Managing blood glucose and exercise in young people with Type 1 Diabetes Dr Alistair Lumb Dr Taffy Makaya Anne Marie Frohock RD May 2018
www.ouh.nhs.uk/childrens-diabetes
Plan • Why might exercise be a challenge in T1 • What strategies do we have for dealing with this? • Before • During • After • Technology and the future • What can be done with T1? Sports Workshop 2018
Why is exercise a challenge in T1? Sports Workshop 2018
What is the body doing during exercise? Sports Workshop 2018
Which fuels? Sports Workshop 2018
How is this controlled? • Variation in a number of hormones of which insulin is only one • Other important hormones include adrenaline and noradrenaline (catecholamines) and glucagon Sports Workshop 2018
Different needs for different sports Sports Workshop
Muscle glycogen is Sprinting, swimming sprints a limited pool. Main fuel is carbohydrate from Weightlifting, Climbing Which is why muscle glycogen Gymnastics, Fencing sprint-speed is not Athletics Field events sustainable Football, Rugby, Hockey, Lacrosse Tennis, Squash, Rounders Running (middle distance) Playground games Skiing, Ice skating Jogging/cross country Burning fat needs Fuel can be fat from stores and Brisk walking, long walks oxygen and takes carbohydrate from blood glucose and Cycling, Marathon running longer. Endurance muscle glycogen exercise allows this Triathlon Skateboarding
Effect on BG of different sports Graphic courtesy Professor Mike Riddell Sports Workshop 2018
Effect on BG of different sports Graphic courtesy Professor Mike Riddell Sports Workshop 2018
Blood Glucose DURING Exercise -Cardio and weights in the gym Yardley et al (2012) Diabetes Care 35 : 669-675 Sports Workshop 2018
Blood Glucose AFTER after exercise - Late hypoglycaemia Yardley et al (2012) Diabetes Care 35 : 669-675 Sports Workshop 2018
Blood Glucose AFTER after exercise - The Double dip BGs may drop again 7-11hrs afterwards BGs may drop 1-4 hrs afterwards McMahon et al (2007) JCEM 92(3) :963-968
Blood Glucose AFTER after exercise - The ‘Whip, Double Dip‘ Exercise hormones remain Pump off BGs may be high elevated – Insulin Resistance immediately after Anaerobic, sprinting or intermittent exercise BGs may drop BGs may drop again 7- 1-4 hrs after 11hrs after As muscle stores of The hormonal response to a glycogen replenish Sensitivity to insulin falling glucose is not as strong remains increased
Responses are individual Sports Workshop 2018
Management strategies for exercise with T1 Sports Workshop 2018
Master your own diabetes • Check • Check • Check!! There is no other way Before, During, After Sports Workshop 2018
Be prepared! • Practice your diabetes and exercise management plan • Monitor glucose closely when you train and when you compete • Think about the intensity • Practice your refuelling plan • Learn your own patterns • Make sure you are safe – • if you have been hypo earlier in the day know the increased risk of hypo during training and consider going ahead. • Be aware that things can change on “game day” (and practice dealing with this if you can) • Expect the unexpected … Sports Workshop 2018
Strategies for Managing Exercise. It’s a balancing act!!
