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

Transcription

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

2 Getting your patients into the game What should you discuss in clinic? Keeping Safe - Wear medical identification bracelet or necklace Considering working out with someone Check blood sugars before, during and after Have food with you If going on long cycle or run, consider taking phone with you Tell someone where you are going Listen to your body don t push it too early

3 Getting your patients into the game Exercise is Medicine! Lipids Endothelial function BMI Insulin sensitivity BP (especially diastolic BP) Mood Note- talk about something other than HbA1c!

4 Practical Examples -How Exercise can help? Effects of Walking after Eating 30 minutes of casual walking after meals 30 mg/dl reduction in Av BGL Peak post-prandial BGL 45% higher when sedentary Kudva et al, Diabetes Care 2012

5 Getting them started Practice runs (a lot) Learn the individual responses to types of activity Learn what differs between practice and competition Have a plan, and then test/modify/retest Hang in there!

6 The psychology of exercise and type 1 diabetes Acta Paediatr Scand 1980 Many patients mean that is easy to be theoretically positive, but quite another thing to really exercise regularly. Too often physical exercise becomes a medicine instead of a natural pleasant habit. It is important that the hospital staff inform the patients without nagging, and then support and stimulate the patients, and give them adequate responsibility.

7 Barriers to exercise participation Teenage girls with T1DM are less active then teenage boys, and less active than nondiabetic girls of the same age (Valerio et al, Nutr Metab Cardiovasc Dis 2007) Data supports importance of all of the following in youth: Intrapersonal factors (lack of energy, perceived competence, negative self image, T1DM stigma) Interpersonal factors (family and peer support) Environmental (access, opportunity)

8 Barriers to exercise participation in adults with T1DM- knowledge and fear Better knowledge of insulin pharmacokinetics Use of approaches to minimize glycemic excursion around exercise Both associated with less perceived barriers Higher perceived barriers correlated with HbA1c Fear of hypoglycemia is significant barrier to exercise in T1DM. That fear needs to be addressed in patients and parents. (Diab Care most common barrier to regular exercise in adults with T1D is fear of lows) (Ped Diab % of parents report fear of nocturnal lows)

9 Role modelling, inspiring examples Provider comfort with data and technology First messages at time of diagnosis (inclusionary vs exclusionary messages?) Specific strategies to allay parental fear- give them control by having a specific plan!

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11 Hyperglycemia Weightlifting Sprints, gymnastics, baseball, Wrestling, volleyball Rugby, football, basketball, tennis, lacrosse Skiing (downhill) Middle distance events Road cycling Skating Nordic skiing Hiking/backpacking Long-distance running/swimming/cycling Hypoglycemia

12 Teach insulin on board Aerobic Exercise Blood Glucose

13 Insulin on Board- dose dependence Courtesy of Tim Heise and colleagues

14 Insulin on Board Glucose falls quicker during exercise when insulin is present Adjustments in insulin or glucose intake will likely be necessary if exercising within 2-4 hours of taking insulin If exercise >3 hours after a meal or first thing in the morning this simplifies things as do not have to think about altering fast acting insulin before exercise

15 The 3 time points to plan for Immediately after Overnight/8-12 hours later During Adapted from McMahon et al JCEM 2005

16 BGL and Performance** Blood Glucose Level **Clinical Experience, personal communication, others (Scheiner G.)

17 Normal vs T1D ISPAD Guidelines- Exercise in Youth with T1D

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19 Training effect on fuel utilization Adapted from: van Loon LJ, et al. J Appl Physiol 1999 ;87(4):

20 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

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

22 Question: What is causing Mike s hypoglycemia during/immediately after running? a) Too much insulin b) Type of exercise c) Not enough carbs d) Duration of exercise e) All of the Above

23 What should he (and we) consider Type of Exercise Duration/ Intensity Timing/ Meals IOB Starting BGL

24 What may happen at the beginning? Type of Exercise Duration/ Intensity Timing/ Meals IOB Starting BGL

25 Hyperglycemia Weightlifting Sprints, gymnastics, baseball, Wrestling, volleyball Rugby, football, basketball, tennis, lacrosse Skiing (downhill) Middle distance events (800 m, 1500m Road cycling Skating Aerobic zone? Nordic skiing Hiking/backpacking Long-distance running/swimming/cycling Hypoglycemia

