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Type 1 Diabetes and Exercise: Strategies for Insulin Management John Devlin, MD, MPH
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Type%1%Diabetes%and%Exercise:%% …...“Itis$impossible$to$ provide%a%single%set%of%guidelines% appropriate$for$all$people$with$diabetes$who$wish$to$exercise,$ $and$the$bestadvice$is$to$

Jul 18, 2020

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Page 1: Type%1%Diabetes%and%Exercise:%% …...“Itis$impossible$to$ provide%a%single%set%of%guidelines% appropriate$for$all$people$with$diabetes$who$wish$to$exercise,$ $and$the$bestadvice$is$to$

Type  1  Diabetes  and  Exercise:    Strategies  for  Insulin  Management  

John  Devlin,  MD,  MPH  

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Type  1  Diabetes  and  Exercise:    How  about  glycemic  control  ?  

How  exercise  affects  blood  glucose  level  

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Lawrence  RD.    Br  Med  J  1926;  1:648-­‐50  

10 U insulin

050

100150200250300

0 30 60 90 120 150

Time, min

Blo

od g

luco

se, m

g/dl

Insulin aloneInsulin + Exercise

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Schematic illustration of the blood glucose response to exercise

Riddell, M.C. et al. Pediatric Diabetes 2006;7:60-70

Ideal control

Over-insulinized

Under-insulinized

Competition and/or heat stress

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Risks of Exercise:

•  Hypoglycemia •  Hyperglycemia •  Ketosis

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•  Not enough food

•  Too much insulin

•  Extra exercise

Causes of Hypoglycemia

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Energy  Sources  During  Exercise  

0%

20%

40%

60%

80%

100%

0 Hrs

1/2 H

r1 H

r

1 1/2

Hrs2 H

rs

2 1/2

Hrs3 H

rs

FatGlucose

Substrate  vs.  DuraHon   Substrate  vs.  Intensity  

0%

20%

40%

60%

80%

100%

50% 60% 70% 80% 90% 100%Percent VO2 Max

Fat

Glucose

BG  drops  more  rapidly  during  15-­‐60                  BG  drops  more  rapidly  as  minute  phase  of  prolonged  exercise    exercise  intensity  increases  

Scheiner,  Gary,  MS  CDE  Source:  Source:  Brooks  &  Fahey:  Exercise  Physiology:  Human  BioenergeHcs  and  its  ApplicaHons,  Macmillan  Pub.,  NY,  1985.  

 

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Insulin  dose  adjustment  before  exercise  

Bruce  Bode,  ADA  2015;    JDRF  PEAK  program,  “T1D  Performance  in  Exercise  and  Knowledge”  

Recommenda4on  

PaHents  on  MDI  •  Reduce  pre-­‐exercise  bolus  insulin  by  50%  and  

take  extra  Carbs  during  exercise  prn  

Exercise  ≤  90  min  a`er  meal  •  Reduce  pre-­‐exercise  insulin  dose  and  consume  

Carbs  with  a  low  G.I.  

Exercise  >  90  min  a`er  meal   •  If  blood  glucose  is  low,  consume  Carbs  

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Insulin  dose  adjustment  before  exercise  (2)  

Toni  et  al.    Acta  Biomed.  2006;77  (Suppl.  1):  34-­‐40.  

Insulin  administra4on    

•  Inject  insulin  into  subcutaneous  fat  in  either  the  abdomen  or  non-­‐exercising  muscle  

•  Reduce  the  pre-­‐meal  insulin  dose  for  exercise  in  the  postprandial  phase  

•  25-­‐50%  if  duraHon  is  <  90  minutes  •  >  50%  if  duraHon  is  >  90  minutes  

•  Reduce  morning  meal  insulin  for  exercise  before  breakfast  

•  25-­‐75%  depending  on  intensity  •  Reduce  prandial  insulin  AND  basal  insulin  for  exercise  over  4  hours,  intense  team  sports,  etc.  

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Watch  Out  for  D’OH!  (Delayed  Onset  Hypoglycemia)  

Ø  Following  high-­‐intensity  exercise  

Ø  Following  extended  duraHon  acHvity  

Ø  Due  to  replenishment  of  muscle  glycogen  stores,  enhanced  insulin  sensiHvity  

Ø May  occur  up  to  24  hours  a`erwards  (typically  6-­‐12  hours  later)  

Source:  Colberg,  Sheri:    The  DiabeHc  Athlete,  Human  KineHcs,  Champaign,  IL,  2001.  

     

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Figure 1 Mean glucose levels on the exercise and sedentary days.

