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Managing glucose before, during and after exercise in type 1 diabetes

Managing glucose before, during and after exercise in type 1 diabetes. Rob Andrews University of Bristol/ Taunton and Somerset Foundation Trust. Beneficial. Beneficial. Fitness Insulin requirement Lipids Endothelial function Mortality Insulin resistance CVD Wellbeing (only children ).

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Managing glucose before, during and after exercise in type 1 diabetes

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  1. Managing glucose before, during and after exercise in type 1 diabetes Rob Andrews University of Bristol/ Taunton and Somerset Foundation Trust

  2. Beneficial Beneficial Fitness Insulin requirement Lipids Endothelial function Mortality Insulin resistance CVD Wellbeing (only children) Fitness Insulin requirement Lipids Endothelial function Mortality Blood pressure Beta cell function Glycaemic control Uncertain / Limited data Uncertain / Limited data Microvascular complications Osteoporosis Cancer Beta cell function Blood pressure Glycaemic control Microvascular complications Osteoporosis Cancer CVD Wellbeing Type 1 diabetes Type 2 diabetes Physical activity

  3. So what do Specialist in Diabetes know about exercise and diabetes?

  4. Result of survey of diabetes HCP – No 138

  5. Exercise and blood sugar HCP knowledge on what to do with high BG (>13), and slightly low 3.6 was good but • 75% HCP did not know what to do with patients who had has severe hypo night before • 50% HCP did not know what to do with BG of 5.5 • 75% did not know what to do with blood sugar of 1.8 Doctors no better than nurses or dietitians.

  6. Exercise and insulin Fast acting insulin • 1/3 of HCP not clear as what should be done with fast acting insulin if exercising 2 hours after a meal • 55% HCP not sure what should be done with fast acting insulin if exercise before breakfast Long acting insulin • 50-80% HCP (dependent on time of day) not knowing what to do with background when exercising Doctors significantly worse than nurses or dietitians.

  7. Exercise and injection sites Where to inject • 1/3 of HCP did not know the injection sites that should be avoided when cycling or lifting weights. Doctors no better than nurses or dietitians.

  8. What you need to know • Type of exercise

  9. Aerobic exercise Aerobic exercise is physical exercise of relatively low intensity that depends primarily on the aerobic energy-generating process.

  10. Aerobic • Hiking • Golf • Road cycling • Cycle tour • Mountain biking • Distance running • Distance swimming • Triathlon, etc

  11. Anaerobic exercise Anaerobic exercise is exercise intense enough to trigger use of non oxygen using metabolism. It normally last less than 2 minutes

  12. Anaerobic exercises • Weight lifting • Body Building • Dressage • Fencing • Track and field events (Javelin, Shot put, Long jump, Pole-vault, High jump, Sprinting) • Archery • Wrestling

  13. Hormonal response to exercise - 1 GH Cortisol Glucagon Testosterone Noradrenaline Adrenaline Hormone concentration 40 80 120 160 Exercise Recovery

  14. Hormonal response to exercise - 2 Rest Resistance Sprint Endurance Kate L. Gilbert et al 2008

  15. Hormonal response to exercise - 3 Aerobic Anaerobic

  16. Summary 1 • With Aerobic exercises blood sugars will tend to fall. • With anaerobic exercise blood sugars will tend to rise

  17. What you need to know • Type of exercise • Intensity of the exercise

  18. Hormonal response to exercise - 4 • Dependent • Exercise intensity • Type of exercise • Competition • Body temperature • Age • ? Blood glucose • Independent • Circadian rhythm • Meal time • Menstrual cycle • Sex Exercise intensity Hormone concentration 0 20 40 60 80 100 V02 max

  19. Fuels used during exercise

  20. Lactate during exercise

  21. Insulin in response to different exercises Sprint Weight training Endurance

  22. Summary 2 As the intensity of exercise rises • Glucose becomes the major fuel • Lactate levels rise • Insulin levels rise to compensate for this

  23. Cardiovascular response to exercise 200 180 Systolic BP 160 140 120 160 140 120 Heart rate 100 80 60 Rest Exercise Recovery

  24. Borg Scale 6 7 8 9 10 11 12 13 14 15 >16 Very Light Light Moderate Heavy <90bpm ~100-110bpm ~120-130bpm 146-160bpm Under 6 = Rest Over 16 = Very Heavy

  25. Summary 3 • Exercise induced HR rise is Less in patients with Type 1 Diabetes • Thus using Predicted HR for training is not very useful in patients with Type 1 Diabetes • One helpful scale that can be used is the borg scale

