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Sheri R. Colberg, Ph.D. Old Dominion University Norfolk, Virginia Exercise & Busy Kids – Exercise & Busy Kids – Preventing and Managing Hypos.

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Presentation on theme: "Sheri R. Colberg, Ph.D. Old Dominion University Norfolk, Virginia Exercise & Busy Kids – Exercise & Busy Kids – Preventing and Managing Hypos."— Presentation transcript:

1 Sheri R. Colberg, Ph.D. Old Dominion University Norfolk, Virginia Exercise & Busy Kids – Exercise & Busy Kids – Preventing and Managing Hypos

2 Diabetic Athlete - An Oxymoron? No! There are many diabetic athletes worldwide competing even at elite levels No! There are many diabetic athletes worldwide competing even at elite levels Chris Dudley (NBA basketball) Chris Dudley (NBA basketball) Jay Leeuwenburg (NFL football) Jay Leeuwenburg (NFL football) Kris Freeman (U.S. XC ski team) Kris Freeman (U.S. XC ski team) Gary Hall, Jr. (Olympic swimming) Gary Hall, Jr. (Olympic swimming) Many others have run marathons, done triathlons, and competed in every type of sport and physical activity Many others have run marathons, done triathlons, and competed in every type of sport and physical activity

3 Goals of Exercise Management Prevention of hypoglycemia during and after any physical activity Prevention of hypoglycemia during and after any physical activity Rapid management of hypos caused by exercise Rapid management of hypos caused by exercise Prevention of hyperglycemia and DKA Prevention of hyperglycemia and DKA Optimal athletic performance Optimal athletic performance

4 Effects of Low BG on Exercise Early, rapid- onset fatigue Early, rapid- onset fatigue Potential loss of coordination Potential loss of coordination Reduced endurance Reduced endurance Decreased performance Decreased performance

5 What Is Optimal BG for Exercise? Varies, but most athletes perform best with BG levels of Varies, but most athletes perform best with BG levels of Some start out higher, but few lower Some start out higher, but few lower

6 Fuel Use and Acute Effects of Exercise on BG Control

7 Exercise Energy Systems The way energy is produced and used during an activity affects BG use The way energy is produced and used during an activity affects BG use Three distinct energy systems exist: Three distinct energy systems exist: Immediate (phosphates, or ATP-CP) Immediate (phosphates, or ATP-CP) Lactic acid system (rapid glycolysis) Lactic acid system (rapid glycolysis) Aerobic (oxygen) Aerobic (oxygen) Their use is a continuum and depends on exercise type, duration, and intensity Their use is a continuum and depends on exercise type, duration, and intensity

8 10 sec 30 sec 1 min 3 min 5 min Exercise Energy Systems

9 Fuel Use during Exercise For most exercise, carbs are main fuel: glycogen (~80%), BG (20%) For most exercise, carbs are main fuel: glycogen (~80%), BG (20%) Romijn JA, et al., JAP, 88(5): , 2000

10 Fuel Use during Exercise BG uptake into muscles occurs 2 ways: BG uptake into muscles occurs 2 ways: Insulin-mediated Insulin-mediated Contraction-induced Contraction-induced These two mechanisms act separately, but additively using GLUT4 These two mechanisms act separately, but additively using GLUT4 Thus, active insulin levels affect BG response to exercise by BG more Thus, active insulin levels affect BG response to exercise by BG more

11 Glucose Transport into Muscles Wojtaszewski JF, et al., Acta Physiol Scand, 162(3): 351-8, 1998

12 Insulin Levels and BG Response If active insulin levels are high, then BG during extended activity If active insulin levels are high, then BG during extended activity If insulin is deficient and ketones present, BG usually during exercise If insulin is deficient and ketones present, BG usually during exercise Check for ketones if BG>250 mg/dl and has been elevated for a while Check for ketones if BG>250 mg/dl and has been elevated for a while Exercise if ketones are none, but take corrective insulin (~50%) if >250 mg/dl Exercise if ketones are none, but take corrective insulin (~50%) if >250 mg/dl