The Diabetes Research in Children Network (DirecNet) Study Group

Impact of Exercise on Overnight Glycemic Control in Children with Type 1 Diabetes Mellitus

The Journal of Pediatrics, Volume 147, Issue 4, 2005, 528 - 534

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Insulin  dose  adjustment  a`er  exercise  

First  4me  exercise    •  Insulin  may  need  all  night  dose  reducHon  

Regular  exercise    •  Reduce  insulin  dose  unHl  3  am  

Bruce  Bode,  ADA  2015;    JDRF  PEAK  program  

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AlternaHves  to  Carbohydrate  Intake  

Bruce  Bode,  ADA  2015;    JDRF  PEAK  program,  “T1D  Performance  in  Exercise  and  Knowledge”  

•  Intermihent  high  intensity  sprint  for  10  sec,  to  maintain  BG  while  awaiHng  Carb  intake  

•  Used  to  counter  the  rapid  fall  in  glycemia  due  to  moderate-­‐intensity  exercise  in  individuals  with  T1D  

•  NOTE:  Repeated  circuits  of  high-­‐intensity  exercise,  especially  when  mixed  with  aerobic  exercise,  could  result  in  significant  reducHons  in  BG  levels  

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Avoidance  of  nocturnal  hypoglycemia  

Bruce  Bode,  ADA  2015;    JDRF  PEAK  program,  “T1D  Performance  in  Exercise  and  Knowledge”  

•  Nocturnal  hypoglycemia  may  result  from:  •  Glycogen  levels  not  being  replaced  •  Bolus  insulin  following  high-­‐intensity  exercise  in  the  late  a`ernoon/evening  

•  ReducHon  of  basal  insulin  dose  by  10-­‐20%  in  the  first  12  hours  a`er  exercise  reduces  the  risk  of  hypoglycemia  

•  AutomaHc  suspension  of  insulin  delivery  significantly  reduces  the  duraHon  and  severity  of  exercise-­‐induced  hypoglycemia  without  rebound  hyperglycemia  

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Can  Exercise  Cause    

Rise  in  BG?  

Ketoacidosis?  

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Adrenaline  Raises  BG!  Activities that often produce a short-

term blood glucose rise include:    

               æ Weight lifting (high weight, low reps) æ Sports w/ “bursts” of activity (golf, baseball, martial arts)

æ Sprints (running, swimming) æ Judged performances

(gymnastics, skating) æ Events in which WINNING is the primary objective

     

Sources:    Colberg,  Sheri:    The  DiabeHc  Athlete,  Human  KineHcs,  Champaign,  IL,  2001.  

 

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Exercise-­‐induced  ketosis  

00.5

11.5

22.5

33.5

4

0 30 60 90 120

150

180

Time, min

Plas

ma

keto

nes,

mm

ol/l

0

50

100

150

200

250

300

350

400

0 30 60 90 120 150 180

Time, min

Blo

od g

luco

se, m

g/dl

Adapted from Berger M. Diabetologia 1977; 13:355.

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To  Prevent  Ketoacidosis  

ü  Check  urine  for  ketones  prior  to  exercise  w/BG  >  250  mg/dl  (7  mmol)  

ü  No  exercise  w/posiHve  ketones  (small  or  more  on  urine  ketosHx;  >0.5  mmol/l  on  ß  Ketone  test  using  Precision  Xtra  meter)  

ü  OK  to  exercise  if  non-­‐ketoHc  –  take  50%  of  usual  “correcHon”  bolus  and  drink  plenty  of  water  

ü  Do  not  disconnect  for  more  than  2  hours  

 

Source:  Diabetes  Care  vol.  30  Supplement  1:  ADA  Clinical  PracHce  RecommendaHons  2007  

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Exercise  with  Use  of  Technology  

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History of Pumps

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Alterna4ves  to  extended  pump  disconnec4on  

Wear  It!  ü   Clip  to  Hght  clothing  ü   Sport  Pack  

ü   Fanny  Pack  ü   Backpack  Harness  

   

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Infusion  Set  Adhesion  During  Exercise  

ü Smart  Set  Placement  Ø  Under  Hght  clothing  

Ø   Body  part  w/less  skin              movement  

ü   Skin  prep  agent            w/adhesive    (IV  Prep,              Skin  Prep,  MasHsol)  

ü   Tape  over  site    (Smith            +  Nephew,  3M)  

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The  Athlete  with  Diabetes  

Gary  Hall  Jr.   Jason  Johnson  

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Pump  &  Temperature  Extremes  During  Exercise  

Cold:  Generally  not  a  concern  when    pump  is  worn  against  body  

Heat:    

Insulin  analogs  can  denature  if:  Ø Exposed  to  >  98°F  Ø Stored  or  worn  >  86°F  Pump  funcHon  OK  under  most  condiHons    

Sources:  insulin  package  inserts,  insulin  pump  manufacturers  

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Pump  &  Temperature  Extremes  During  Exercise  

“Cool”  Ideas:  ü   Keep  pump  out  of  direct  sunlight  

•   Wear  under  clothing  •   Store  in  a  cool  place  when  disconnected  •   Don’t  forget  the  tubing!!!  

ü Spend  less  Hme  in  extreme  heat  •   Get  into  a/c  and  shade  periodically  •   Humidity  is  not  a  factor  

ü   FRIO  Cooling  Case  

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Bionic  Pancreas  

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Bionic  Pancreas:    Role  of  Glucagon  

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“It  is  impossible  to  provide  a  single  set  of  guidelines    appropriate  for  all  people  with  diabetes  who  wish  to  exercise,    and  the  best  advice  is  to  encourage  pa:ents  with  diabetes  to  document  for  themselves  what  works  and  what  does  not  work.”  

Wallberg-­‐Henriksson  Diabetes  1982;31:1044-­‐50.  

“Instead  of  focusing  on  the  summit,  focus  on  developing  and  building  those  growth  habits.      It’s  not  a  recipe,  it’s  an  equaPon.    Three  important  words  -­‐        Educate  

               Prepare                  Experiment                      in  that  order,  and  in  a  loop.”  

 


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