  26. What you need to know • Type of exercise • Intensity of the exercise • The length of the exercise

  27. Prepares body Insulin resistance Activation of CNS Insulin levels fall Increased lipolysis Increased glucose Output Glucagon levels Rise Adrenaline levels Rise Normal response to exercise GH and Cortisol rise Pre Exercise

  28. Adrenaline Noradrenaline Glucagon Insulin T4 T3 Cortisol Glucagon Pyruvate Co2 Cortisol Adrenaline Noradrenaline GH Hormones during exercise. Liver Muscle Glycogen Glucose Glucose Glucose FFA’s Glycerol TG Amino acids

  29. Summary 4 Fuel for exercise comes from three sources • Muscle (few minutes) • Liver (40 minutes) • Fat breakdown And is under the control of hormones

  30. Prepares body Insulin resistance Activation of CNS Insulin levels fall Reduced lipolysis and decreased glucose output Glucagon levels Rise Adrenaline levels Rise Response to exercise in diabetics GH and Cortisol rise Pre Exercise

  31. Adenaline Noradrenaline Glucagon Insulin T4 T3 Cortisol Glucagon Pyruvate Co2 Cortisol Adrenaline Noradrenaline GH Hormones during exercise in diabetes. Liver Muscle Glycogen Glucose Glucose Glucose FFA’s Glycerol TG Amino acids

  32. Summary 5 • In patients with T1DM less fuel comes from the liver and fat, with the fat more effected than the liver. • So glucose may be needed for short bouts of exercise and definitely will be needed for longer durations of exercise

  33. What you need to know • Type of exercise • Intensity of the exercise • The length of the exercise • When they are exercising in relation to their fast acting insulin

  34. Insulin Sensitivity: 1922 Lawrence 14 12 10 8 Plasma glucose mmol.l-1 6 4 No Insulin 2 Insulin 0 30 60 120 240 Time mins

  35. Actrapid or Humulin S Novorapid or Humalog Different insulin regimes Hypo risk Hypo 0 2 h 4 h 6h

  36. Summary 6 • Glucose falls quicker during exercise when insulin is around. • Adjustments in insulin or glucose intake will thus need to be made if exercising within 2-4 hours of taking insulin

  37. What you need to know • Type of exercise • Intensity of the exercise • The length of the exercise • When they are exercising in relation to their fast acting insulin • What time of day they are exercising

  38. Changes in insulin sensitivity with exercise

  39. Changes in glucose with exercise

  40. Summary 7 Insulin sensitivity increases • During exercise • For an hour after exercise • At 6-8 hours post exercise Glucose thus needs to be watched at 2 time points

  41. How to do it!

  42. Step 1: Dietary intake

  43. Diet 33 yr female, diagnosed type 1 DM age 16 Training for a triathlon Weight currently 63 kg, height 1.65 m Her current problems – dips and highs in glucose levels and running out of energy in training. 3 February 2012 Janet Gorton Diabetes Specialist Dietitian Taunton & Somerset NHS Foundation Trust

  44. Food diary Breakfast - 40g (bowl) whole oats, 100 ml skimmed milk & water, small banana, actimel 1 hr training - refuel 350ml flavoured sk milk Lunch - Egg s’wich, 1 slice toast , 200g baked beans 1 hr 45 training/yoga - refuel 200ml sk milk, 500ml water Dinner - Liver, bubble & squeak, yoghurt, herbal tea 3 February 2012 Janet Gorton Diabetes Specialist Dietitian Taunton & Somerset NHS Foundation Trust

  45. Energy Expenditure • Most athletes expend 45-50 kcal/kg body weight • 63kg 2835 – 3150 • 90kg 4050 – 4500 kcals • Other factors 3 February 2012 Janet Gorton Diabetes Specialist Dietitian Taunton & Somerset NHS Foundation Trust

  46. 14 -16 pints skimmed Milk 63 kg 3 February 2012 Janet Gorton Diabetes Specialist Dietitian Taunton & Somerset NHS Foundation Trust

  47. Carbohydrate requirements body mass, exercise intensity & duration 2010 International Olympic Committee (IOC) Concensus statement on Sports Nutrition *Burke, L.M., (2010)

  48. Insulin Insulin Pyruvate Co2 Cortisol Cortisol GH Hormones post exercise. Liver Muscle Glycogen Glucose Glucose Glucose FFA’s Glycerol TG Amino acids

  49. Recovery • Protein and Carbohydrate together improve glycogen storage 2 hours post exercise • 4 carb : 1 protein • 20-25 g protein optimal • Total 1.2g/kg 3 February 2012 Janet Gorton Diabetes Specialist Dietitian Taunton & Somerset NHS Foundation Trust

  50. Step 2: Starting blood sugars

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