26 When is the safest time for Mike to exercise? Type of Exercise Duration/ Intensity Timing/ Meals IOB Starting BGL

27 When is the safest time for Mike to exercise? Lispro action Risk Exercise here if possible? minutes

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

29 Which of the following is true regarding his night time hypoglycemia? a) Insulin sensitivity is increased b) Avoidance of low glucose during exercise would reduce his risk overnight c) Basal insulin dose adjustments in the order of 20% have been shown in studies to reduce the risk d) He would still be at risk if he did pure resistance exercise (weights) e) All of the above

30 Which of the following is true regarding his night time hypoglycemia? a) Insulin sensitivity is increased b) Avoidance of low glucose during exercise reduces his risk overnight c) Basal insulin dose adjustments in the order of 20% have been shown in studies to reduce the risk d) He would still be at risk if he did pure resistance exercise (weights) e) All of the above

31 Another Consideration: Lows Beget Lows exercise

32 Doc- I want to gain muscle! Should I eat lots of protein? ** ** said the adolescent male Adapted from PEAK working group

33 Doc- I want to gain muscle! Should I eat lots of protein? Adapted from PEAK working group

34 Recommendations regarding protein?* If calorie intake is high, likely to meet protein needs, but may still need to pay attention to timing. For muscle growth aim to have 15-25g protein within the first 2 hours post-exercise (Higher amounts of protein unlikely to result in further increases in muscle growth) Higher amounts of protein post-strenuous exercise may reduce risk of hypoglycemia in the hours following exercise Distribute protein throughout the day Have protein after exercise, especially strenuous exercise Examples of whole food, protein-rich snacks include yoghurt with fruit, or a sandwich with protein filling. Quality matters - eat unprocessed protein foods as much as possible. Ideally only use supplemental protein (protein powders) around exercise bouts and if protein needs are high and cannot be met with food alone (ideally avoided in adolescents and children) *JDRF PEAK Working group (in press)

35 Do I bolus for protein? - How? Large amounts of protein may require additional insulin dosing >50g protein as part of a mixed meal - for some it may be less >70g protein when consumed on its own Consider using dual or combination waves for protein If on MDI give an additional bolus 1 hour after the meal May choose not to bolus for protein when consumed post-exercise May also need to consider fat >35g fat may require additional insulin dosing

36 Low Carb? General rule: If doing high intensity exercise almost daily may benefit from a higher carbohydrate diet If weight loss is the goal or if lower intensity exercise may benefit from a lower to moderate carbohydrate diet. Recommendations for total carbohydrate intake: If not exercising daily, or if doing low intensity exercise or if doing less than an hour per day of low to moderate intensity exercise: 2-4g/kg body weight per day (e.g. 64kg x 2-4 = ~ g per day) If exercising daily, doing high intensity and glycogen depleting exercise: 5-8g/kg body weight per day (= ~ g per day)

37 How low is low? Less than 30-40% of calories from carbohydrate: 30% carb (2000 cal) = 150g carbohydrate Ketogenic diet: typically 50-70g carbohydrate per day Not advisable for growing children Carbohydrates are necessary for normal development and growth May lead to ketone production Unclear as to if there is a safe amount of ketones that may be produced

38 Fuel Utilization: Muscle Glycogen Demand Increases with Intensity

39 Oh no- I m low! Emma is a 15 year old female who is a competitive cyclist. During a 30 mile ride, despite her strategy to reduce insulin prior to exercise and take in adequate carbohydrates, she feels her blood glucose dropping. 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? A. Stop and treat her hypoglycaemia again B. Keep going because there s only a couple miles to go C. Ride faster to bring up her blood sugars

40 For many athletes, the competitive instinct can be powerful and interfere with smart decision-making Hypoglycemia itself can impair decision-making. There is a fine line between the optimal performance range and inability to perform at all! Ideally hypoglycemia is prevented with insulin adjustment, carb replacement, and/or intermittent high intensity exercise If hypoglycemia occurs, competition should be stopped to allow for treatment and recovery Consider the benefits of continuous glucose monitoring or frequent glucose monitoring to predict/prevent lows

41 Spontaneous Exercise in Youth 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. He has a sensitivity of 1:50 mg/dl >120mg/dL. His I:C ratio is 1:15 grams. 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 today.

42 What would be the best option for James in this situation? (Assume his ketones are negative) A. Skip practice today. His blood sugar is just too high. B. Take additional correction dose of insulin and wait until his blood sugar starts coming down C. Go ahead and play without additional insulin.

