Workshop 4 and 9 Helping Endurance Athletes Manage Diabetes Anne Peters, MD Saturday, February 18, :00 p.m. 3:30 p.m.

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1 Workshop 4 and 9 Helping Endurance Athletes Manage Diabetes Anne Peters, MD Saturday, February 18, :00 p.m. 3:30 p.m. The treatment of diabetes involves ensuring adequate delivery of fuel to muscle. During, particularly in elite athletes, this can be a particular challenge. However, due to new insulins and technology we are better able to help athletes with diabetes succeed. This talk will discuss the barriers to and competition in individuals with diabetes, and will detail approaches to overcome them. Case studies of successful athletes will be discussed and conclusions for helping all individuals with type 1 diabetes achieve their goals will be shared. References: 1. Riddell MC, Gallen IW, Smart CE, Taplin CET, Adolfsson P, Lumb AN, Kowalski A, Rabasa-Lhoret R, McCrimmon R, Hume C, Annan F, Fournier PA, Graham C, Bode B, Galassetti P, Jones TW, Milan IS, Heise T, Peters AL, Petz A, Laffel LM. Exercise management in type 1 diabetes: a consensus statement. The Lancet Diabetes & Endocrinology. Published on-line Jan 12, Colberg SR, Sigal RJ, Yardley JE, Riddell MC, Dunstan DW, Dempsey PC, Horton ES, Castorino K, Tate DF. Physical Activity/Exercise and Diabetes: A Position Statement of the ADA. Diabetes Care 2016;39:

2 HELPING ENDURANCE ATHLETES MANAGE DIABETES Anne Peters, MD Director, USC Clinical Diabetes Programs Professor, USC Keck School of Medicine Disclosure of Potential Conflicts of Interest Consultantship Abbott Diabetes Care Astra Zeneca Bigfoot Biomedical BD, BI FDA Janssen, Lexicon, Lilly Medscape, Medtronic, Merck NovoNordisk Omada Health OptumRX Research Funding Dexcom Case #1 Why Should People with Diabetes Exercise? Same potential benefits as for people without diabetes Plus added benefits of improving insulin sensitivity and possibly improving BG control Diabetes Care 39: , 2016

3 Why Should People with Diabetes Exercise? All adults should decrease the amount of time spent in daily sedentary behavior Prolonged sitting should be interrupted with bouts of light activity every 30 minutes for glucose benefits Additionally, daily structured, not allowing more than 2 days to elapse between sessions, is recommended to enhance insulin action. Ideally should consist of both aerobic and resistance training Additional Recommendations for T1D Blood glucose responses to PA in all people with type 1 diabetes are highly variable based on activity type/timing and require different adjustments May need adjustments in carbohydrate intake and/or insulin requirements. Technology can help Diabetes Care 39: ,2016 Diabetes Care 39: , 2016 Exercise Challenges for Individuals with Diabetes Varying workouts type/duration/intensity Different responses to training vs competition Unpredictability Risk for hypoglycemia Impact of on performance Physical factors (sweat/water/heat/cold) Everything else that impacts individuals without diabetes Exercise Physiology 101 Muscles use glucose as primary energy source initially this comes from muscle glycogen stores Once these sources are depleted there is a balance between glucose production (mostly from hepatic glycogenolysis) and glucose uptake by exercising muscle. Immediately post- there is a rapid decrease in catecholamines and increase in insulin levels with restoration of muscle glycogen Gallen IW et al. Diabetes, Obesity and Metabolism 13: , 2011 During Exercise and Muscle Contraction Act on Glucose Uptake by Skeletal Muscle Cells During, 2 simultaneous mechanisms act on glucose uptake by skeletal muscle cells: insulin and muscle contraction Receptor glucose Receptor glucose Insu lin Insu Insu lin lin Insuli n Rece ptor glucose Insu lin Insuli n Rece ptor Insu lin Insuli n Rece ptor glucose vesicles Muscle cell Rest vesicles Muscle cell Muscle Contraction Hayashi, T., Wojtaszewski, J. F., & Goodyear, L. J. American Journal of Physiology Endocrinology And Metabolism, 1997 Rose, A. J., & Richter, E. A. Physiology, 2015 vesicles vesicles Muscle cell vesicles Muscle cell Muscle cell Rest Muscle contraction, increased Hyperinsulinemia/muscle blood flow contraction, increased blood flood

4 Case #2 13 Biphasic Effect of Exercise on Glucose Requirements in Adolescents with T1 DM Euglycemic Clamp Study McMahon SK, Ferreira LD, Ratnam N, Davey RJ, Youngs LM, Davis EA, Fournier PA, Jones TW. JCEM 92: , 2007 Competitive athletes: Prevention of post- Post is very common after a competition and affects many athletes There is always a much higher chance of developing it when intensity is high during, or at the end of competition* Proper cool down helps greatly to avoid or mitigate post *High intensity increases catecholamine production eliciting liver and muscle glycogen breakdown (glycogenolysis) and therefore. Lactate is always increased during high intensity. Lactate is the major gluconeogenic precursor (new glucose) of the body potentially contribuiting to post Moderate Intensity Vs. Intermittent High Intensity Exercise In Type 1 DM Guelfi KJ, Jones TW, Fournier. Diabetes Care 28: , 2005 Mean ± SE plasma glucose during the experimental sessions (represented by box) and 60 min of recovery (n = 12 for aerobic and no- control; n = 11 for resistance )., no- control;, resistance,, aerobic. Mean ± SE glucose as measured by CGM from 1 to 12 h post., no- control session;, aerobic session;, resistance session. Jane E. Yardley et al. Dia Care 2013;36: Jane E. Yardley et al. Dia Care 2013;36: by American Diabetes Association 2013 by American Diabetes Association

