Presentation on theme: "Blood Glucose Control with Sports & Fitness Activities"— Presentation transcript:
1 Blood Glucose Control with Sports & Fitness Activities Gary Scheiner MS, CDEOwner/Clinical DirectorIntegrated Diabetes ServicesWynnewood, PA
2 ObjectivesOptimize glycemic control to enhance physical/athletic performancePrevent hypoglycemia during and after physical activityPrevent exercise-induced hyperglycemia, ketosis and DKAManage the logistics of wearing an insulin pump during physical activity
3 Blood Glucose Affects: StrengthStaminaSpeed/AgilityFlexibilitySafetyMental SharpnessSources: Colberg, Sheri: The Diabetic Athlete, Human Kinetics, Champaign, IL, 2001.Walsh J et al: Using Insulin, Torrey Pines Press, San Diego, 2003.Powers & Howley: Exercise Physiology, Wm C Brown Publishers, 1990.Diabetes Exercise & Sports Association North American Conferences, 2004 through 2007
4 What BG Is Optimal?Mmol:Source: Diabetes Exercise & Sports Association North American Conferences, 2004 through 2007
6 Fuel Utilization During Exercise 1st 5-10 seconds10 sec ~ 10 min~ 10 –~30 min.~ 30 min onwardStored ATP/CPAnaerobic GlycolysisOxidative(aerobic) metabolismIM glucoseHepaticGlycogenolysisHepatic (FFA)GluconeogenesisLikelihood of very low moderate very highHypoglycemia: low highScheiner, Gary, MS CDESource: Source: Brooks & Fahey: Exercise Physiology: Human Bioenergetics and its Applications, Macmillan Pub., NY, 1985.
7 Energy Sources During Exercise Substrate vs. DurationSubstrate vs. IntensityBG drops more rapidly during BG drops more rapidly asminute phase of prolonged exercise exercise intensity increasesScheiner, Gary, MS CDESource: Source: Brooks & Fahey: Exercise Physiology: Human Bioenergetics and its Applications, Macmillan Pub., NY, 1985.
9 Hormonal Responses to Exercise (diabetes, using insulin) Insulin Levels or Counterregulatory HormoneAction Suppressed Substrate Breakdown BlockedGlucose Uptake AcceleratedHypoglycemia May ResultScheiner, Gary, MS CDESource: Brooks & Fahey: Exercise Physiology: Human Bioenergetics and its Applications, Macmillan Pub., NY, 1985.
10 Insulin Adjustment Based on Timing and Duration Activity Within 2 Hours After MealActivity Before or Between MealsShort Duration(<90 Minutes)Mealtime BolusSnack Prior to ActivityDerived from: Diabetes Care, vol. 24, no. 4, 4/2001,
11 Insulin Adjustment Based on Timing and Duration Activity Within 2 Hrs After MealActivity Before or Between MealsLong Duration (>90 Minutes)Mealtime BolusBasal RateSnack at regular intervalsWatch for delayed-onset hypoglycemiaSnack Prior to ActivityBasal Rate (if using pump)
13 Insulin Adjustments Basal Adjustment (for > 90 min. activity) CSII: Basal rate 50% starting 1 hr pre-activity, or:CSII: Disconnect 1-hr prior, but reconnect hourly and bolus 50% of usual basal rate(for day-long activity)CSII: basal 50% daytime, 25% nighttimeShots: basal insulin 25%Derived from: Diabetes Care, vol. 24, no. 4, 4/2001,Source: Scheiner, Gary: Think Like A Pancreas, Marlowe Publishing, NY, 2005
14 “Automated” Pump Adjustments To Prevent Hypoglycemia Custom Bolus Options:Can label different I:C ratios for active situationsTemp Basal Presets:Can use pre-set tempbasal reduction forprolonged physicalactivityPalm/Zire Calculations:Can make percentageadjustments to full bolusamount for activity
15 Which is better for promoting weight loss? Exercise BEFORE eating?Exercise AFTER eating?
16 Pump disconnection: Effect on basal insulin level Based on observed pharmacodymanics of rapid-acting insulin analogs
17 Pump disconnection: Effect on basal insulin level Based on observed pharmacodymanics of rapid-acting insulin analogs
18 Pump disconnection: Effect on basal insulin level Disconnection during a short exercise session has minimal effect !
19 Pump disconnection: Effect on basal insulin level Based on observed pharmacodymanics of rapid-acting insulin analogs
20 Pump disconnection: Effect on basal insulin level Disconnection for > 90 minutes has little benefit early on, and can result in a serious insulin deficiency later!
