6/5/2014 1 DIABETES AND EXERCISE PHYSIOLOGY Anne Peters, MD Professor, USC Keck School of Medicine Director, USC Clinical Diabetes Programs Disclosure of Financial Relationships Consultantship Abbott Diabetes Care BD Janssen Lilly Medscape Medtronic Minimed NovoNordisk Sanofi Takeda Speakers Bureau BMS/AstraZeneca NovoNordisk Challenges for Athletes with Diabetes • Varying workouts—type/duration/intensity • Different responses to training vs competition • Unpredictability • Risk for hypoglycemia • Impact of hyperglycemia on performance • Physical factors (sweat/water/heat/cold) • Everything else that impacts athletes without diabetes… Exercise Physiology 101 • Muscles use glucose as primary energy source initially—this comes from muscle glycogen stores • Once these sources are depleted there is a balance between glucose production (mostly from hepatic glycogenolysis) and glucose uptake by exercising muscle. • Immediately post-exercise there is a rapid decrease in catecholamines and increase in insulin levels with restoration of muscle glycogen Gallen IW et al. Diabetes, Obesity and Metabolism 13:130-136, 2011 The Problem • Savanah wants to train for a 10 K. She starts to train. • She tests her BG pre-exericse which is 105 mg/dl. Ate 35 g CHO. No insulin. Waits to work out. • 1 hour later BG = 240 mg/dl. Suspended pump. Four mile walk/jog. • 15 mins after exercise BG = 102 mg/dl. Ate 10 g CHO. • 15 minutes later BG = 144 mg/dl. Ate 30 g CHO in a snack and gave 3.4 units insulin. Time = 4 PM. The Problem • 6 pm (2 hours later) BG = 45 mg/dl. Ate 100 g CHO (she notes: overate due to hunger/workout/poor choice). • Waited for 30 mins and gave 8.1 units. • 10 PM = 133 mg/dl. • 11 PM = 46 mg/dl, felt nauseated, ate 30 g CHO. • 11:15 PM = 59 mg/dl. • 11:30 PM = 35 mg/dl. Ate 30 g CHO.
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6/5/2014
1
DIABETES AND EXERCISE
PHYSIOLOGY
Anne Peters, MD
Professor, USC Keck School of Medicine
Director, USC Clinical Diabetes Programs
Disclosure of Financial Relationships
Consultantship
Abbott Diabetes Care
BD
Janssen
Lilly
Medscape
Medtronic Minimed
NovoNordisk
Sanofi
Takeda
Speakers Bureau
BMS/AstraZeneca
NovoNordisk
Challenges for Athletes with Diabetes
• Varying workouts—type/duration/intensity
• Different responses to training vs competition
• Unpredictability
• Risk for hypoglycemia
• Impact of hyperglycemia on performance
• Physical factors (sweat/water/heat/cold)
• Everything else that impacts athletes without diabetes…
Exercise Physiology 101
• Muscles use glucose as primary energy source
initially—this comes from muscle glycogen stores
• Once these sources are depleted there is a balance
between glucose production (mostly from hepatic
glycogenolysis) and glucose uptake by exercising
muscle.
• Immediately post-exercise there is a rapid decrease in
catecholamines and increase in insulin levels with
restoration of muscle glycogen
Gallen IW et al. Diabetes, Obesity and Metabolism 13:130-136, 2011
The Problem
• Savanah wants to train for a 10 K. She starts to train.
• She tests her BG pre-exericse which is 105 mg/dl. Ate 35 g CHO.
No insulin. Waits to work out.
• 1 hour later BG = 240 mg/dl. Suspended pump. Four mile
walk/jog.
• 15 mins after exercise BG = 102 mg/dl. Ate 10 g CHO.
• 15 minutes later BG = 144 mg/dl. Ate 30 g CHO in a snack and
gave 3.4 units insulin. Time = 4 PM.
The Problem
• 6 pm (2 hours later) BG = 45 mg/dl. Ate 100 g CHO (she
notes: overate due to hunger/workout/poor choice).
• Waited for 30 mins and gave 8.1 units.
• 10 PM = 133 mg/dl.
• 11 PM = 46 mg/dl, felt nauseated, ate 30 g CHO.
• 11:15 PM = 59 mg/dl.
• 11:30 PM = 35 mg/dl. Ate 30 g CHO.
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The Problem
• Midnight BG = 90 mg/dl, 12:15 am = 88 mg/dl.
• Afraid to sleep. Suspends pump for 2 hours.
• 2:30 AM BG = 355 mg/dl. Suggested dose = 4.7 units. She
gave 3.5 units.
• 7 AM BG = 297 mg/dl. Suggested dose = 3.7 units, she gave
3.3 units.
• 10 AM BG = 66 mg/dl. 15 g CHO.
• 10:15 AM BG = 68 mg/dl. 30 g CHO.
• Noon = 110 mg/dl.
The Problem
• Total extra CHO due to lows = 230 g
• Total extra calories due to lows = 920
• Total impact on confidence = huge
Nondiabetic Athletes’ Fuel Focus: Carbs
• Providing adequate fuel to muscle
• May cycle carbohydrate intake during phases of
training
• Carbohydrate loading (3 days of a carbohydrate
intake of 8-12 g/kg/day or 70 – 85% of total caloric
intake with a taper in training) can double muscle
glycogen
• To replete glycogen stores: CHO intake of ~1.0–1.5
g/kg BW (0.5–0.7 g/lb) during the first 30 min after
exercise and every 2 h for 4–6 h.
Carbohydrate Requirements for Exercise
Training Load CHO recommendation
(g/kg/day)
Very Light Training 3-5
Moderate intensity for 1 hr/day 5-7
Mod to high intensity for 1-3 hr/day 7-10
Mod to high intensity for 4-5 hr/day 10-12
Gallen IW et al. Diabetes, Obesity and Metabolism 13:130-136, 2011
Typical Training Day Meal for Michael Phelps Muscle Glycogen and Training
Ryan M. Sports Nutrition for Endurance Athletes
Mu
scle
Gly
co
gen
Level
(mm
ol
kg
)
Time (Days)
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Barriers to Physical Activity Among Patients With
Type 1 Diabetes
CONCLUSION— Fear of hypoglycemia is the strongest
barrier to regular physical activity
Diabetes Care 31:2108–2109, 2008
Causes of Hypoglycemia During Exercise
• Inability to reduce basal insulin levels during exercise