90 mins of exercise – by 25-50%

Do not give bolus insulin

Reduce insulin for food eaten at the meal following exercise by 25-50%

Bas

al

Reduce basal rate 90 mins before by 50-75%

Reduce basal insulin rate by 50-80% (keep pump on if possible – if not replace half missed basal as a bolus before you take it off)

If intense afternoon or evening exercise Reduce long acting insulin by 10% Or Reduce basal rate at bedtime for 4hrs by 20%

Insulin – PLAN if you can


Before During After

Depends on BG & exercise & IoB BG 4-5 = 10-15g snack (fast/medium) BG 5-8 & exercise >30 mins = 10-15g snack (medium) BG >8 = no extra carbs – drink plenty of water

For exercise over 1hr extra carbs are likely to be needed. May be sooner if strenuous or no insulin adjustments made 0.5 g/kg/hr for every hour over the first hour FAST acting

Hydrate through the day with water

Hydrate with fluids Water should be adequate for exercise under 1hr Longer duration (over 1hr) switch to sports drinks

Carbohydrate

Exercise Nutrition - Snacks

• Medium acting

– Cereal bar (20-30g carb)

– 30g raisins (20g carbs)

– Banana (25g carbs)

• Fast acting

– 30g Jelly beans (25g carbs)

– Sports energy gels

– Glucose tablets

• Sports Drinks

– Fast carbohydrate for longer events (30g carbs in 500ml)

– Isotonic – improves hydration – GI side-effects – Easy to over-do it – BGs too high

Hydration

Water

Fine for shorter events

No side-effects

Using exercise to help you

• If glucose is high before activity – you can use a low intensity warm-up to help bring this down

• If on the low side – can you use a 10s sprint to help you?

• If going to the gym – can you adjust the order in which you do things?



The 10 second sprint

7

6

5

4

3 Blo

od

Glu

cose

Le

vel (

mM

)

Time (min)

A

a a

a

a a a a a a

a

Insulin release is able to control glucose rise in people without T1

Without insulin administration, glucose rise is unchecked in people with T1

7

6

5

4

3 Blo

od

Glu

cose

Le

vel (

mM

)

Time

B

b b b b

Fahey et al., J Clin Endocrinol Metab, 2012

After Exercise


Delayed hypoglycaemia

can be a problem

Before During After

Bo

lus

Reduce insulin for food eaten within 90 mins of exercise – by 25-50%

Do not give bolus insulin

Reduce insulin for food eaten at the meal following exercise by 25-50%

Bas

al

Reduce basal rate 90 mins before by 50-75%

Reduce basal insulin rate by 50-80% (keep pump on if possible – if not replace half missed basal as a bolus before you take it off)

If intense afternoon or evening exercise Reduce long acting insulin by 10% Or Reduce basal rate at bedtime for 4hrs by 20%

Insulin – Insulin sensitivity increases after exercise so you need less of it!


Before During After

Depends on BG & exercise & IoB BG 4-5 = 10-15g snack BG 5-8 & exercise >30 mins = 10-15g snack BG >8 = no extra carbs – drink plenty of water

For exercise over 1hr extra carbs are likely to be needed. May be sooner if strenuous or no insulin adjustments made 0.5 g/kg/hr for every hour over the first hour FAST acting

‘The Golden Hour’ 10-15g carbohydrate without insulin And PROTEIN Meal/snack

Hydrate through the day with water

Hydrate with fluids Water should be adequate for exercise under 1hr Longer duration (over 1hr) switch to sports drinks

Carbohydrate


• Replenish stores of glycogen in the body

• Eat carbohydrate within 1-2 hours of exercise

– Aim is 1g/kg bodyweight to replenish stores

• Include protein with this to reduce risk of ‘double dip’ hypos

After exercise - ‘The Golden Hour’


• If you are eating a full meal:

– Include carbohydrate (1g/kg)

and protein (20g)

– Reduce the dose of insulin by 50%

• If not eating a meal

– Eat a 10-20g carbohydrate snack without insulin - include some protein with this snack

Eating during the Golden Hour


• Milk shakes (300-400ml)

• Cereal (or cereal bar) and 200ml milk

• Nutty cereal bar

• Fruit and Nut mix

• Yoghurt and fruit

• Cheese and crackers

• Peanut butter sandwich

• Beans on toast

• Meat/fish sandwich

Golden Hour Snack ideas

• Check • Check • Check!!

There is no other way

Before, During, After

How do I know it works?


Overall nutrition

• Youngsters have high energy requirements for growth • It is recommended about half of this energy comes from

carbohydrate

• Exercise increases energy requirements further

• For optimal growth, exercise performance and recovery – we must ensure that nutritional intake is adequate for exercise to be undertaken

Hydration is essential too


Recommended energy requirements

Diabetes, Obesity and Metabolism (2011) 13:130-136

Age EAR - boys Guideline carb intake (g/d) EAR - Girls Guideline carb intake (g/d)

kcal/d kcal/d

1 765 717

2 to 3 1088 122 - 145 1004 113 - 134

4 to 6 1482 166 - 198 1378 155 - 184

7 to 10 1817 204 - 242 1703 191 - 227

11 to 14 2500 281 - 333 2000 225 - 267

15 to 18 2500 281 - 333 2000 225 - 267

* Calculations based on SCAN DRV for energy (2011) population based average activity levels

with 45-50% total energy from carbohydrates

Energy requirements for 11-18yr olds are capped at 2500kcal/2000kcal per day to address issue

of overweight/obesity


Technology and the future


• Chance to review plans and make adjustments

• Chance to respond to changing situations in real time

• Less accurate during exercise due to rapidly changing BG levels • Time lag between Blood Glucose and Sensor glucose

CGM and Exercise

How could we use real-time info?

Adapted from: Riddell & Milliken (2011) Diabetes Technology and Therapeutics 13(8):813-825



Closed loop systems: overnight

Sherr et al (2013) Diabetes Care 36:2909-2914


Closed loop systems are getting better

Oxford Diabetes Sports Service

Dr Alistair Lumb Dr Taffy Makaya

Anne Marie Frohock RD

Thank you!

What can be achieved with T1?



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Documents

Managing blood glucose and exercise in young people with ... · -Cardio and weights in the gym Sports Workshop 2018 Yardley et al (2012) Diabetes Care 35: 669-675 . ... •It is recommended