"Everyone is an athlete. The
only difference is that
some of us are in training,
and some are not."
Dr. George Sheehan




Optimize exercise performance
Prevent hypoglycemia during and
after any physical activity
Rapidly manage hypoglycemia caused
by or following exercise
Prevent hyperglycemia and DKA

Assess patients for conditions that might contraindicate
certain types of exercise such as:
 Uncontrolled hypertension
 Severe autonomic neuropathy or peripheral
neuropathy
 History of foot lesions
 Unstable proliferative retinopathy
 Patient’s age and previous physical activity level
should be considered

Encourage patient to start with short periods of lowintensity exercise and slowly increase intensity and duration

Advise people with diabetes to perform:
 At least 150 min/week of moderate-
intensity aerobic physical activity
▪ 50–70% of maximum heart rate
▪ Spread over at least 3 days per week with
▪ No more than 2 consecutive days without
exercise
DIABETES CARE, VOLUME 35, SUPPLEMENT 1, JANUARY 2012,
www.care.diabetesjournals.org
Factors That Affect Blood Glucose Levels
INSULIN
Time
STRESS
Type
EXERCISE &
BLOOD
GLUCOSE
Amount
ALCOHOL/drugs
BLOOD
GLUCOSE
Time
Type
Amount
FOOD
Time
EXERCISE
ILLNESS
Farquar, A July 17, 2008 DESA International Toronto, Canada
Type
Amount
Weightlifting, Power lifting
Track (sprinting/field events), Diving (Platform & springboard)
American football, Swimming (sprints), Gymnastics, Fencing
Wrestling, Volleyball, Ice hockey, Track cycling
Basketball, Soccer, Tennis, Lacrosse
Speed skating (500-1000m)
Skiing (slalom & downhill), Field hockey
Rowing (middle distance)
Running (middle distance), Speed skating (>1500m)
Road cycling
In-line skating
Cross country skiing
Race walking
Marathon running
Iron Man triathlon
Ultra-marathon running
Hyperglycemia
ANAEROBIC
Short duration
High-intensity
AEROBIC
Longer duration
Lower Intensity
Hypoglycemia
Absorption Rate

The rate at which subcutaneously injected
insulin is absorbed increases with exercise
due to increases in body temperature and in
subcutaneous and skeletal muscle blood flow

Exogenously administered insulin levels do
not decrease during exercise
Zinman B, Murray FT, Vranic M, et al. Glucoregulation during moderate
exercise in insulin treated diabetics. J Clin Endocrinol Metab. 1977;45:641–652.
Humalog, Novolog, Apidra (4–6 hours)
Regular (6–10 hours)
Plasma Insulin Levels
NPH (12–20 hours)
Detemir (Up to 24 hours)
Glargine (20–26 hours)
0
2
4
6
8
10
12
14
16
18
Hours
Adapted from American Diabetes Association. Diabetes in the Latino Population.
Diabetes Core Curriculum Workshop
Available at: http://www.diabetes.org/uedocuments/LatinoSlidesAugust05.ppt.
20
22
24
Hypoglycemia Risk
 Weekend warriors or untrained person
 Increased duration, intensity and/or frequency
 New activity
 Hypoglycemia unawareness
 Recent physical activity or hypoglycemia within
last 24 hours
 Alcohol use
*Alcohol will stop liver from releasing glycogen
Duration
Adjustment
Notes
2 hrs per
drink
-50%
Begin after
drinking

Frequently, strenuous exercise causes an
increase in insulin sensitivity as well as
the restoration in muscle glycogen
storage
 May need insulin level adjustment to
avoid frequent carbohydrate correction
 More frequent glucose monitoring




Frequent monitoring
Consume extra carbohydrates when
necessary
Keep accurate records of duration, intensity,
and frequency
Reduce insulin that is active at time of
exercise





Check BG often during exercise and in the
following 24 to 36 hours (look for patterns)
Begin Temp rate before exercise begins
May need to lower boluses before exer. ~50%
less as a starting point
May need lower bolus to correct high BG
before or during longer periods of exer.
Disconnect can be an option up to one hour
 Or 0% Temp rate
Smart Pumping, Howard Wolpert, MD
Exercise 2 to 3 hours after eating
Know your individual glucose response to exercise
(determined from pre/post BG checks)
 Check you glucose levels before you exercise (30
minutes apart – Why?)
 Decrease the insulin dose that is working while
you are exercising (consult healthcare team first)
 Pt. may need extra food or basal insulin
adjustments up to 24hrs after exercising
depending on the length/intensity of the exercise



Hyperglycemia
◦ Counter regulatory hormones
are released: cortisol,
glucagon, growth hormone,
adrenalin
◦ Glucose can increase during
exercise
 Delay exercise if ketotic
Diabetes Core Curriculum Workshop
GLUCOSE LEVEL
»
COMMENT
»