13 Insulin Levels and BG Response Nondiabetic Controls DM with Insulin DM lacking Insulin

14 Hormones and BG Levels Some insulin is needed to moderate the effects of glucose-raising hormones: Some insulin is needed to moderate the effects of glucose-raising hormones: Adrenaline and noradrenaline Adrenaline and noradrenaline Glucagon, cortisol, and growth hormone Glucagon, cortisol, and growth hormone Cortisol and GH are higher during morning exercise (insulin resistance) Cortisol and GH are higher during morning exercise (insulin resistance) Hormone release is intensity-dependent (more adrenaline at higher workloads) Hormone release is intensity-dependent (more adrenaline at higher workloads)

15 High Adrenaline Activities BG Sports w/ intense bursts Sports w/ intense bursts Sprinting of any type Sprinting of any type Heavy weight lifting Heavy weight lifting Scary activities (e.g.,hang gliding or downhill skiing) Scary activities (e.g.,hang gliding or downhill skiing) Intense competition (mental stress) Intense competition (mental stress)

16 Endurance Exercise Effects Extended exercise usually results in BG levels if any insulin on board Extended exercise usually results in BG levels if any insulin on board Pre-exercise, short- or rapid-acting insulin doses will likely need to be lowered Pre-exercise, short- or rapid-acting insulin doses will likely need to be lowered BG likely after activity, with less insulin needed in post-exercise period BG likely after activity, with less insulin needed in post-exercise period insulin action during muscle glycogen repletion insulin action during muscle glycogen repletion

17 Balancing Exercise Blood Sugars

18 Exercise Diet Medication Exercise Diet Medication Diabetes Therapy

19 Challenges with Busy Kids Insulin doses and diet must match precisely with exercise to avoid hypos Insulin doses and diet must match precisely with exercise to avoid hypos Risk of hypoglycemia is higher both during and following exercise Risk of hypoglycemia is higher both during and following exercise May be no improvement in overall BG control in active kids w/o appropriate changes in diet and/or insulin doses May be no improvement in overall BG control in active kids w/o appropriate changes in diet and/or insulin doses

20 Regimen Changes for Exercise Increase carbohydrate intake for the activity to prevent hypos Increase carbohydrate intake for the activity to prevent hypos Adjust insulin doses before, during, and after activities Adjust insulin doses before, during, and after activities Try to prevent acute and delayed-onset hypoglycemia, which can occur for up to 48 hours after exercise Try to prevent acute and delayed-onset hypoglycemia, which can occur for up to 48 hours after exercise

21 Predicting Glycemic Responses Checking BG before, often during, & after exercise is key to learning BG responses Checking BG before, often during, & after exercise is key to learning BG responses BG levels during usual activities can become somewhat predictable & a pattern established BG levels during usual activities can become somewhat predictable & a pattern established

22 Factors Affecting BG Response Exercise intensity, duration, and type Exercise intensity, duration, and type Carbohydrate supplementation Carbohydrate supplementation Initial blood glucose levels Initial blood glucose levels Insulin dose before and/or during exercise and insulin peak times Insulin dose before and/or during exercise and insulin peak times Training effects on fuel use Training effects on fuel use Timing of exercise bout Timing of exercise bout Other factors affecting BG Other factors affecting BG

23 Exercise Intensity

24 Competitive events may be shorter, but much more intense than practices Competitive events may be shorter, but much more intense than practices Greater release of glucose-raising hormones causes BG to less Greater release of glucose-raising hormones causes BG to less Mental stress of competition alone can levels of hormones as well Mental stress of competition alone can levels of hormones as well Extra insulin may be needed after competition to bring blood glucose down Extra insulin may be needed after competition to bring blood glucose down

25 Exercise Duration

26 The longer an activity lasts, the greater glucose-lowering effect it can have The longer an activity lasts, the greater glucose-lowering effect it can have Rate of muscle glycogen use with increasing exercise intensity Rate of muscle glycogen use with increasing exercise intensity Longer duration at same intensity will result in greater muscle glycogen use Longer duration at same intensity will result in greater muscle glycogen use Greater glycogen depletion will cause reliance on BG use Greater glycogen depletion will cause reliance on BG use

