Kathleen Dunn, RN CDE Jason Pelzek, RN CDE Ksenia Tonyushkina, MD Baystate Pediatric Endocrinology June, 2018
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1 Kathleen Dunn, RN CDE Jason Pelzek, RN CDE Ksenia Tonyushkina, MD Baystate Pediatric Endocrinology June, 2018 Ksenia Tonyushkina, MD 1
2 Objectives What does it mean to live with T1DM? Why exercise is important? Exercise physiology: effects of various sports and durations What do we teach about blood sugar (BG) control around sports? How can a school nurse help to get ready for afternoon sports? How can a coach help on the field? Questions Case 16 y.o. wrestler with T1DM for 10 years Diabetes control depends on whether he is in the season Weight fluctuates +/- 8lbs Checks BG occasionally Hates feeling «low» Uses insulin pump, disconnects pump for sports Does not think his coach needs to know about his DM 2
3 What is Diabetes? Serious, potentially life-threatening condition resulting form inability to regulating blood sugar levels. Type 1 diabetes Pancreatic destruction by immune system Insulin-dependent Type 2 diabetes Due to insulin resistance Can be managed by insulin and/or oral medications Goals for Therapy Normal growth and development A1C <7.5% Minimize hypo-/hyperglycemia/ketosis Reduce risk of long term complications Allow full participation Provide care without overly interfering with social, academic, emotional development 3
4 What does it mean to live with T1DM? 6-8 times/day 365 days/yr x/year Every meal Every snack 3-6 times/day 365 days/year 4-6 times/day 365 days/yr Insulin Pumps 4
5 Continuous Glucose Monitors (CGM)/Sensors New school orders will have guidelines on how to deal with the sensor data Hybrid Closed Loop System Artificial pancreas Insulin pump + CGM + algorithm Algorithm automatically adjusts insulin rate based on CGM data Patients are still required to bolus for meals 5
6 What does it mean to live with T1DM? Peer influence - fear of not fitting in Depression: 15-30% Disordered eating: 15% mid-teen females to 30% late teen young adults restrict insulin Why exercise is important? Exercise Lowers BG levels Helps maintain proper weight Helps feeling better Improves self-esteem Allows for making friends, connections, helps to fit in 6
7 How can a school nurse or coach help a student with T1DM to stay healthy? Make sure they do not feel different Help recognize and treat hypo- /hyperglycemia Motivate to take better care to improve performance Exercise Physiology and Practical Approach Kathleen Dunn, RN CDE Jason Pelzek, RN CDE 7
8 How Does Physical Activity Affect the Blood Sugar? BG goes down during physical activity, true or false? BG increases during physical activity, true or false? BG drops after physical activity for up to 12 hours, true or false? Exercise and Blood Sugars Exercise 8
9 Blood Glucose & Exercise Blood Sugar Considerations during Exercise Exercise is a very effective way to lower a high BG If a person is not physically fit; BG might drop rapidly BG levels might increase during exercise due to excitement hormones Insulin might work faster of injection site is close to a working muscle 9
10 Exercise Physiology Muscles can uptake glucose without insulin during the exercise -> BG drops Hungry muscles continue to uptake glucose after the exercise to replenish the stores -> BG drops Intensity, duration, and exercise types, affect BG differently Physical Activity Vigorous Running/ jogging (5 mph) Cycling (>10 mph) Swimming (slow freestyle laps) Aerobics Walking (4.5 mph) Heavy yard work Weight lifting (vigorous effort) Basketball (vigorous) Hiking Moderate Light gardening/ yard work Dancing Golf Cycling (<10 mph) Walking (3.5 mph) Weight lifting (general light workout) Stretching Everybody responds differently to the same physical activity monitoring BG levels before, during, and after exercise is essential to identify patterns 10
11 Practical Approach: What is our Goal for Kids with DM? Participation in sports - Minimize hypoglycemia and hyperglycemia Optimal sports performance Case Study A 14 year old reports to the nurses office for lunch. She participates in track after school. Student mentions her blood sugars have been dropping frequently at practice. As a school nurse, can you help your student prevent the troubles with lows at practice? No, it is too early to think about her sports now. Yes, I need more data 11
12 Blood Sugar Management Before During After Before 12