21 Pump Temp Basal: Effect on basal insulin level Based on observed pharmacodymanics of rapid-acting insulin analogs
22 Pump temp basal: Effect on basal insulin level This approach results in a modest reduction in basal insulin throughout and immediately post-exercise.
23 Insulin Adjustment: Case Study 2-Hour Lacrosse Practice(after dinner) Dinner bolus 50% Disconnect 1-hr pre-practice, re-connect hourly & bolus 50% of usual basalSnack at midpoint (if BG appears to be dropping)
24 Snacking to prevent hypoglycemia Basic Rules:Snack prior to activity to prevent hypoglycemia Adjust quantity based on pre-activity BG or direction of BG BG low or dropping: usual carbs BG OK or stable: usual carbs BG High or rising: usual carbs Snack at least once per hour during prolonged activity Choose high-glycemic-index forms of carbohydrate Sports drinks / Sweetened beverages Dry cereal, pretzels, crackersSource: Scheiner, Gary: Think Like A Pancreas, Marlowe Publishing, NY, 2005
25 Which approach keeps BG in range for the majority of the workout? 13mmol6mmol4mmolSource: Scheiner, Gary, MS CDE
26 Snacking to prevent a low Carbohydrate Requirement Per 60 Minutes of Activity(if no insulin adjustments are made)50 lbs100 lbs150 lbs200 lbs250 lbsDancing or Gymnastics8-12g17-23g25-35g34-46g42-57gTennis (singles)18-22g37-43g55-65g74-86g92-107gSwimming (fast pace)22-25g44-50g65-75g88-100ggSources: Scheiner, Gary: Think Like A Pancreas, Marlowe Publishing, NY, 2005Walsh, John and Roberts, Ruth: Pumping Insulin, 4th ed., Torrey Pines Press, San Diego, 2006.Heyward, Vivian: Designs for Fitness, Macmillan Publishing, NY, 1984.
27 Snacking to prevent a low Carbohydrate Requirement Per 60 Minutes of Activity(if no insulin adjustments are made)50 lbs100 lbs150 lbs200 lbs250 lbsCleaning Up3-7g7-13g10-20g14-26g17-32gBrisk Walking (mall/theme park)8-12g17-23g25-35g34-46g42-57gMowing (push-mower)13-17g27-33g40-50g54-66g67-82gSources: Scheiner, Gary: Think Like A Pancreas, Marlowe Publishing, NY, 2005Walsh, John and Roberts, Ruth: Pumping Insulin, 4th ed., Torrey Pines Press, San Diego, 2006.Heyward, Vivian: Designs for Fitness, Macmillan Publishing, NY, 1984.
28 Snacking to prevent low: Case Study After School Tennis (85 lb girl) Check BG priorSnack 20g (if BG / 9-11mmol)Snack 30g (if BG / 5-9mmol) Snack 40g (if BG <100 / 5mmol)No snack (if BG >200 / 11mmol)Addl. 20g snack after each hr of play
29 Vai@bL$: Just a Few Factors that affect Blood Glucose During Exercise Active InsulinInfusion SiteWhat You AteWhen You AteEmotional StateTemp/HumidityFamiliarity w/ActivityAmt. Of Prior ActivitySize/Number of Muscles InvolvedDurationIntensitySources: Walsh J et al: Using Insulin, Torrey Pines Press, San Diego, 2003.Scheiner, Gary: Think Like A Pancreas, Marlowe Publishing, NY, 2005.
30 Watch Out for D’OH! (Delayed Onset Hypoglycemia) Following high-intensity exerciseFollowing extended duration activityDue to replenishment of muscle glycogen stores, enhanced insulin sensitivityMay occur up to 24 hours afterwards (typically 6-12 hours later)Source: Colberg, Sheri: The Diabetic Athlete, Human Kinetics, Champaign, IL, 2001.
31 D’OH! Prevention Keep records – track the patterns Decrease basal insulin (modestly) or meal/snack boluses post-activity“Free” Snacks (slow-acting carbs) following activity
32 D’OH! Prevention Check BGs more frequently q 2 hrs during “high risk” period3am night following activityWear a continuous glucose monitor
33 Symlin: Exercise Implications Acts on central nervous system AppetiteSlows gastric emptyingInhibits glucagon secretionMain benefit: blunt post-meal spikeSource: Symlin product insert!!! Symlin is not needed or recommended if exerciseis planned after the meal.!!! Avoid using Symlin immediately after heavy orlong-duration exercise due to risk of low BG.