27 Exercise Type

28 Aerobic vs. anaerobic activities – is there a metabolic difference? Aerobic vs. anaerobic activities – is there a metabolic difference? Blood glucose easier to maintain during short, intense exercise Blood glucose easier to maintain during short, intense exercise Longer duration activities generally necessitate greater regimen changes Longer duration activities generally necessitate greater regimen changes Increased muscle mass improves insulin sensitivity overall Increased muscle mass improves insulin sensitivity overall

29 Intermittent High Intensity Ex Guelfi KJ, et al., Diab. Care, 28(6): , second sprints every 2 minutes during 30 min mod (~40%) exercise

30 Carbohydrate Intake (Grams) Exercise Duration Exercise Intensity BG <100 BG BG BG >200 Low NoneNone 30 min Mod High Low min Mod High Adapted from Colberg, S. The Diabetic Athlete, 2001

31 General Snacking Guidelines Begin carb intake prior to exercise to prevent hypos Begin carb intake prior to exercise to prevent hypos Adjust quantity based on pre-exercise BG levels (none may be needed) Adjust quantity based on pre-exercise BG levels (none may be needed) Plan on snacking more when active insulin levels are higher Plan on snacking more when active insulin levels are higher Snack hourly during prolonged exercise to provide alternate carbs (besides BG) Snack hourly during prolonged exercise to provide alternate carbs (besides BG)

32 Carbs to Prevent & Treat Hypos Best carbs for exercise: glucose tablets or gels, sugary candy, regular soft drinks, sports drinks, diluted juice, skim milk, power bars, pretzels, dry cereal, crackers Best carbs for exercise: glucose tablets or gels, sugary candy, regular soft drinks, sports drinks, diluted juice, skim milk, power bars, pretzels, dry cereal, crackers Do not consume: chocolate, donuts, potato chips, most candy bars, fat-laden cookies, high-fat dairy products, etc. Do not consume: chocolate, donuts, potato chips, most candy bars, fat-laden cookies, high-fat dairy products, etc.

33 Carb Intake Examples *Soccer: A pump user drinks sports drinks during practices, consuming gm of carbs per hour (insulin ) *Soccer: A pump user drinks sports drinks during practices, consuming gm of carbs per hour (insulin ) Weight training: An NPH user eats 15 grams of carbs only if BG 85 to start; another eats a higher-fat bedtime snack Weight training: An NPH user eats 15 grams of carbs only if BG 85 to start; another eats a higher-fat bedtime snack Swimming: For an AM swim before any insulin, a Lantus user drinks a regular soda to his BG to 225 mg/dl Swimming: For an AM swim before any insulin, a Lantus user drinks a regular soda to his BG to 225 mg/dl

34 Effect of Active Insulin Levels Exercise Plasma Insulin Liver Glucose Output Muscle Glucose Uptake Resulting Blood Glucose Normal Level Markedly Decreased Above Normal Adapted from Colberg, S. The Diabetic Athlete, 2001

35 Peak & Action of Various Insulins Rapid-acting insulin analogs (Humalog, Novolog, Apidra): peak in 1-2 hrs Rapid-acting insulin analogs (Humalog, Novolog, Apidra): peak in 1-2 hrs Short-acting Regular: 2-3 hrs Short-acting Regular: 2-3 hrs Intermediate-acting (NPH): peak in 4-6 hrs Intermediate-acting (NPH): peak in 4-6 hrs Long-acting, basal (Lantus, Detemir, UL): mild or no peak Long-acting, basal (Lantus, Detemir, UL): mild or no peak

36 Insulin for Exercise Timing For pre-meal exercise when insulin levels low, little or no insulin needed For pre-meal exercise when insulin levels low, little or no insulin needed For exercise done 1-2 hours post-meal, short/rapid insulin may need to be For exercise done 1-2 hours post-meal, short/rapid insulin may need to be Insulin should be for exercise done during insulin peak times Insulin should be for exercise done during insulin peak times Basal insulin or pump basal rate may be prior to and during extended exercise Basal insulin or pump basal rate may be prior to and during extended exercise