13 BEFORE: Preparation for Exercise 2-3 hours before min before Nutrition: Fuel your body - Complex carbs and protein Recheck BG before sports Insulin: - Adjust insulin dose based on the desired BG range before exercise (120/150-/180mg/dL) Is BG in the range? mg/dL Check BG every 60 min or if felling/ looks LOW - Decrease bolus insulin/ basal rate Student s Bag on the Field Treatment of lows, snack, water and low sugar sports drink Glucose meter Infusion sets Insulin pen 13
14 Blood Sugar Targets and Interventions VIGOROUS physical activity (>1hr) BG goal mg/dl MODERATE physical activity (<1hr) BG goal mmg/dL BG <80mg/dl: treat BG and then eat a 30g snack BG mg/dl: eat a 30g snack BG mg/dl: eat a 15g snack BG mg/dl: no snack needed BG >180mg/dl: use ½ correction BG <80 mg/dl: treat BG and then eat a 15g snack BG mg/dl: eat a 15g snack BG mg/dl: no snack needed BG >180mg/dl: use ½ correction Case: Low BG at Dismissal Nurse Intervention 16 year old M Well controlled T1DM x6y Basketball practice at 3:30 pm BG at 11:30 pm= 110 mg/dl Full coverage for lunch BG at 2:30 pm=55 Treat his low with 15 grams of snack and re-check in 15 min. Provide another 15 grams of mixed carb snack - May require more based on next BG Check 30 min before practice Don t forget to re-check after treating lows 14
15 Highs and Lows High If BG>300mg/dL -> check ketones. If ketones are moderatelarge do not exercise. Take insulin and drink water. Low If BG is low- > treat with 4oz of Gatorade, juice, sugar tabs. Follow up with mixed snack to prevent future low BG If you are hungry and eat more snacks or a meal, cover with insulin!!! Case: High BG at Dismissal Nurse Intervention 14 year old female Managed on insulin pump Soccer at 5:30 pm BG at 11:30 pm= 240 mg/dl Full coverage for lunch BG at 2:30 pm=305mg/dl Trouble shoot Test ketones Administer insulin, correct to target Check 30 min before game 15
16 During Exercise During Exercise Plan and communicate with athlete Check BG every 60 min you might need an extra 15g snack for every additional hour Stay hydrated Drink water if BGs are steady, switch to Gatorade if BG drops Recognize symptoms of hypoglycemia & hyperglycemia 16
17 Hypoglycemia Treatment of Low Blood Sugar BG below target (<80mg/dL) 4 glucose tablets gel tube 4 ounces (1/2 cup) of juice or regular soda (not diet) 8 ounces of energy drink 15 g Snack Fresh fruit Peanut butter crackers Mini bags of cookies ½ sandwich 4-5 whole grain crackers or pretzels Small granola bar 6 saltine crackers 30g Snack 1 banana or a small fruit 1 whole grain English muffin or small (2oz) whole grain bagel ½ cup cereal with 1 cup milk ½ cup yogurt or trail mix 17
18 Case: Low BS on the Field - Coach Intervention 16 y.o. boy feels dizzy, pale and shaky What is going on? Check BS? Juice, how much? BS = 62 mg/dl Treat with 4 oz juice and recheck in 15 min rule of gm snack, back to sports Don t allow kids to participate in sports with persistent low BS Hyperglycemia 18
19 Hyperglycemia and Exercise BG > 250mg/dL -> ketones are produced Symptoms of ketones: - nausea, stomach pain, vomiting Exercising with ketones is contraindicated Exercise with hyperglycemia but without ketones may lower BG Case: High BG on the Field - Coach Intervention 14 y.o. girl feeling tired, complaining of stomach pain What is going on? BG now = 388 mg/dl BG at lunch = 298 mg/dl Headache since morning Does she have a pump? Check BG? Ask about her lunch BG? Suspect ketones Call family No sports with moderate to high ketones You can fix mild ketones 19
20 After Exercise After the Exercise Check blood sugar - If BG is low: treat & have a 15g snack to help recovery, recheck in 15 min - If BG is high: correct conservatively Refuel your body BG lowering effect from exercise lasts for up to 12 hours - Afternoon sports versus nighttime sports 20
21 Pumps and sports Before: - take less insulin, decrease the basal rate During: - try to wear your pump during activity - for contact sports you may disconnect for minutes After: - reconnect your pump - decrease the basal rate - use a temp basal rate Summary Everyone is different! Most teens have their own strategies Nurses can promote success on the field by ensuring BGs are in range at dismissal Frequent (hourly) snacks for longer practices Be aware of signs of lows and highs Make every effort to encourage sports participation!!! 21
22 Thank you!! 22
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