Presentation on theme: "Blood Glucose Control with Sports & Fitness Activities"— Presentation transcript:
1Blood Glucose Control with Sports & Fitness Activities Gary Scheiner MS, CDEOwner/Clinical DirectorIntegrated Diabetes ServicesWynnewood, PA
2ObjectivesOptimize 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
3Blood 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
4What BG Is Optimal?Mmol:Source: Diabetes Exercise & Sports Association North American Conferences, 2004 through 2007
6Fuel 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.
7Energy 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.
9Hormonal 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.
10Insulin 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,
11Insulin 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)
13Insulin 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
15Which is better for promoting weight loss? Exercise BEFORE eating?Exercise AFTER eating?
16Pump disconnection: Effect on basal insulin level Based on observed pharmacodymanics of rapid-acting insulin analogs
17Pump disconnection: Effect on basal insulin level Based on observed pharmacodymanics of rapid-acting insulin analogs
18Pump disconnection: Effect on basal insulin level Disconnection during a short exercise session has minimal effect !
19Pump disconnection: Effect on basal insulin level Based on observed pharmacodymanics of rapid-acting insulin analogs
20Pump disconnection: Effect on basal insulin level Disconnection for > 90 minutes has little benefit early on, and can result in a serious insulin deficiency later!
21Pump Temp Basal: Effect on basal insulin level Based on observed pharmacodymanics of rapid-acting insulin analogs
22Pump temp basal: Effect on basal insulin level This approach results in a modest reduction in basal insulin throughout and immediately post-exercise.
23Insulin 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)
24Snacking 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
25Which approach keeps BG in range for the majority of the workout? 13mmol6mmol4mmolSource: Scheiner, Gary, MS CDE
26Snacking 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.
27Snacking 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.
28Snacking 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
29Vai@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.
30Watch 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.
31D’OH! Prevention Keep records – track the patterns Decrease basal insulin (modestly) or meal/snack boluses post-activity“Free” Snacks (slow-acting carbs) following activity
32D’OH! Prevention Check BGs more frequently q 2 hrs during “high risk” period3am night following activityWear a continuous glucose monitor
33Symlin: 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.
35Adrenaline Raises BG! Blood Glucose Homeostasis: The Grand Balancing ActMuscle ActivityInsulinCarbohydrateCounterregulatory / Stress HormonesAdrenaline Raises BG!
36Adrenaline 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.
37Preventing / 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
38Snacking 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.
39Dehydration 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
41Normal (Sufficient Insulin) Source: Scheiner, Gary, Think Like a Pancreas, Marlowe Pub., NY, 2005
42Abnormal (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
43Exercise 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
44To 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)
46Alternatives 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
47Alternatives to extended pump disconnection Wear It!Clip to tight clothingSport PackFanny PackBackpack Harness
48Infusion 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)
49Pump & 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
50Pump & 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
51Diabetes Exercise & Sports Association (DESA) InformationResourcesNetworkingInspiration