37 General Insulin for Exercise Duration Low Intensity Moderate Intensity High Intensity 30 min None10-20%10-30% 60 min 10-20%20-40%30-60% 90 min 15-30%30-55%45-75% 120 min 20-40%40-70%60-90% 180 min 30-60%60-90%75-100% Adapted from Colberg, S. The Diabetic Athlete, 2001

38 Adjustments by Insulin Type Meal Boluses: Meal Boluses: Low intensity cardio 25% Low intensity cardio 25% Moderate cardio 33% Moderate cardio 33% High intensity cardio 50% High intensity cardio 50% Short/intense 0%, plus bolus afterwards Short/intense 0%, plus bolus afterwards Basal: Basal: Pump: basal rate by 50% starting 1 hr prior, or Pump: basal rate by 50% starting 1 hr prior, or Reconnect hourly to give 50% of usual basal rate Reconnect hourly to give 50% of usual basal rate Prior to prolonged ex injected basal up to 25% Prior to prolonged ex injected basal up to 25%

39 Insulin Reduction Examples *Soccer: A pump user disconnects his pump during practices and pre-ex meal Humalog by 3 units (carbs ) *Soccer: A pump user disconnects his pump during practices and pre-ex meal Humalog by 3 units (carbs ) Weight training: A Lantus user takes no Humalog within 2 hrs of weight training Weight training: A Lantus user takes no Humalog within 2 hrs of weight training Swimming: During swim team season, a Lantus user decreases her total basal dose by 1/3 Swimming: During swim team season, a Lantus user decreases her total basal dose by 1/3

40 Training Effects Training BG use and fat use Training BG use and fat use Thus, less muscle glycogen used after 2-3 weeks of training Thus, less muscle glycogen used after 2-3 weeks of training Need to absolute exercise intensity for same effect Need to absolute exercise intensity for same effect

41 Other Training Adjustments Regular exercise improves BG control by increasing insulin sensitivity Regular exercise improves BG control by increasing insulin sensitivity Lower insulin doses may be needed overall with consistent training Lower insulin doses may be needed overall with consistent training Lesser carbohydrate intake may be needed for the training activity Lesser carbohydrate intake may be needed for the training activity Training effects on BG are specific to the activity (with little carryover) Training effects on BG are specific to the activity (with little carryover)

42 Timing of Exercise Cortisol and growth hormone higher in AM, insulin action Cortisol and growth hormone higher in AM, insulin action Similar exercise done later in the day (even post-breakfast) BG more Similar exercise done later in the day (even post-breakfast) BG more

43 Other Factors Poor BG control insulin action Poor BG control insulin action Physical/mental stress can insulin action Physical/mental stress can insulin action Insulin action during 2 nd half of menstrual cycle in teens/women Insulin action during 2 nd half of menstrual cycle in teens/women Environmental conditions (hot/cold) Environmental conditions (hot/cold)

44 Exercise Precautions

45 Prevention of Acute Hypoglycemia Hypoglycemia (BG < 65 mg/dl) is the most immediate risk during and after exercise Hypoglycemia (BG < 65 mg/dl) is the most immediate risk during and after exercise Monitor glucose levels; avoid lows with preventive, corrective regimen changes Monitor glucose levels; avoid lows with preventive, corrective regimen changes Access to simple carbs is essential for the rapid treatment of hypos Access to simple carbs is essential for the rapid treatment of hypos Glucagon emergency kits should also be available, especially for longer activities Glucagon emergency kits should also be available, especially for longer activities

46 Most common following long duration or repeated bouts of high-intensity exercise Most common following long duration or repeated bouts of high-intensity exercise Caused by combination of enhanced insulin action & muscle glycogen repletion Caused by combination of enhanced insulin action & muscle glycogen repletion May occur up to hours afterwards, but 6-12 hours most common May occur up to hours afterwards, but 6-12 hours most common May be prevented by insulin doses and/or food intake May be prevented by insulin doses and/or food intake Prevention of Delayed-Onset Hypo

