Managing blood glucose and exercise in young people with Type 1 Diabetes. Dr Alistair Lumb Dr Taffy Makaya Anne Marie Frohock RD

Transcription

1 Managing blood glucose and exercise in young people with Type 1 Diabetes Dr Alistair Lumb Dr Taffy Makaya Anne Marie Frohock RD May 2018

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3 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?

4 Why is exercise a challenge in T1?

5 What is the body doing during exercise?

6 Which fuels?

7 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

8 Different needs for different sports Sports Workshop

9 Sprinting, swimming sprints Weightlifting, Main fuel is carbohydrate Climbing from Gymnastics, muscle Fencing glycogen Athletics Field events Muscle glycogen is a limited pool. Which is why sprint-speed is not sustainable Football, Rugby, Hockey, Lacrosse Tennis, Squash, Rounders Running (middle distance) Playground games Skiing, Ice skating Jogging/cross country Brisk Fuel walking, can be fat long from walks stores and carbohydrate Cycling, Marathon from blood running glucose and Triathlon muscle glycogen Skateboarding Burning fat needs oxygen and takes longer. Endurance exercise allows this

10 Effect on BG of different sports Graphic courtesy Professor Mike Riddell

11 Effect on BG of different sports Graphic courtesy Professor Mike Riddell

12 Blood Glucose DURING Exercise -Cardio and weights in the gym Yardley et al (2012) Diabetes Care 35:

13 Blood Glucose AFTER after exercise - Late hypoglycaemia Yardley et al (2012) Diabetes Care 35:

14 Blood Glucose AFTER after exercise - The Double dip McMahon et al (2007) JCEM 92(3): BGs may drop 1-4 hrs afterwards BGs may drop again 7-11hrs afterwards

15 Blood Glucose AFTER after exercise - The Whip, Double Dip BGs may be high immediately after Exercise hormones remain elevated Insulin Resistance Anaerobic, sprinting or intermittent exercise Pump off BGs may drop 1-4 hrs after BGs may drop again 7-11hrs after As muscle stores of glycogen replenish The hormonal response to a falling glucose is not as strong Sensitivity to insulin remains increased

16 Responses are individual

17 Management strategies for exercise with T1

18 Check Check Check!! Master your own diabetes Before, During, After There is no other way

19 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

20 Strategies for Managing Exercise. It s a balancing act!!

21 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

22 Aims of strategies BG level 5-8 when starting exercise and throughout exercise Prevent hypoglycaemia after exercise Prevent high BGs during exercise and afterwards

23 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

24 Before, During, After Things to consider 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?

25 Before and During Exercise

26 BG readings Before During After BG below 4 Treat the hypo Only exercise when BG has recovered to above 5 mmol/l. If you have been hypo earlier during the day be aware you are more likely to hypo during exercise BG 4-7 Consider 10-15g extra carbs without insulin BG 8-14 No extra carbs Drink plenty of water. Start low intensity exercise BG over 14 CHECK KETONES Ketones over 1 mmol/l, do not exercise 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) BG over 8 Do not correct immediately after exercise After 2hrs, consider giving a small correction (half usual)

27 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

28 Insulin level Effect of lowering insulin by 50% Fast acting insulin Basal insulin Time (h) Normal Reduced dose dose

29 Bolus insulin before aerobic exercise

30 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 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

31 Basal Bolus Insulin PLAN if you can Before During After Reduce insulin for food eaten within 90 mins of exercise by 25-50% Do not give bolus insulin Reduce insulin for food eaten at the meal following exercise by 25-50% Reduce basal rate 90 mins before by 50-75% Reduce basal insulin rate by 50-80% (keep pump on if possible if not replace half missed basal as a bolus before you take it off) If intense afternoon or evening exercise Reduce long acting insulin by 10% Or Reduce basal rate at bedtime for 4hrs by 20%

32 Carbohydrate Before During After Depends on BG & exercise & IoB BG 4-5 = 10-15g snack (fast/medium) BG 5-8 & exercise >30 mins = 10-15g snack (medium) BG >8 = no extra carbs drink plenty of water Hydrate through the day with water For exercise over 1hr extra carbs are likely to be needed. May be sooner if strenuous or no insulin adjustments made 0.5 g/kg/hr for every hour over the first hour FAST acting Hydrate with fluids Water should be adequate for exercise under 1hr Longer duration (over 1hr) switch to sports drinks

33 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)

34 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

35 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?

