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Type 1 and Exercise Management Rick Philbin, MBA, M.Ed., ATC

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

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Type 1 and Exercise Management Rick Philbin, MBA, M.Ed., ATC

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  1. Type 1 and Exercise ManagementRick Philbin, MBA, M.Ed., ATC

  2. 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

  3. 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

  4. 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

  5. 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

  6. Factors That Affect Blood Glucose Levels INSULIN EXERCISE & BLOOD GLUCOSE Time Type Amount STRESS ALCOHOL/drugs BLOOD GLUCOSE Time Type Amount Time Type Amount FOOD EXERCISE ILLNESS Farquar, A July 17, 2008 DESA International Toronto, Canada

  7. Hyperglycemia ANAEROBIC Short duration High-intensity 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 AEROBIC Longer duration Lower Intensity Hypoglycemia Types of Exercise Effect on BG

  8. Absorption Rate • 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 moderate exercise in insulin treated diabetics. J Clin Endocrinol Metab. 1977;45:641–652.

  9. Profiles of Human & Analog Insulins Humalog, Novolog, Apidra (4–6 hours) Regular (6–10 hours) NPH (12–20 hours) Detemir (Up to 24 hours) Plasma Insulin Levels Glargine (20–26 hours) Hours 4 2 6 8 12 14 16 18 20 22 24 0 10 Adapted from American Diabetes Association. Diabetes in the Latino Population. Available at: http://www.diabetes.org/uedocuments/LatinoSlidesAugust05.ppt. Diabetes Core Curriculum Workshop

  10. Hypoglycemia Risk • 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

  11. Alcohol Use -Temporary Basal Rates *Alcohol will stop liver from releasing glycogen

  12. “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

  13. 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

  14. 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

  15. 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

  16. 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

  17. ADA Guidelines Hyperglycemia & Exercise Glucose Level » » 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* 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** *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

  18. 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

  19. When to Use Temporary Basal • Exercise - 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

  20. Temporary Basal Rates Prevention of Delayed-Onset Hypoglycemia

  21. Temporary Basal Rates • Prolonged Activity

  22. The 30% Rule – How it Started Pumping Insulin, Walsh J, Roberts R

  23. 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

  24. Alternatives to Disconnection: Physical Activities  Wear It! (Sport Pack, Bum Bag, Backpack Harness) • Re-Connect hourly & bolus 50% of missed basal rate

  25. Borg Scale - 15 PointRate 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%

  26. 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

  27. 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.

  28. 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

  29. Challenges • One size doesn’t fit all • Variability intraindividual • ~10 - 20% • Variability interindividual • ~20 - 35% Heinemann L, Weyer C, Rauhaus M, Heinrichs S, Heiseet all, ”Variability of the Metabolic Effect of Soluble Insulin and the Rapid-Acting Insulin analog Insulin Aspart”, 2003.

  30. Exercise Using CGM 40 mins on Stairmaster Level 10 Intensity 197 mg/dl - start 170 117 – ate 15 grams of carbs 81 188 at 7am 15 grams of carbs/protein 50% decrease in basal 8hrs Minutes 20 30 40

  31. Thank You From The Bottom of My Pancreas! That means from the bottom of my heart but only deeper

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