43 Key Points Know the effect of insulin-on-board (IOB) under normal circumstances versus during exercise In this case: Blood glucose of 280 mg/dl with 3.5 units IOB with a correction factor 1:50 mg/dl would normally drop blood glucose to 105 mg/dl This same scenario in the presence of exercise will almost certainly cause hypoglycemia Thus he needs to take carbohydrates to cushion the fall He can use a temporary basal rate or remove his pump for exercise <60-90 minutes to avoid lows but in this case it is too late these interventions will have little impact due to the high IOB

44 Here s the math I would take him through Predicted BGL due to IOB = 105 mg/dl Basketball usually causes him to drop by ~80 mg/dl per hour at his normal basal rate (without any carbs eaten) based on his experiences. Thus he could theoretically be 25 mg/dl (yikes) after/during exercise. This requires a reverse correction equivalent to a rise of 100 mg/dl to get/keep him at about 125 mg/dl. That is equivalent to 2 units of insulin for him (1:50 sensitivity) - minimum 30 grams uncovered carbs, and likely more (based on 1:15 grams). - He may also reduce his basal (if even an option)

45 How to cushion the fall? Treating blood glucose based on trend information will: Allow him to keep exercising Require less carbs Help him feel better and stronger during and after basketball

46 Caroline is a 10 year old girl with type 1 diabetes who loves soccer. Usually soccer practice causes her BGL to drift down (though it varies a lot) This Saturday she has a semi-final- a 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.

47 Game Time! It is likely that she will: A. Keep a steady BGL the entire time and the whole game will be a breeze B. Have persistent hypoglycemia C. Be at risk for stress hyperglycemia

48 The Adrenaline Effect 1. Adjust carb intake for higher expected sugars (lower carb breakfast) 2. Cautious correction if BG > 250 in hour before (25-50% correction) 3. Hydrate 4. Get to the game early, calm down with a light aerobic warm-up, visualization, whatever works to stay calm

49 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? A. Continue as planned because her blood sugars are now in a good range B. Participate but take it easy C. Consider skipping today s activity completely

50 Ok to exercise once issue resolves after treatment of a mild low Avoid overtreatment with carbohydrate which can lead to: hyperglycemia and need to take insulin and lead to roller-coaster phenomenon Ideal treatment would raise glucose into target range of mg/dl pre-activity A single severe hypoglycemic event will predispose to further hypoglycemic events, especially during exercise be careful and watch her closely Glucagon, epinephrine, and norepinephrine secretion are diminished the next time a hypoglycemic event occurs

51 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? A. Give his usual correction of insulin and keep his fingers crossed B. Give a reduced correction of insulin C. Go back to sleep don t give a correction at all

52 High BGL beforehand He gave 50% bolus for correction at 4am in advance of his 6:30am run Starting the run with a blood glucose of 178 mg/dl Carbohydrate replacement peaked blood sugar at 223 mg/dl Using 50% temporary basal and 40g carbohydrates per hour, blood glucose stabilized and finished at 101 mg/dl

53 Other issues for the active person with T1DM Hydration Essential to performance Calculate anticipated sweat loss/replacement regimen Use electrolyte tablets/powders if needed Account for carbohydrate replacement in glucose-containing electrolyte solutions and carbohydrate in gel/solid forms CGM/infusion set adhesion/issues Much more difficult during exercise of long duration or in humid climate Result in loss of key glucose information or ability to manage Change sites/sets 1 day prior to competition Use additional adhesives as necessary (Tegaderm, Mastisol) Insulin is absorbed more quickly into exercised portions of the body CGM accuracy during exercise

54 Dexcom G4 Platinum vs Medtronic Enlite System, at Rest and During Exercise MARD 13.8% MARD 22.5% MARD 12.4% MARD 20.4% Taleb et al, Diabetes Technology & Therapeutics. September 2016, 18(9)

55 Possible Actions Factors affecting risk of hypoglycemia Frequent Monitoring of BGL and/or CGM Exercise Type, intensity, duration Time since last meal and insulin dose Time of Day Physical Fitness Recent hypoglycemia, hypo unawareness Emotional/stress hormone factors Risk of delayed hypoglycemia Preceding meal Following meal Night Reduce insulin bolus Reduce basal insulin snack Reduce basal insulin Resume basal insulin snack +/- max effort Reduce insulin bolus snack Reduce basal insulin Adapted from Nadine Taleb and Rémi Rabasa-Lhoret. Diabetologia August 2016,59(8),

