Exercise in the recreational and competitive athlete with type 1 diabetes- the benefits, the risks and management strategies

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1 Exercise in the recreational and competitive athlete with type 1 diabetes- the benefits, the risks and management strategies Craig E. Taplin, MD Division of Endocrinology and Diabetes Seattle Children s Hospital Department of Pediatrics University of Washington

2 Quotes from JDRF Ride team My glucose levels seem to vary widely with exercise It seems to depend upon: What I eat How much insulin I have given How hard I ride How long I ride The day of the week How I slept last night The color of my cycling jersey The Dow Jones Industrial Average

4 Case studies Practical management Exercise Physiology

5 Case 1 Mike is a 14 year old adolescent T1D since age 6 Last HbA1c 8.2% (generally high 7s to low 9s) On Lispro 1:12 grams at each meal and Glargine 22 units qhs He is doing Cross Country this season for the first time At the moment he is running 2-3 times per week for 1.5 hours each time, with practices always after school

6 Mike s reported profile Cross Country Run Dinner BGL Symptoms of hypoglycemia- eats a snack Adapted from PEAK Working group (JDRF)

7 Case 2- Oh no- I m low! Emma is a 15 year old competitive cyclist. During a 30 mile ride, despite reducing insulin prior to exercise and taking in extra carbohydrates, she starts to feel weak and stops to check blood glucose which is 60 mg/dl. She takes 25g of carbohydrate and is determined to finish her ride. 20 minutes later she checks again and her blood glucose is 59 mg/dl, still feeling a bit weak and is on the fence about whether she can finish. What should Emma do?

Case 3: Spontaneous Exercise with T1D James is an 13 year old with type 1 diabetes who loves basketball. He ate lunch 90 minutes ago and now his blood glucose is 280 mg/dl. He has 3.

8 Case 3: Spontaneous Exercise with T1D James is an 13 year old with type 1 diabetes who loves basketball. He ate lunch 90 minutes ago and now his blood glucose is 280 mg/dl. He has 3.5 units of insulin on board from his pump bolus. Settings are 1:15 grams and 1:50 >120 He was originally planning on practice in 3-4 hours when his blood glucose would be at target but his coach calls for an early practice now.

9 Case 4 Caroline is a 10 year old girl with type 1 diabetes who loves soccer. Usually soccer practice causes her BGL to fall (though it varies a lot) This Saturday she has a semi-finala big game for her and she is nervous and excited. She has her whole family in attendance and they will be cheering hard for her on the sideline.

10 Case 5 - Can I play anyway? Iris is 9 and at diabetes camp. She loves to run, play and swim. She has significantly increased the frequency and duration of her activity at camp. Last night she awoke with her heart racing and feeling confused and her cabin leader checked her blood glucose for her it was 43 mg/dl She had some juice and glucose tablets and within 20 minutes was up to 120 mg/dl. Today the kids are playing capture the flag. What do we do?

11 Case 6 What if I have a high BGL beforehand? Chris knew that he wanted to keep his blood sugars in a good range overnight for early morning run at 6:30am Unfortunately he woke up at 3am to check his blood glucose, his reading was higher than he wanted 250 mg/dl due to excessive snacking the night before. He knew that if he took too much insulin, he would crash with exercise, but if he didn t take enough, his performance would suffer due to his levels being out of range. What should Chris do?

12 Compliance with physical activity recommendations- SEARCH for Diabetes in Youth

13 Youth with type 1 diabetes may exercise at least as much as their non-diabetic peers. This is a huge success story in and of itself! But Is physical fitness affected by T1DM in children? What about the role of exercise specifically with regard to overall glycemic control?

14 2012 UK study - 60 young people with T1DM, mean age 12.5 years, mean HbA1c 8.4% and 37 controls (siblings) no difference in degree of physical activity no difference in fitness Moderate vigorous physical activity(but not fitness) predicted 1/3 of the variance in HbA1c, even when accounting for confounding variables such as insulin dose, age, weight, puberty stage

106 youth with T1DM, 130 controls Mean HbA1c 8.2-8.