35 Adrenaline Raises BG! Blood Glucose Homeostasis: The Grand Balancing ActMuscle ActivityInsulinCarbohydrateCounterregulatory / Stress HormonesAdrenaline Raises BG!
36 Adrenaline Raises BG!Activities that often produce a short-term blood glucose rise include: Weight lifting (high weight, low reps) Sports w/ “bursts” of activity(golf, baseball, martial arts) Sprints (running, swimming) Judged performances(gymnastics, skating)Events in which WINNING is the primaryobjectiveSources: Colberg, Sheri: The Diabetic Athlete, Human Kinetics, Champaign, IL, 2001.
37 Preventing / Offsetting BG Rise Keep Records to determine avg. BG riseCheck BG Min. Pre-ActivityBolus min. prior to activity to offset rise(give 50% of usual amount required) Take 50% of Usual “Correction Dose” If High(reduce based on insulin-on-board)Sources: Scheiner, Gary: Think Like A Pancreas, Marlowe Publishing, NY, 2005
38 Snacking to prevent high: Case Study Late-Morning Basketball; disconnects for 1 hour; BG typically rises from 100s to 300s (5 to 15 mmol). Check BG 30 min priorBolus 50% of amount required to covercurrent BG (including IOB)Bolus 50% of amount needed to offset200 mg/dl riseCheck BG at halftime; keep sugareddrinks handy.
39 Dehydration Can Raise Blood Glucose Concentration Decreased blood volume will give the impression that blood sugar level has risenWater is needed to convert fat & glucose into energyAdequate hydration improves performance and prevents crampingThirst occurs after dehydration has occurredDrink before & after exerciseExtra fluids during extended exercise or with warm/humid conditionsSource: Osterberg, Kris, MS, RD – Senior Scientist, Gatorade Sports Science Institute
41 Normal (Sufficient Insulin) Source: Scheiner, Gary, Think Like a Pancreas, Marlowe Pub., NY, 2005
42 Abnormal (Insulin Deficiency) possibly due to: Missed Injection Pump Problem: Spoiled Insulin - Occlusion Poor Absorption - Air in Tubing Insufficient Dose - Canula Dislodgement Illness - Extended DisconnectionSource: Scheiner, Gary, Think Like a Pancreas, Marlowe Pub., NY, 2005
43 Exercise During Insulin Deficiency Exercise During Insulin Deficiencyresults: Higher Blood Sugar+ More Ketones+ Dehydration (urination, perspiration) **KETOACIDOSIS**Source: Scheiner, Gary, Think Like a Pancreas, Marlowe Pub., NY, 2005
44 To Prevent Ketoacidosis Check urine for ketones prior to exercise w/BG > 250 mg/dl (7mmol)No exercise w/positive ketones (small or more on urine ketostix; >.5 mmol/l on ß Ketone test using Precision Xtra meter)OK to exercise if nonketotic – take 50% of usual “correction” bolus and drink plenty of waterDo not disconnect for more than 2 hoursSource: Diabetes Care vol. 30 Supplement 1: ADA Clinical Practice Recommendations 2007
45 “Automated” Pump Features for Extended Disconnection Disconnect Feature:Can bolus up to 50% of anticipated missed basalCan replace missed basal upon reconnectionCan remind user to reconnect after preset time interval ( min)
46 Alternatives to extended pump disconnection Re-Connect hourlyBolus a portion (50%?)of missed basal rateExample:Disconnecting for 3 hours, usual basal rate .6u/hrPrior to dx: bolus .31 hr: connect, bolus .3, dx2 hrs: connect, bolus .3, dx3 hrs: reconnect
47 Alternatives to extended pump disconnection Wear It!Clip to tight clothingSport PackFanny PackBackpack Harness
48 Infusion Set Adhesion During Exercise Smart Set PlacementUnder tight clothingBody part w/less skinmovementSkin prep agentw/adhesive (IV Prep,Skin Prep, Mastisol)Tape over site (Smith+ Nephew, 3M)
49 Pump & Temperature Extremes During Exercise Cold:Generally not a concern whenpump is worn against bodyHeat:Insulin analogs can denature if:Exposed to > 98°FStored or worn > 86°FPump function OK under most conditionsSources: insulin package inserts, insulin pump manufacturers
50 Pump & Temperature Extremes During Exercise “Cool” Ideas:Keep pump out of direct sunlightWear under clothingStore in a cool place when disconnectedDon’t forget the tubing!!!Spend less time in extreme heatGet into a/c and shade periodicallyHumidity is not a factorFRIO Cooling Case
51 Diabetes Exercise & Sports Association (DESA) InformationResourcesNetworkingInspiration