5 Mean ± SE plasma glucose during and recovery for aerobic performed before resistance (AR, dashed line with ) and resistance performed before aerobic (RA, solid line with ) (n = 11). *Difference from baseline during where P < Difference between conditions where P < Change throughout recovery from end- level where P < Mean glucose (n = 12) as measured by continuous glucose monitoring from 1 to 12 h after following aerobic performed before resistance (AR, dashed line) and resistance performed before aerobic (RA, solid line). Jane E. Yardley et al. Dia Care 2012;35: Jane E. Yardley et al. Dia Care 2012;35: by American Diabetes Association 2012 by American Diabetes Association Adjustments for Exercise Results: One Example Patients with type 1 diabetes on ultralente insulin and preprandial lispro insulin were studied. 90 minute postprandial for minutes at 25%, 50% and 75% VO 2 max was performed doses given at 100%, 50% or 25% of the current dose of lispro (~1 unit/10 g CHO) Diabetes Care 24: , 2001 Change in glu from baseline (mg/dl) Exercise at 50% VO 2 max for 30 min % LP 100% LP Guidelines for the reduction in premeal RA dose York University/Diabetes Hope Foundation- Diabetes Youth Sports Camp Exercise Intensity % Dose Reduction (%VO 2 max) 30 min 60 min

6 Sensor Rate-of-Change Guided CHO Algorithm for Exercising Youth with T1DM CGM BG <126 mg/dl = take action <90 mg/dl mg/dl mg/dl Riddel M Diabetes Tech Therap 13:819-25, 2011 Competitive athletes: Prevention of post- hypoglycemia Prevention of post- hypoglycemia Carbohydrate use based on Swedish experience Food group Recommendations Carbohydrates* Amount needed depends on intensity of the In training camps, consider individual weight and duration of Proteins Consume 0.5 g/kg body weight Cool down muscles slowly to avoid rebound hyperglycaemia and allow gradual glycogen restoration Type of Aerobic Strenuous and exhausting Strength training Recommendations Restore with 1 g of carbohydrates/kg body weight/ hour of as long as there is no Restore with 1.5 g of carbohydrates/kg body weight/ hour of as long as there is no Restore with 0.5 g of carbohydrates/kg body weight/ hour of as long as there is no *There are many schools of thought about replenishing carbohydrates before and after, that are not particularly studied in patients with type 1 diabetes. 2 Recovery and cool down Early recovery may require: 1. Additional insulin if and/or a cool down period 2. Reduced insulin administration at the next meal or an extra snack if hypoglycemia Late recovery may require: 1. A low glycemic index snack and/or 2. Reduced basal insulin at bedtime (20%) Cool down could significantly decrease blood lactate levels which may help to decrease post Blood Lactate Concentration (mm) % cyclists with Type 1 Diabetes finished under No extra insulin was used. 5,3 Blood lactate concentration equivalent to intensity above LACTATE THRESHOLDS Resting Protocol n=6 P<0.01 1,9 Blood lactate concentration slightly above RESTING LEVELS Cooling Down Protocol n=8 San Millan, I et al. Unpublished data 2 Strategies For Reducing Hypoglycemia During Exercise Strategy Advantages Disadvantages Reduce pre- bolus insulin Reduce pre- basal insulin Take extra CHO Reduces hypos during and post, reduces CHO requirement As above Useful for unplanned or prolonged Needs preplanning. Not helpful for late postprandial As above, causes pre and late post May not be possible with some sports. Less helpful when weight control important. Can cause Current Opinion in Endocrinology, Diabetes & Obesity 2009, 16:

7 Strategies For Reducing Hypoglycemia During Exercise The Ideal Strategy Advantages Disadvantages Pre- or post sprint pump therapy Reducing basal insulin post Reduces hypos following Offers flexibility and rapid change in insulin infusion rates post Reduces nocturnal hypoglycemia Effect limited to shorter and less intense. No effect on late hypoglycemia Expensive. May not be practical for contact sports (e.g., rugby/football/judo) and some water sports May cause morning Current Opinion in Endocrinology, Diabetes & Obesity 2009, 16: Delayed Hypoglycemia When It Works: Chicago Marathon When It Doesn t: Wildflower Triathalon LA Marathon: Craig

8 LA Marathon: Reny LA Marathon: James Delaney Delaney BG Level at Start of Exercise Starting glycemia below target (<90 mg/dl) Inject g of glucose before starting Delay until BG >90 mg/dl and monitor closely for hypoglycemia Starting glycemia near target ( mg/dl) Ingest 10 g of glucose before starting aerobic Anaerobic and high intensity interval training sessions can be started Starting glycemia at target level ( mg/dl) Aerobic can be started Anaerobic and high intensity interval training sessions can be started but glucose concentrations could rise BG Level at Start of Exercise Starting glycemia slightly above target ( mg/dl) Aerobic can be started Anaerobic and high intensity interval training sessions can be started but glucose concentrations could rise Starting glycemia above target (>270 mg/dl) If the is unexplained, check blood ketones. If ketones modestly elevated ( mmol/l), limit to a light intensity for a brief duration (<30 min). A small pre- corrective dose of insulin might be needed. If blood ketones >1.5 mmol/l, is contraindicated and glucose management should be initiated rapidly by the patients diabetes health care team.

9 CHO Intake at Start of Exercise Adjustments adjustment for the meal preceding Decision Tree for Exercise of >30 Minutes How to Adjust for Aerobic Exercise The End ½ Usual Dose Meal Before gm CHO if < gm CHO q30 mins gm snack with ½ usual insulin dose Less basal overnight