15 106 youth with T1DM, 130 controls Mean HbA1c % (depending on group) Eurofit physical fitness test T1DM group just as active as the controls Decreased fitness (VO2 max) in: girls pubertal boys with T1DM ** not validated in T1DM

16 Is Glycemic Control a/w Aerobic Capacity in Adults with Type 1 Diabetes? Adult (trained) athletes A1c <7% were as fit or fitter than those without T1DM A1c>7% less fit Hoffman group, Auckland NZ

17 Is exercise associated with HbA1c in youth? 19,143 patients 1-2 x week >2 x week Herbst, A. et al. Arch Pediatr Adolesc Med 2006;160: Copyright restrictions may apply.

A systematic review of physical activity and sedentary behavior intervention studies in youth with type 1 diabetes: study characteristics, intervention design, and efficacy Different interventions

18 A systematic review of physical activity and sedentary behavior intervention studies in youth with type 1 diabetes: study characteristics, intervention design, and efficacy Different interventions (aerobic/strength), settings (home/supervised), schedules (days per week), goals (A1c vs fitness) Pediatric Diabetes Volume 15, Issue 3, pages , 29 JUL 2013 DOI: /pedi

19 Is HbA1c the right (or only useful) construct when considering T1D and exercise? Perhaps we should consider cardiovascular health as well as HbA1c when considering the data on physical activity and exercise? What does that data tell us? Not surprisingly (!) better lipids, lower insulin dose, lower BMI in youth and young adults with T1D, in addition to lower HbA1c, in systematic reviews of exercise Physical activity interventions in children and young people with Type 1 diabetes mellitus: a systematic review with meta analysis. Diabetic Medicine Volume 31, Issue 10, pages

Nineteen adolescents with T1DM, ages 14-19 years Maximal aerobic capacity (VO2 max) 1-hour treadmill exercise session for accumulated metabolic workload Mean

20 Nineteen adolescents with T1DM, ages years Maximal aerobic capacity (VO2 max) 1-hour treadmill exercise session for accumulated metabolic workload Mean amplitude of glycemic excursion (MAGE) calculated from CGM data VO2 max 1 MAGE Aerobic work 1 MAGE Which leads to what? Or again, is it circular/bidirectional?

21 Glucose Provision During Exercise Requires Glycogen Mobilization Glucose ~90 mg/dl

22 GLUT4

23 What are the acute effects of different types of exercise Resistance versus Aerobic High Intensity vs low intensity Early vs Late effects

24 Change in glucose concentrations during exercise (n = 48). Tansey M, Tsalikian E et al **No insulin adjustment The Diabetes Research in Children Network (DirecNet) Study Group Dia Care 2006;29: by American Diabetes Association

25 Nadir glucose during exercise versus baseline concentration (n = 48). The Diabetes Research in Children Network (DirecNet) Study Group Dia Care 2006;29: by American Diabetes Association

26 Resistance vs Aerobic Diabetes Care 2013;36: adults, mean HbA1c 7.1% 45 minutes of weight lifting or 45 minutes of cardio Higher sugars during and immediately after resistance exercise

28 Practice vs. Race/Competition Kris Freeman, national ski champion and Olympian In practice events, I try to dial in the basal rate I need, but adrenaline changes things In training, without the adrenaline working, my BG tends to drop. For races, I've started changing basal rates up to 2 hours in advance, in anticipation of the adrenaline spike. I know it's coming. I can lie bed and see my BG rise 80 points just from race nerves.

29 1-diabetic-going-for-olympic-gold#2 So what was your dosing strategy? What I ended up doing is.7 units/hr 24/7, and then leading up to the race, three hours before, I upped my basal to 1.0 units/hr to cover the sugar I release from being nervous. Twenty minutes prior to the 15k race, I actually upped to 7units/hr, and then took a half-unit bolus, because the amount of sugar I release in an event like that is incredible. I only take a bolus before a race if I'm in an upward trend. If I get much over 200, I'm putting myself at a disadvantage, because my lactate levels go up and that creates that heavy, nasty feeling people sometimes get when exercising. It hurts. I don't want that.

Breakout Session. Exercise and Type 1 Diabetes -Practical management - Case studies

Breakout Session. Exercise and Type 1 Diabetes -Practical management - Case studies Breakout Session Exercise and Type 1 Diabetes -Practical management - Case studies Getting your patients into the game What should you discuss in clinic? Keeping Safe - Wear medical identification bracelet