Exercise & Busy Kids
Smart Pumps & Sports
Rick Philbin, MBA, MED, ATC
Sports Program Coordinator, CWD
Board Member, Diabetes, Exercise, & Sports Assoc.
Regional Manager, Animas Corporation
A Typical Blood Sugar
Response
200
180
160
140
120
100
80
60
40
20
0
Blood Sugar
10
20
30
40
Joslin Medical Publication
60
80
100
120
Effect of Exercise on Blood Sugar Levels
500
450
400
350
300
250
200
150
100
50
0
Lacking insulin
DM- Not
Controlled
DM - Controlled
With insulin
Non- DM
No diabetes
10
20
Joslin Medical Publication
30
40
Exercising After Food
200
180
160
140
120
100
80
60
40
20
0
Exercise Effect
Meal Effect
0
20 40 60 80 100 120 140 160 180
Know the Action of Your Insulin
NovoLog
Glargine
(no peak)
Considerations
Factors affecting BG during exercise
– Time of day
– BG at start of exercise (do you have a
target?)
– Bolus timing for meal prior to exercise
– Site location (absorption issues)
– Food eaten prior to exercise (when?)
– Type, duration, intensity of exercise
– Physical condition (fit or unfit?)
– Hydration
Smart Pumping, Howard Wolpert, MD
Temporary Basal
Enables patient to temporarily
reduce or increase the active basal
rate
Accommodates for exercise or any
substantial prolonged change in
normal activity level
All smart pumps have this feature
When to Use Temporary Basal
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
– Off season
– Long Car Rides
Key Elements
Dose
– Amount of decrease or increase
percentage
Duration for temporary adjustment
Test often to see a pattern
What to do with the Pump?
Pre-exercise meal boluses may be
reduced as much as 50% depending on
when exercise will take place
Basal Adjustments?
– 0-20% decrease for exercise/activity of
moderate intensity and short duration
– 25-100% decrease for exercise/activity of
moderate to high intensity and longer duration
– Trial and error
Challenges
Delayed onset
hypoglycemia
– What is it?
Varying requirements
for different activities
– Testing to establish
patterns and BG targets
Supplemental snack
may still be necessary
for replacing glycogen
stores lost during
exercise
Tools for Success
Target BG goals
established
– Exercise (e.g., 150 mg/dl)
Test effectiveness of the
settings
Ability to adjust key
elements for fine-tuning
Understand preventing
hypoglycemia is easier
than treating
Insulin Pump Therapy and Exercise
Where do you
carry it during
exercise?
Can you play
contact sports?
How often do you
change the
infusion site?
You may give yourself
a bolus of insulin for a
high glucose reading
You may adjust your
basal delivery of
insulin depending on
your glucose readings
(temporary basal rate)
Variables
Blood flow differences
– Activity
– Site selection
Abdomen is fastest ~34
min*
Deltoid, Femoral, Gluteal
about the same (rapidacting)
– Ambient temperature
Hot, increased absorption
Cold, decreased
absorption
Dose size
– Larger, longer
– Smaller, shorter
Weight
– Insulin resistance
Insulin quality
*Insulin Aspart: A Fast-Acting Analog of Human Insulin, Mudaliar S, et. Al.
Competition?
Children on insulin pumps
If basal insulin is set correctly, changes in meal
scheduling due to exercise should not present a
problem.
Kids can disconnect their pump for 1 hour, test and
correct if above target.
They may need to eat a snack in order to bolus if
they want to stay disconnected for a second hour.
Two hours without any insulin is too long, this can
lead to ketones. You can have ketones with a
normal blood glucose reading.
If they stay connected, they may need a temporary
basal. This may need extended beyond the activity.
To Connect or Disconnect the Pump
During Exercise or Competition?
This may be left to
the discretion of the
individual
Should not disconnect
for more than one
hour
What are the rules for
wearing a pump
during competition?
Carbohydrate Calculator
BG Correction
Calculator
– Input BG reading
– Input personal Insulin
Sensitivity Factor (ISF)
– A correction dose is
calculated
– Correct back to target
BG prior to exercise not
normal range
Definition:
Insulin on Board (IOB)
The amount of insulin still
active at a given time after a
bolus.
The 30% Rule
Pumping Insulin, Walsh J, Roberts R
Benefits
Decreased risk of stacking insulin
– Less chance of hypoglycemia
Decreased risk of intentionally
running high due to fear of
hypoglycemia
– Improved HbA1c
Challenges
One size doesn’t fit
all
– Variability
intraindividual
~10 - 20%
– Variability
interindividual
~20 - 35%
Variability of the Metabolic Effect of Soluble Insulin and the Rapid-Acting Insulin analog Insulin
Aspart, Heinemann L, Weyer C, Rauhaus M, Heinrichs S, Heise T
The after school sport
It may be beneficial to have an
afternoon snack.
Sports drinks should be used with
caution.
– Many kids drink too much because they
are thirsty.
– You don’t want to take away the benefit
of exercise by being hyperglycemic.
Tips
Check 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 exercise
– ~50% less as a starting point
May need lower bolus to correct high BG
before or during longer periods of exercise
Disconnect can be an option up to one hour
– Or 0% Temp rate
Smart Pumping, Howard Wolpert, MD
Lows, Highs, and Exercise
The longer and more
strenuous the exercise,
the more likely the blood
glucose will go low
Less trained individuals
will more likely go low
Strenuous and anaerobic
exercise may raise blood
glucose
Strategies for Avoiding
Hypoglycemia
Exercise 11/2 to 3 hours
after eating
Know your individual
glucose response to
exercise
Test you glucose levels
before you exercise (30
minutes apart)
Decrease the insulin dose
that is working while you
are exercising ( with
physicians knowledge)
Summary
These concepts have been under utilized
across the country due to its complexity
as it relates to the patient, as well as
the relatively recent arrival of rapidacting insulin analogs
With new products available that simplify
the calculation and allow for intra and
inter patient variability, we expect to
see more widespread education and
practical application of these features
Healthcare Team Involvement
Your physician should be in
the loop for exercise
prescription
Look for healthcare providers
with an expertise in diabetes
and exercise
Look for healthcare providers
with a proactive approach to
exercise (avoid professionals
that routinely use words likecan’t, stop, and don’t)
Diabetes, Exercise & Sports Association (DESA)
http://www.diabetes-exercise.org
Leading national
nonprofit diabetes
organization dedicated
to diabetes health,
wellness and
prevention through
exercise
Health-conscious
people with diabetes
as well as health care
professionals who care
for them
cavorite-lis
n
-fGET
tg/stores/d
communit
rate-item
cust-rec
just-say-no
true
m/justsay
THANK YOU FROM THE BOTTOM
OF MY PANCREAS!