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Page 1: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

Exercise & Busy KidsExercise & Busy Kids Smart Pumps & SportsSmart Pumps & Sports

Rick Philbin, MBA, MED, ATCRick Philbin, MBA, MED, ATCSports Program Coordinator, CWDSports Program Coordinator, CWD

Board Member, Diabetes, Exercise, & Sports Assoc.Board Member, Diabetes, Exercise, & Sports Assoc.Regional Manager, Animas CorporationRegional Manager, Animas Corporation

Page 2: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

A Typical Blood Sugar A Typical Blood Sugar ResponseResponse

020406080

100120140160180200

10 20 30 40 60 80 100 120

Blood Sugar

Joslin Medical Publication

Page 3: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

Effect of Exercise on Blood Sugar LevelsEffect of Exercise on Blood Sugar Levels

050

100150200250300350400450500

10 20 30 40

DM- NotControlled

DM - Controlled

Non- DM

Joslin Medical Publication

Lacking insulin

With insulin

No diabetes

Page 4: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

Exercising After FoodExercising After Food

020406080

100120140160180200

0 20 40 60 80 100 120 140 160 180

Exercise Effect

Meal Effect

Page 5: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

Know the Action of Your InsulinKnow the Action of Your Insulin

Glargine(no peak)

NovoLog

Page 6: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

ConsiderationsConsiderations

Factors affecting BG during exerciseFactors affecting BG during exercise– Time of dayTime of day– BG at start of exercise (do you have a target?)BG at start of exercise (do you have a target?)– Bolus timing for meal prior to exerciseBolus timing for meal prior to exercise– Site location (absorption issues)Site location (absorption issues)– Food eaten prior to exercise (when?)Food eaten prior to exercise (when?)– Type, duration, intensity of exerciseType, duration, intensity of exercise– Physical condition (fit or unfit?)Physical condition (fit or unfit?)– HydrationHydration

Smart Pumping, Howard Wolpert, MD

Page 7: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

Temporary BasalTemporary Basal

Enables patient to temporarily Enables patient to temporarily reduce or increase the active basal reduce or increase the active basal raterate

Accommodates for exercise or any Accommodates for exercise or any substantial prolonged change in substantial prolonged change in normal activity levelnormal activity level

All smart pumps have this featureAll smart pumps have this feature

Page 8: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

When to Use Temporary BasalWhen to Use Temporary Basal

Exercise - decreaseExercise - decrease– Start Temp Basal ~ 1 Start Temp Basal ~ 1

½ to 3+ hours prior to ½ to 3+ hours prior to exerciseexercise

– End Temp Basal ~ 30 End Temp Basal ~ 30 minutes to as much as minutes to as much as 24hrs after exercise24hrs after exercise

Less Activity - increaseLess Activity - increase– Off seasonOff season– Long Car RidesLong Car Rides

Page 9: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

Key ElementsKey Elements

DoseDose– Amount of decrease or increase Amount of decrease or increase

percentagepercentage

Duration for temporary adjustmentDuration for temporary adjustment

Test often to see a patternTest often to see a pattern

Page 10: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

What to do with the Pump?What to do with the Pump?

Pre-exercise meal boluses may be Pre-exercise meal boluses may be reduced as much as 50% depending on reduced as much as 50% depending on when exercise will take placewhen exercise will take place

Basal Adjustments?Basal Adjustments?– 0-20% decrease for exercise/activity of 0-20% decrease for exercise/activity of

moderate intensity and short durationmoderate intensity and short duration– 25-100% decrease for exercise/activity of 25-100% decrease for exercise/activity of

moderate to high intensity and longer durationmoderate to high intensity and longer duration– Trial and errorTrial and error

Page 11: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

ChallengesChallengesDelayed onset Delayed onset hypoglycemiahypoglycemia– What is it?What is it?