We are balancing 3 things • We don’t want to change the exercise, so we need to see what we can do with the insulin and carbohydrate Sports Workshop 2018
Aims of strategies BG level 5-8 when starting exercise and throughout exercise • Prevent hypoglycaemia after exercise • Prevent high BGs during exercise and afterwards Sports Workshop 2018
Muscles work better, reactions are faster, you can train for longer and recover quicker when BG levels are 5- 8mmol/l 5- 8mmol/l Riddle and Pankowska Talk ISPAD 2012
Things to consider • Before, During, After A number of factors which will affect the right management strategy: • What is your BG now? Do you know what direction it is going in? • When did you last eat? What did you last eat? • What insulin do you have on board? • What sort of exercise are you going to do? How long for? Sports Workshop 2018
Before and During Exercise Sports Workshop 2018
BG readings Before During After BG below 4 BG 4-7 Treat the hypo If you have been hypo Consider 10-15g extra Only exercise when BG earlier during the day be carbs without insulin has recovered to aware you are more likely above 5 mmol/l. to hypo during exercise BG 8-14 BG over 8 No extra carbs Do not correct immediately Drink plenty of water. Start low intensity exercise after exercise After 2hrs, consider giving BG over 14 – CHECK KETONES a small correction (half Ketones over 1 mmol/l, do not exercise usual) Give a correction dose. Wait until ketones under 0.5 to exercise Ketones less than 1 mmol/l, start low intensity exercise but drink plenty of water. For high intensity consider a correction dose (less than usual) Sports Workshop 2018
Insulin • Do not exercise at peak insulin action – (with significant Insulin on Board) For aerobic exercise: • Reduce IoB by reducing bolus insulin if taken in the 2hrs before exercise • Reduce basal insulin 90mins before if able For anaerobic exercise: • No bolus reduction may be needed Sports Workshop 2018
Effect of lowering insulin by 50% Fast acting insulin Basal insulin nsulin level Ins 2 3 1 Normal Tim ime (h (h) dose Reduced dose
Bolus insulin before aerobic exercise Sports Workshop 2018
Basal insulin – aerobic activity MDI • Generally not advised to reduce basal insulin prior to activity • Would only recommend this for extended periods of aerobic activity (e.g. activity weekends, skiing holidays) Insulin pump • Ideally reduce basal rate 60-90 minutes before exercise • Best reduction will be individual , starting point reduction by 50- 80% • Can remove pump, but think about reconnecting approximately every hour to replace missed basal Sports Workshop 2018
Insulin – PLAN if you can Before During After Reduce insulin for food Do not give bolus insulin Reduce insulin for eaten within 90 mins of food eaten at the exercise – by 25-50% meal following exercise by 25-50% Bolus Reduce basal rate 90 Reduce basal insulin rate by 50-80% If intense afternoon mins before by 50-75% (keep pump on if possible – if not or evening exercise replace half missed basal as a bolus Reduce long acting before you take it off) insulin by 10% Or Reduce basal rate at Basal bedtime for 4hrs by 20% Sports Workshop 2018
Carbohydrate Before During After Depends on BG & exercise & IoB For exercise over 1hr extra carbs are likely to be needed. May be BG 4-5 = 10-15g snack (fast/medium) sooner if strenuous or no insulin adjustments made BG 5-8 & exercise >30 mins = 10-15g snack (medium) 0.5 g/kg/hr for every hour over the first hour BG >8 = no extra carbs – drink plenty of water FAST acting Hydrate through the day with water Hydrate with fluids Water should be adequate for exercise under 1hr Longer duration (over 1hr) switch to sports drinks
Exercise Nutrition - Snacks • Fast acting – 30g Jelly beans (25g carbs) – Sports energy gels – Glucose tablets • Medium acting – Cereal bar (20-30g carb) – 30g raisins (20g carbs) – Banana (25g carbs)
Hydration Water Fine for shorter events No side-effects • Sports Drinks – Fast carbohydrate for longer events (30g carbs in 500ml) – Isotonic – improves hydration – GI side-effects – Easy to over-do it – BGs too high
Using exercise to help you • If glucose is high before activity – you can use a low intensity warm-up to help bring this down • If on the low side – can you use a 10s sprint to help you? • If going to the gym – can you adjust the order in which you do things? Sports Workshop 2018
The 10 second sprint Insu nsuli lin re rele lease is able able to to con ontrol With thou out ins nsulin adm administration, glucos ose glucose ri gluc rise in n peop people le wi without T1 T1 ri rise is unc unchecked in peop people le wi with T1 T1 7 7 Blood Glucose Level (mM) B Blood Glucose Level (mM) A a a a a a a a a 6 6 a a b b b b 5 5 4 4 3 3 Time Time (min Tim (min) Fahey et al., J Clin Endocrinol Metab, 2012 Sports Workshop 2018
After Exercise Delayed hypoglycaemia can be a problem Sports Workshop 2018
Insulin – Insulin sensitivity increases after exercise so you need less of it! Before During After Reduce insulin for food Do not give bolus insulin Reduce insulin for food eaten eaten within 90 mins of at the meal following exercise exercise – by 25-50% by 25-50% Bolus Reduce basal rate 90 Reduce basal insulin rate by If intense afternoon or mins before by 50-75% 50-80% evening exercise (keep pump on if possible – Reduce long acting insulin by if not replace half missed 10% basal as a bolus before you Or take it off) Reduce basal rate at bedtime Basal for 4hrs by 20% Sports Workshop 2018
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