Fasting* blood glucose level
is 250 mg/dL (13.9 mmol/L)**

Test urine and/or blood for
ketones - If ketones present,
exercise is contraindicated**

Blood glucose value is 300
mg/dl (16.7 mmol/L) and
without ketones**

Exercise with caution, and
continue to monitor blood
glucose levels**
*Fasting is defined as 4 h or more after eating a meal.
**Zinman B, Ruderman N, Campaigne BN, Devlin JT, Schneider SH. Physical activity/exercise and
diabetes. Diabetes Care. 2004
 Allows greater flexibility
 Decide whether it is
The Pump Club
Insulin Pump
best to disconnect or
not
 May program the pump
to accommodate
exercise (temporary
basal or separate basal
program)
Diabetes Core Curriculum Workshop


Exercise - decrease
 Start Temp Basal ~ 1 ½
to 3+ hours prior to
exercise
 End Temp Basal ~ 30
minutes to as much as
24hrs after exercise
Less Activity - increase
 Long meetings
 All day seminars
 Long car rides
The Pump Club
Insulin Pump
Prevention of
Delayed-Onset Hypoglycemia
Duration
Adjustment
Notes
6-10 hours
-50%
Base timing
on experience

Prolonged
Activity
Duration
Adjustment
Notes
Minimum
2 hrs.
-50%
Start 1-2
hours prior
Pumping Insulin, Walsh J, Roberts R

Decreased risk of stacking insulin
 Less chance of hypoglycemia

Decreased risk of intentionally
running high due to fear of
hypoglycemia
 May improve A1c
Alternatives to Disconnection:
Physical Activities
 Wear It! (Sport Pack,
Bum Bag, Backpack
Harness)
 Re-Connect hourly &
bolus 50% of missed basal
rate
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6 - 20% effort
7 - 30% effort - Very, very light (Rest)
Very light < 10
8 - 40% effort
9 - 50% effort - Very light - gentle walking
10 - 55% effort
11 - 60% effort - Fairly light
Moderate 12-13
12 - 65% effort
13 - 70% effort - Somewhat hard - steady pace
14 - 75% effort
15 - 80% effort - Hard
16 - 85% effort
Hard 14-16
17 - 90% effort - Very hard
18 - 95% effort
19 - 100% effort - Very, very hard
20 - Exhaustion
Heart Rate 70-89%
Borg, G, "Perceived Exertion as an indicator of somatic stress",
Scandinavian journal of Rehabilitation Medicine 1970, 2(2), 92-98

Muscle glycogen contains
 300-400 grams of glycogen
▪ 1200-1600 calories

Liver glycogen contains
 75-100 grams of glycogen
▪ 300-400 calories

Blood glucose contains
 25 grams of glucose
▪ 100 calories





Normally takes 24 to 36 hours to replace muscle energy
(glycogen)
Consuming carbohydrates immediately post exercise
(w/n 15 minutes) can reload the muscles in 12 to 16
hours
Snack should be mostly carbohydrates and some
protein (4 parts CHO’s and 1 part Pro)
Added protein does not help with glycogen reloading
but may repair and help with protein synthesis after
exercise
Nutrition shake, smoothie, peanut butter sandwich,
energy bar, yogurt, turkey sandwich, string cheese and
crackers
Clark N, et al., “Sports Nutrition”, 124-28, 2003.
•In place of more common sports drinks
•When pitted against commercial sports recovery
drinks, several new studies have found that chocolate
milk is the superior beverage when it comes to postexercise recovery and fluid replacement
•Chocolate milk is 90 percent water, so it’s ideal for
rehydration
•It has the perfect combination of carbohydrates and
protein to refuel a tired athlete’s body, and it’s packed
with many other nutrients including calcium and
vitamins A and D (4 grams of carbs to 1 gram of
protein)
Applied Physiology, Nutrition, and Metabolism, Sept 2010

One size doesn’t fit all
 Variability
intraindividual
▪ ~10 - 20%
 Variability
interindividual
▪ ~20 - 35%
Heinemann L, Weyer C, Rauhaus M, Heinrichs S, Heise et all, ”Variability of the Metabolic
Effect of Soluble Insulin and the Rapid-Acting Insulin analog Insulin Aspart”, 2003.
197 mg/dl - start
170
117 – ate 15 grams of carbs
81
Minutes 20 30
40
188 at 7am
15 grams of carbs/protein
50% decrease in basal 8hrs
cavorite-lis
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-fGET
tg/stores/d
communit
rate-item
cust-rec
just-say-no
true
m/justsay
That means from the bottom of my heart
but only deeper