Varying requirements Varying requirements for different activitiesfor different activities– Testing to establish Testing to establish

patterns and BG targetspatterns and BG targets

Supplemental snack Supplemental snack may still be necessary may still be necessary for replacing glycogen for replacing glycogen stores lost during stores lost during exerciseexercise

Page 12: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

Tools for SuccessTools for Success

Target BG goals Target BG goals establishedestablished– Exercise (e.g., 150 mg/dl)Exercise (e.g., 150 mg/dl)

Test effectiveness of the Test effectiveness of the settingssettings

Ability to adjust key Ability to adjust key elements for fine-tuningelements for fine-tuning

Understand Understand preventingpreventing hypoglycemia is easier hypoglycemia is easier than treatingthan treating

Page 13: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

Insulin Pump Therapy and ExerciseInsulin Pump Therapy and Exercise

Where do you Where do you carry it during carry it during exercise?exercise?

Can you play Can you play contact sports?contact sports?

How often do you How often do you change the change the infusion site?infusion site?

You may give yourself You may give yourself a bolus of insulin for a a bolus of insulin for a high glucose readinghigh glucose readingYou may adjust your You may adjust your basal delivery of basal delivery of insulin depending on insulin depending on your glucose readings your glucose readings (temporary basal rate)(temporary basal rate)

Page 14: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

VariablesVariables

Blood flow differencesBlood flow differences– ActivityActivity– Site selectionSite selection

Abdomen is fastest ~34 Abdomen is fastest ~34 min*min*Deltoid, Femoral, Gluteal Deltoid, Femoral, Gluteal about the same (rapid-about the same (rapid-acting)acting)

– Ambient temperatureAmbient temperatureHot, increased absorptionHot, increased absorptionCold, decreased Cold, decreased absorptionabsorption

Dose sizeDose size– Larger, longerLarger, longer– Smaller, shorterSmaller, shorter

WeightWeight– Insulin resistanceInsulin resistance

Insulin qualityInsulin quality

*Insulin Aspart: A Fast-Acting Analog of Human Insulin, Mudaliar S, et. Al.

Page 15: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

Competition?Competition?

Page 16: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

Children on insulin pumpsChildren on insulin pumpsIf basal insulin is set correctly, changes in meal If basal insulin is set correctly, changes in meal scheduling due to exercise should not present a scheduling due to exercise should not present a problem.problem.

Kids can disconnect their pump for 1 hour, test and Kids can disconnect their pump for 1 hour, test and correct if above target.correct if above target.

They may need to eat a snack in order to bolus if They may need to eat a snack in order to bolus if they want to stay disconnected for a second hour. they want to stay disconnected for a second hour. Two hours without any insulin is too long, this can Two hours without any insulin is too long, this can lead to ketones. You can have ketones with a lead to ketones. You can have ketones with a normal blood glucose reading.normal blood glucose reading.

If they stay connected, they may need a temporary If they stay connected, they may need a temporary basal. This may need extended beyond the activity.basal. This may need extended beyond the activity.

Page 17: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

To Connect or Disconnect the Pump To Connect or Disconnect the Pump During Exercise or Competition?During Exercise or Competition?

This may be left to This may be left to the discretion of the the discretion of the individualindividual

Should not disconnect Should not disconnect for more than one for more than one hourhour

What are the rules for What are the rules for wearing a pump wearing a pump during competition?during competition?

Page 18: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

Carbohydrate CalculatorCarbohydrate CalculatorBG Correction BG Correction CalculatorCalculator– Input BG readingInput BG reading– Input personal Insulin Input personal Insulin

Sensitivity Factor (ISF)Sensitivity Factor (ISF)– A correction dose is A correction dose is

calculatedcalculated– Correct back to target Correct back to target

BG prior to exercise not BG prior to exercise not normal rangenormal range

Page 19: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

Definition:Definition:Insulin on Board (IOB)Insulin on Board (IOB)

The amount of insulin still The amount of insulin still active at a given time after a active at a given time after a bolus.bolus.

Page 20: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

The 30% RuleThe 30% Rule

Pumping Insulin, Walsh J, Roberts R

Page 21: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

BenefitsBenefits

Decreased risk of stacking insulinDecreased risk of stacking insulin– Less chance of hypoglycemiaLess chance of hypoglycemia

Decreased risk of intentionally running Decreased risk of intentionally running high due to fear of hypoglycemiahigh due to fear of hypoglycemia– Improved HbA1cImproved HbA1c

Page 22: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

ChallengesChallengesOne size doesn’t fit One size doesn’t fit allall– Variability Variability

intraindividual intraindividual ~10 - 20%~10 - 20%

– Variability Variability interindividualinterindividual

~20 - 35%~20 - 35%

Variability of the Metabolic Effect of Soluble Insulin and the Rapid-Acting Insulin analog Insulin Aspart, Heinemann L, Weyer C, Rauhaus M, Heinrichs S, Heise T

Page 23: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

The after school sportThe after school sport

It may be beneficial to have an It may be beneficial to have an afternoon snack.afternoon snack.

