1	Blood Glucose Control with Sports & Fitness Activities
2	Objectives Optimize glycemic control to enhance physical/athletic performance Prevent hypoglycemia during and after physical activity Prevent exercise-induced hyperglycemia, ketosis and DKA Manage the logistics of wearing an insulin pump during physical activity
3	Blood Glucose Affects: Strength Stamina Speed/Agility Flexibility Safety Mental Sharpness
4	What BG Is Optimal?
5	Hypoglycemia Prevention
6	Fuel Utilization During Exercise
7	Energy Sources During Exercise
8	Hormonal Responses to Exercise (non-diabetic)
9	Hormonal Responses to Exercise (diabetes, using insulin)
10	Insulin Adjustment Based on Timing and Duration
11	Insulin Adjustment Based on Timing and Duration
12	Insulin Adjustments Meal Bolus Adjustment (for post-meal activity) Low Intensity Cardio ê 25% Mod. Intensity Cardio ê 33% High Intensity Cardio ê 50% Competitive/Anaerobic ???
13	Insulin Adjustments Basal Adjustment (for > 90 min. activity) CSII: ê Basal rate 50% starting 1 hr pre-activity, or: CSII: Disconnect 1-hr prior, but reconnect hourly and bolus 50% of usual basal rate (for day-long activity) CSII: ê basal 50% daytime, 25% nighttime Shots: ê basal insulin 25%
14	“Automated” Pump Adjustments To Prevent Hypoglycemia Custom Bolus Options: Can label different I:C ratios for active situations
15	Which is better for promoting weight loss? Exercise BEFORE eating? Exercise AFTER eating?
16	Pump disconnection: Effect on basal insulin level
17	Pump disconnection: Effect on basal insulin level
18	Pump disconnection: Effect on basal insulin level
19	Pump disconnection: Effect on basal insulin level
20	Pump disconnection: Effect on basal insulin level
21	Pump Temp Basal: Effect on basal insulin level
22	Pump temp basal: Effect on basal insulin level
23	Insulin Adjustment: Case Study 2-Hour Lacrosse Practice (after dinner) ò Dinner bolus 50% ò Disconnect 1-hr pre-practice, re-connect hourly & bolus 50% of usual basal Snack at midpoint (if BG appears to be dropping)
24	Snacking to prevent hypoglycemia Basic Rules: Snack prior to activity to prevent hypoglycemia ? Adjust quantity based on pre-activity BG or direction of BG Ø BG low or dropping: ñ usual carbs Ø BG OK or stable: usual carbs Ø BG High or rising: ò usual carbs Ž Snack at least once per hour during prolonged activity ? Choose high-glycemic-index forms of carbohydrate Ø Sports drinks / Sweetened beverages Ø Dry cereal, pretzels, crackers
25	Which approach keeps BG in range for the majority of the workout?
26	Snacking to prevent a low
27	Snacking to prevent a low
28	Snacking to prevent low: Case Study
29	V^a_â_i@bLS_$: Just a Few Factors that affect Blood Glucose During Exercise Familiarity w/Activity Amt. Of Prior Activity Size/Number of Muscles Involved Duration Intensity Active Insulin Infusion Site What You Ate When You Ate Emotional State Temp/Humidity
30	Watch Out for D’OH! (Delayed Onset Hypoglycemia) Following high-intensity exercise Following extended duration activity Due to replenishment of muscle glycogen stores, enhanced insulin sensitivity May occur up to 24 hours afterwards (typically 6-12 hours later)
31	D’OH! Prevention Keep records – track the patterns Decrease basal insulin (modestly) or meal/snack boluses post-activity “Free” Snacks (slow-acting carbs) following activity
32	D’OH! Prevention Check BGs more frequently q 2 hrs during “high risk” period 3am night following activity Wear a continuous glucose monitor
33	Symlin: Exercise Implications
34	Can Exercise Cause Rise in BG? Ketoacidosis?
35	Adrenaline Raises BG! Carbohydrate Counterregulatory / Stress Hormones Muscle Activity Insulin
36	Adrenaline Raises BG! Activities that often produce a short-term blood glucose rise include: æ Weight lifting (high weight, low reps) æ Sports w/ “bursts” of activity (golf, baseball, martial arts) æ Sprints (running, swimming) æ Judged performances (gymnastics, skating) Events in which WINNING is the primary objective
37	Preventing / Offsetting BG Rise Keep Records to determine avg. BG rise Check BG 30-60 Min. Pre-Activity Bolus 30-60 min. prior to activity to offset rise (give 50% of usual amount required) Take 50% of Usual “Correction Dose” If High (reduce based on insulin-on-board)
38	Snacking to prevent high: Case Study
39	Dehydration Can Raise Blood Glucose Concentration Decreased blood volume will give the impression that blood sugar level has risen Water is needed to convert fat & glucose into energy Adequate hydration improves performance and prevents cramping Thirst occurs after dehydration has occurred Drink before & after exercise Extra fluids during extended exercise or with warm/humid conditions
40	What the *&!%#! Is a KETONE???
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44	To Prevent Ketoacidosis Check urine for ketones prior to exercise w/BG > 250 mg/dl (7mmol) No exercise w/positive ketones (small or more on urine ketostix; >.5 mmol/l on ß Ketone test using Precision Xtra meter) OK to exercise if nonketotic – take 50% of usual “correction” bolus and drink plenty of water Do not disconnect for more than 2 hours
45	“Automated” Pump Features for Extended Disconnection Disconnect Feature: Can bolus up to 50% of anticipated missed basal Can replace missed basal upon reconnection Can remind user to reconnect after preset time interval (15-120 min)
46	Alternatives to extended pump disconnection
47	Alternatives to extended pump disconnection
48	Infusion Set Adhesion During Exercise
49	Pump & Temperature Extremes During Exercise
50	Pump & Temperature Extremes During Exercise
51	Diabetes Exercise & Sports Association (DESA)