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Type 1 Diabetes and Exercise: Strategies for Insulin Management
John Devlin, MD, MPH
Type 1 Diabetes and Exercise: How about glycemic control ?
How exercise affects blood glucose level
Lawrence RD. Br Med J 1926; 1:648-‐50
10 U insulin
050
100150200250300
0 30 60 90 120 150
Time, min
Blo
od g
luco
se, m
g/dl
Insulin aloneInsulin + Exercise
Schematic illustration of the blood glucose response to exercise
Riddell, M.C. et al. Pediatric Diabetes 2006;7:60-70
Ideal control
Over-insulinized
Under-insulinized
Competition and/or heat stress
Risks of Exercise:
• Hypoglycemia • Hyperglycemia • Ketosis
• Not enough food
• Too much insulin
• Extra exercise
Causes of Hypoglycemia
Energy Sources During Exercise
0%
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r1 H
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FatGlucose
Substrate vs. DuraHon Substrate vs. Intensity
0%
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50% 60% 70% 80% 90% 100%Percent VO2 Max
Fat
Glucose
BG drops more rapidly during 15-‐60 BG drops more rapidly as minute phase of prolonged exercise exercise intensity increases
Scheiner, Gary, MS CDE Source: Source: Brooks & Fahey: Exercise Physiology: Human BioenergeHcs and its ApplicaHons, Macmillan Pub., NY, 1985.
Insulin dose adjustment before exercise
Bruce Bode, ADA 2015; JDRF PEAK program, “T1D Performance in Exercise and Knowledge”
Recommenda4on
PaHents on MDI • Reduce pre-‐exercise bolus insulin by 50% and
take extra Carbs during exercise prn
Exercise ≤ 90 min a`er meal • Reduce pre-‐exercise insulin dose and consume
Carbs with a low G.I.
Exercise > 90 min a`er meal • If blood glucose is low, consume Carbs
Insulin dose adjustment before exercise (2)
Toni et al. Acta Biomed. 2006;77 (Suppl. 1): 34-‐40.
Insulin administra4on
• Inject insulin into subcutaneous fat in either the abdomen or non-‐exercising muscle
• Reduce the pre-‐meal insulin dose for exercise in the postprandial phase
• 25-‐50% if duraHon is < 90 minutes • > 50% if duraHon is > 90 minutes
• Reduce morning meal insulin for exercise before breakfast
• 25-‐75% depending on intensity • Reduce prandial insulin AND basal insulin for exercise over 4 hours, intense team sports, etc.
Watch Out for D’OH! (Delayed Onset Hypoglycemia)
Ø Following high-‐intensity exercise
Ø Following extended duraHon acHvity
Ø Due to replenishment of muscle glycogen stores, enhanced insulin sensiHvity
Ø May occur up to 24 hours a`erwards (typically 6-‐12 hours later)
Source: Colberg, Sheri: The DiabeHc Athlete, Human KineHcs, Champaign, IL, 2001.
Figure 1 Mean glucose levels on the exercise and sedentary days.
The Diabetes Research in Children Network (DirecNet) Study Group
Impact of Exercise on Overnight Glycemic Control in Children with Type 1 Diabetes Mellitus
The Journal of Pediatrics, Volume 147, Issue 4, 2005, 528 - 534
Insulin dose adjustment a`er exercise
First 4me exercise • Insulin may need all night dose reducHon
Regular exercise • Reduce insulin dose unHl 3 am
Bruce Bode, ADA 2015; JDRF PEAK program
AlternaHves to Carbohydrate Intake
Bruce Bode, ADA 2015; JDRF PEAK program, “T1D Performance in Exercise and Knowledge”
• Intermihent high intensity sprint for 10 sec, to maintain BG while awaiHng Carb intake
• Used to counter the rapid fall in glycemia due to moderate-‐intensity exercise in individuals with T1D
• NOTE: Repeated circuits of high-‐intensity exercise, especially when mixed with aerobic exercise, could result in significant reducHons in BG levels
Avoidance of nocturnal hypoglycemia
Bruce Bode, ADA 2015; JDRF PEAK program, “T1D Performance in Exercise and Knowledge”
• Nocturnal hypoglycemia may result from: • Glycogen levels not being replaced • Bolus insulin following high-‐intensity exercise in the late a`ernoon/evening
• ReducHon of basal insulin dose by 10-‐20% in the first 12 hours a`er exercise reduces the risk of hypoglycemia
• AutomaHc suspension of insulin delivery significantly reduces the duraHon and severity of exercise-‐induced hypoglycemia without rebound hyperglycemia
Can Exercise Cause
Rise in BG?
Ketoacidosis?
Adrenaline Raises BG! Activities that often produce a short-
term blood glucose rise include:
æ Weight lifting (high weight, low reps) æ Sports w/ “bursts” of activity (golf, baseball, martial arts)
æ Sprints (running, swimming) æ Judged performances
(gymnastics, skating) æ Events in which WINNING is the primary objective
Sources: Colberg, Sheri: The DiabeHc Athlete, Human KineHcs, Champaign, IL, 2001.
Exercise-‐induced ketosis
00.5
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22.5
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Adapted from Berger M. Diabetologia 1977; 13:355.
To Prevent Ketoacidosis
ü Check urine for ketones prior to exercise w/BG > 250 mg/dl (7 mmol)
ü No exercise w/posiHve ketones (small or more on urine ketosHx; >0.5 mmol/l on ß Ketone test using Precision Xtra meter)
ü OK to exercise if non-‐ketoHc – take 50% of usual “correcHon” bolus and drink plenty of water
ü Do not disconnect for more than 2 hours
Source: Diabetes Care vol. 30 Supplement 1: ADA Clinical PracHce RecommendaHons 2007
Exercise with Use of Technology
History of Pumps
Alterna4ves to extended pump disconnec4on
Wear It! ü Clip to Hght clothing ü Sport Pack
ü Fanny Pack ü Backpack Harness
Infusion Set Adhesion During Exercise
ü Smart Set Placement Ø Under Hght clothing
Ø Body part w/less skin movement
ü Skin prep agent w/adhesive (IV Prep, Skin Prep, MasHsol)
ü Tape over site (Smith + Nephew, 3M)
The Athlete with Diabetes
Gary Hall Jr. Jason Johnson
Pump & Temperature Extremes During Exercise
Cold: Generally not a concern when pump is worn against body
Heat:
Insulin analogs can denature if: Ø Exposed to > 98°F Ø Stored or worn > 86°F Pump funcHon OK under most condiHons
Sources: insulin package inserts, insulin pump manufacturers
Pump & Temperature Extremes During Exercise
“Cool” Ideas: ü Keep pump out of direct sunlight
• Wear under clothing • Store in a cool place when disconnected • Don’t forget the tubing!!!
ü Spend less Hme in extreme heat • Get into a/c and shade periodically • Humidity is not a factor
ü FRIO Cooling Case
Bionic Pancreas
Bionic Pancreas: Role of Glucagon
“It is impossible to provide a single set of guidelines appropriate for all people with diabetes who wish to exercise, and the best advice is to encourage pa:ents with diabetes to document for themselves what works and what does not work.”
Wallberg-‐Henriksson Diabetes 1982;31:1044-‐50.
“Instead of focusing on the summit, focus on developing and building those growth habits. It’s not a recipe, it’s an equaPon. Three important words -‐ Educate
Prepare Experiment in that order, and in a loop.”