Sports drinks should be used with Sports drinks should be used with caution.caution.– Many kids drink too much because they Many kids drink too much because they

are thirsty.are thirsty.– You don’t want to take away the benefit You don’t want to take away the benefit

of exercise by being hyperglycemic.of exercise by being hyperglycemic.

Page 24: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

TipsTips

Check often during exercise and in the Check often during exercise and in the following 24 to 36 hours (look for patterns)following 24 to 36 hours (look for patterns)Begin Temp rate Begin Temp rate beforebefore exercise begins exercise beginsMay need to lower boluses before exerciseMay need to lower boluses before exercise– ~50% less as a starting point~50% less as a starting point

May need lower bolus to correct high BG May need lower bolus to correct high BG before or during longer periods of exercisebefore or during longer periods of exerciseDisconnect can be an option up to one hourDisconnect can be an option up to one hour– Or 0% Temp rateOr 0% Temp rate

Smart Pumping, Howard Wolpert, MD

Page 25: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

Lows, Highs, and ExerciseLows, Highs, and Exercise

The longer and more The longer and more strenuous the exercise, strenuous the exercise, the more likely the blood the more likely the blood glucose will go lowglucose will go low

Less trained individuals Less trained individuals will more likely go lowwill more likely go low

Strenuous and anaerobic Strenuous and anaerobic exercise may raise blood exercise may raise blood glucoseglucose

Page 26: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

Strategies for Avoiding Strategies for Avoiding HypoglycemiaHypoglycemia

Exercise 11/2 to 3 hours Exercise 11/2 to 3 hours after eatingafter eatingKnow your individual Know your individual glucose response to glucose response to exerciseexerciseTest you glucose levels Test you glucose levels before you exercise (30 before you exercise (30 minutes apart)minutes apart)Decrease the insulin dose Decrease the insulin dose that is working while you that is working while you are exercising ( with are exercising ( with physicians knowledge)physicians knowledge)

Page 27: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

SummarySummary

These concepts have been under utilized These concepts have been under utilized across the country due to its complexity across the country due to its complexity as it relates to the patient, as well as as it relates to the patient, as well as the relatively recent arrival of rapid-the relatively recent arrival of rapid-acting insulin analogsacting insulin analogs

With new products available that simplify With new products available that simplify the calculation and allow for intra and the calculation and allow for intra and inter patient variability, we expect to inter patient variability, we expect to see more widespread education and see more widespread education and practical application of these featurespractical application of these features

Page 28: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

Healthcare Team InvolvementHealthcare Team Involvement

Your physician should be in Your physician should be in the loop for exercise the loop for exercise prescription prescription Look for healthcare providers Look for healthcare providers with an expertise in diabetes with an expertise in diabetes and exerciseand exerciseLook for healthcare providers Look for healthcare providers with a proactive approach to with a proactive approach to exercise (avoid professionals exercise (avoid professionals that routinely use words like-that routinely use words like-can’t, stop, and don’t)can’t, stop, and don’t)

Page 29: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

Diabetes, Exercise & Sports Association (DESA)Diabetes, Exercise & Sports Association (DESA)

http://www.diabetes-exercise.orghttp://www.diabetes-exercise.orgLeading national Leading national nonprofit diabetes nonprofit diabetes organization dedicated organization dedicated to diabetes health, to diabetes health, wellness and wellness and prevention through prevention through exercise exercise

Health-conscious Health-conscious people with diabetes as people with diabetes as well as health care well as health care professionals who care professionals who care for themfor them

Page 30: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

GETncm/justsaycust-recrate-itemcommunittg/stores/dtg/stores/d-favorite-listruejust-say-no

Page 31: Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc.

THANK YOU FROM THE BOTTOM OF MY PANCREAS!


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