36 Blood Glucose Level (mm) Blood Glucose Level (mm) The 10 second sprint Insulin release is able to control glucose rise in people without T1 Without insulin administration, glucose rise is unchecked in people with T1 7 6 B 7 6 A a a a a a a a a a a 5 b b b b Time Time (min) Fahey et al., J Clin Endocrinol Metab, 2012

37 After Exercise Delayed hypoglycaemia can be a problem

38 Basal Bolus Insulin Insulin sensitivity increases after exercise so you need less of it! Before During After Reduce insulin for food eaten within 90 mins of exercise by 25-50% Do not give bolus insulin Reduce insulin for food eaten at the meal following exercise by 25-50% Reduce basal rate 90 mins before by 50-75% Reduce basal insulin rate by 50-80% (keep pump on if possible if not replace half missed basal as a bolus before you take it off) If intense afternoon or evening exercise Reduce long acting insulin by 10% Or Reduce basal rate at bedtime for 4hrs by 20%

39 Carbohydrate Before During After Depends on BG & exercise & IoB BG 4-5 = 10-15g snack BG 5-8 & exercise >30 mins = 10-15g snack BG >8 = no extra carbs drink plenty of water For exercise over 1hr extra carbs are likely to be needed. May be sooner if strenuous or no insulin adjustments made 0.5 g/kg/hr for every hour over the first hour FAST acting The Golden Hour 10-15g carbohydrate without insulin And PROTEIN Meal/snack 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

40 After exercise - The Golden Hour Replenish stores of glycogen in the body Eat carbohydrate within 1-2 hours of exercise Aim is 1g/kg bodyweight to replenish stores Include protein with this to reduce risk of double dip hypos

41 Eating during the Golden Hour If you are eating a full meal: Include carbohydrate (1g/kg) and protein (20g) Reduce the dose of insulin by 50% If not eating a meal Eat a 10-20g carbohydrate snack without insulin - include some protein with this snack

42 Golden Hour Snack ideas Milk shakes ( ml) Cereal (or cereal bar) and 200ml milk Nutty cereal bar Fruit and Nut mix Yoghurt and fruit Cheese and crackers Peanut butter sandwich Beans on toast Meat/fish sandwich

43 Check Check Check!! How do I know it works? Before, During, After There is no other way

44 Overall nutrition Youngsters have high energy requirements for growth It is recommended about half of this energy comes from carbohydrate Exercise increases energy requirements further For optimal growth, exercise performance and recovery we must ensure that nutritional intake is adequate for exercise to be undertaken Hydration is essential too

45 Recommended energy requirements Age EAR - boys Guideline carb intake (g/d) EAR - Girls Guideline carb intake (g/d) kcal/d kcal/d to to to to to * Calculations based on SCAN DRV for energy (2011) population based average activity levels with 45-50% total energy from carbohydrates Energy requirements for 11-18yr olds are capped at 2500kcal/2000kcal per day to address issue of overweight/obesity Diabetes, Obesity and Metabolism (2011) 13:

46 Technology and the future

47 CGM and Exercise Chance to review plans and make adjustments Chance to respond to changing situations in real time Less accurate during exercise due to rapidly changing BG levels Time lag between Blood Glucose and Sensor glucose

48 How could we use real-time info? Adapted from: Riddell & Milliken (2011) Diabetes Technology and Therapeutics 13(8):

49 Closed loop systems: overnight Sherr et al (2013) Diabetes Care 36:

50 Closed loop systems are getting better

51 Oxford Diabetes Sports Service Thank you! Dr Alistair Lumb Dr Taffy Makaya Anne Marie Frohock RD

52 What can be achieved with T1?

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54 Marathon Man! Gavin Griffiths lives with type 1 diabetes and will be running 25 marathons around the UK & Ireland in a month between 13 April & 13 May 2018 in the #DiAthlete100 challenge - which if successful will total Gavin's 100th endurance triumph for type 1 diabetes in the last 10 years! A milestone of diabetes empowerment.

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