56 Is the activity primarily aerobic? Is the activity prolonged resistance exercise (weight lifting for >30 minutes)? no no yes Discuss the advantages and disadvantages of insulin dose reduction and carbohydrate intake for exercise. Activities that include anaerobic exercise will require less carbohydrate intake and/or less insulin adjustments. If both resistance/anaerobic and aerobic are to be performed, suggest performing resistance/anaerobic first yes Is the patient willing and able to lower insulin levels for exercise? no Consider increased carbohydrate intake at a rate of ~0.5 grams/kg body mass/hour of activity yes Consider the timing of exercise relative to the last meal Is the activity 3 hours after a meal? yes Consider bolus insulin reduction Riddell, Taplin et al. Ped Diab 2015 no Consider basal insulin reduction Is the patie nt on CSII? no Consider a 20% reduction in basal insulin on days with prolonged activity. Consider CSII therapy if repeated hypo- or hyperglycemia persists Is the activity prolonged intermitten t high intensity activity? yes Reduce bolus insulin by 25-75% at the meal before exercise depending on the intensity (i.e. light=25%; moderate=50%; heavy=75% reduction) no Is the activity 60min in duration? yes Reduce basal insulin by 50-90% minutes before the start of exercise until the exercise stops. Or consider pump suspension at the start of exercise no Discuss the possibility that intense anaerobic sprint-based exercise may increase glucose levels and require conservative insulin correcting in recovery if hyperglycemia exists yes Reduce bolus insulin by 50-75% at the meal before exercise (i.e. light=50%; moderate/heavy 75%) Other notes: 1) Pump suspension at the onset of aerobic exercise may require initial carbohydrate intake (15-20g); 2) Consider CGM where patient or parent preference dictates, or with history of nocturnal or severe hypoglycemia; 3) Downward trending arrows on CGM during exercise should be responded to by the ingestion of 8-20 grams of rapidly acting carbohydrate; 4) consider overnight basal rate reduction of 1-40% on the evenings after prolonged aerobic exercise or resistance training.

57 Practical points Different Kinds of Exercise do Different Things to Blood Glucose acutely But all increase risk of lows many hours later Consider pump suspension or reduction before and during exercise as one option to prevent lows (and/or basal rate reduction beforehand) But beware of highs if this is done with intense or interval exercise Minimizing the amount of rapid acting insulin on board during exercise and then snack to maintain sugar level Planning is important but children and adolescents are spontaneous! Beware of hormonal responses (excitement/nerves) that might quickly wane (highs followed by lows) Consider use of protein before exercise to attenuate risk of hypoglycemia Replenish CHO stores quickly post-exercise but don t over-bolus! Consider decreasing the post-meal bolus, and also night time insulin to prevent night time low blood sugars (this is what the artificial pancreas seems to do Check blood glucose often this is the best management strategy of all! Strongly consider CGM and available technology for threshold suspend and in future predictive low glucose suspend

58 Adapted from Jane E. Yardley et al, Diabetes Care 2012 What about the order of exercise type- Resistance first or aerobic first? Aerobic first

59 Mean glucose (n = 12) as measured by continuous glucose monitoring from 1 to 12 h after exercise following aerobic exercise performed before resistance exercise (AR, dashed line) and resistance exercise performed before aerobic exercise (RA, solid line). Resistance first Jane E. Yardley et al. Dia Care 2012;35: by American Diabetes Association

60 Nocturnal hypoglycemia remains a risk

61 Exercise with Single Hormonal Closed Loop Control may be challenging Closed-Loop Basal Insulin Delivery Over 36 Hours in Adolescents With Type 1 Diabetes Randomized clinical trial. Elleri et al. Diabetes Care 2013 Apr; 36(4):

62 Other Physiologic signals such as Heart Rate may help closed loop control around Exercise 12 adults Light cycling 30 mins > 4 hrs post-meal (minimal IOB) Breton et al. Diabetes Technol Ther Aug 1; 16(8):

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64 No food after 11am 3 x 15 HR 140 with 5 min rest 4pm

65 Heart rate informed artificial pancreas system enhances glycemic control during exercise in adolescents with T1D Pediatric Diabetes 13 OCT 2016 DOI: /pedi

66 Other Closed Loop Options to Safely Exercise? - would a bi-hormonal model have an advantage? Continuous exercise - 60 min session at 60% VO 2 peak Interval exercise -2 min alternating periods of 85% and 50% VO 2 peak for 40 min Both exercises were matched for energy expenditure

67 Continuous aerobic exercise - a dual hormonal AP system Insulin only Insulin + Glucagon Adapted from: Taleb, N. et al. Diabetologia (2016). Online: 04 October 2016

68 Continuous aerobic exercise - a dual hormonal AP system Pooled Data Insulin AP Insulin + Glucagon AP No difference between groups in overnight lows Adapted from: Taleb, N. et al. Diabetologia (2016). Online: 04 October 2016