47 Hernandez JM, et al., Med Sci Sports Exerc, 32(5): , 2000

48 10-second Sprint at Exercise End Bussau VA, et al., Diab. Care, 29(3): , 2006

49 Other Hypoglycemia Risks Prior hypoglycemia (day before) of 70 mg/dl or less can blunt hormone release during mod ex and risk of ex hypo Prior hypoglycemia (day before) of 70 mg/dl or less can blunt hormone release during mod ex and risk of ex hypo Hormonal exercise responses more blunted in males than females Hormonal exercise responses more blunted in males than females Likewise, prior (day before) exercise (prolonged low to moderate) can blunt next day responses to hypoglycemia Likewise, prior (day before) exercise (prolonged low to moderate) can blunt next day responses to hypoglycemia Galassetti, Sandoval, et al., Diab, AJP, 2004, 2006

50 Prevention of Hyperglycemia Hyperglycemia can acutely result from intense activities, or it can be worsened if metabolic control is poor before exercise Hyperglycemia can acutely result from intense activities, or it can be worsened if metabolic control is poor before exercise Avoid exercising if fasting glucose levels are >250 mg/dl with ketosis present (indicative of insulin deficiency) Avoid exercising if fasting glucose levels are >250 mg/dl with ketosis present (indicative of insulin deficiency) Use caution if glucose levels are >300 mg/dl, and no ketosis is present Use caution if glucose levels are >300 mg/dl, and no ketosis is present ADA/ACSM Position Statement on Diabetes Mellitus and Exercise, Diab. Care, 27(1): S58-62, 2004

51 Prevention of Dehydration

52 Hyperglycemia risk, but 1-2% of body fluids already lost when thirsty Hyperglycemia risk, but 1-2% of body fluids already lost when thirsty Dehydration can BG readings as well ( blood volume BG concentration) Dehydration can BG readings as well ( blood volume BG concentration) Hydrate with cool, plain water before & during activities, but dont overdo it Hydrate with cool, plain water before & during activities, but dont overdo it I full mouthful = about 1 oz. of fluid I full mouthful = about 1 oz. of fluid Use diluted fruit juices or sports drinks Use diluted fruit juices or sports drinks

53 Keys to Optimal Performance

54 Glycemic balance at all times is key to optimizing exercise performance Glycemic balance at all times is key to optimizing exercise performance Monitor blood glucose frequently Monitor blood glucose frequently Make diet and/or insulin changes to keep BG as close to normal as possible Make diet and/or insulin changes to keep BG as close to normal as possible

55 Keys to Optimal Performance Consume extra rapidly-absorbed carbs during exercise to prevent hypoglycemia Consume extra rapidly-absorbed carbs during exercise to prevent hypoglycemia Low BG causes early fatigue and poor performance Elevated insulin levels during exercise risk

56 Keys to Optimal Performance Consume carbs for 2-3 hours post-exercise to rapidly restore muscle glycogen Consume carbs for 2-3 hours post-exercise to rapidly restore muscle glycogen Take extra insulin as needed to cover rise in BG levels Glycogen repletion risk of delayed- onset hypoglycemia

57 Keys to Optimal Performance Consume adequate fluids to prevent and correct dehydration (esp. if hyperglycemic) Consume adequate fluids to prevent and correct dehydration (esp. if hyperglycemic) Dehydration performance Elevated BG risk of dehydration Dehydration can also BG readings

58 Keys to Optimal Performance Increase muscle mass to minimize insulin needs overall Increase muscle mass to minimize insulin needs overall Muscle acts as a glucose sink Lower insulin requirements leave less room for error in insulin doses

59 Conclusions

60 Exercise Your Right to Be Active High level, even elite/Olympic, athletic endeavors are possible w/ type 1 diabetes High level, even elite/Olympic, athletic endeavors are possible w/ type 1 diabetes Diabetic exercisers must be in good control of BG levels to perform optimally Diabetic exercisers must be in good control of BG levels to perform optimally Balancing carbohydrate intake with exercise use is key to maintain BG control Balancing carbohydrate intake with exercise use is key to maintain BG control Insulin doses usually have to be lowered for prolonged or frequent training as well Insulin doses usually have to be lowered for prolonged or frequent training as well

61 Gold Medal Dreams Are Still Possible With Type 1 Diabetes!

62 More Activity-Specific Information Sheri Colberg, PhD Human Kinetics (Champaign, IL) 2001 (261 pages) Over 85 sports and activities included


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