Assessing the
patient
Exercise and Type 1 Diabetes
2nd National conference
NEC, 15 May 2015
What would you ask?
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Age
Duration T1D
Other co-morbidities
Complications
Occupation/current activity level
Medication including insulin regime
Current approach to managing T1D (CHO counting,
frequency of glucose testing)
Hypoglycaemia frequency, and any associated with
previous exercise
Hypo aware?
Smoking and alcohol
Planned activity
What would you examine/test?
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Weight/BMI
HR
BP
Fundoscopy/retinal screening results
PVD – foot pulses
Neuropathy
Foot ulceration
Urinary ACR / serum creatinine
HbA1C
(TFT)
(Coeliac screen)
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29yr old accountant. Diagnosed 3yrs.
Little exercise to date. Humulin M3 bd insulin regime.
Abdominal lipohypertrophy. No complications. No troubling
hypoglycaemia. Wants to start cycling at weekends
42yr old shop assistant. Diagnosed 37yrs.
Previous long history of poor control. HbA1c now
73mmol/mol. Had retinopathy previously requiring laser.
Microalbuminurea. Basal bolus insulin regime. Wants to run
the 5K
36yr old businessman. Diagnosed 15yrs.
Moderate control. HbA1c now 67mmol/mol. Basal bolus
insulin regime. Has recently taken up squash in evenings.
Troubled by night hypos following squash.
29yr old accountant. Diagnosed 3yrs.
Little exercise to date. Humulin M3 bd insulin regime.
Abdominal lipohypertrophy. No complications. No troubling
hypoglycaemia. Wants to start cycling at weekends
 Would
you change the insulin regime at
outset? If so, to what and why?
 Where should she inject and with what
needle length?
 Do absorption rates differ according to
site of injection and if so, how?
 What is the recommended technique for
insulin injection?
29yr old accountant. Diagnosed 3yrs.
Little exercise to date. Humulin M3 bd insulin regime.
Abdominal lipohypertrophy. No complications. No troubling
hypoglycaemia. Wants to start cycling at weekends
 Would
you change the insulin regime at
outset? If so, to what and why?
 Where should she inject and with what
needle length?
 Do absorption rates differ according to
site of injection and if so, how?
 What is the recommended technique for
insulin injection?
Absorbtion rates
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Human insulin
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Premixed insulin (human or analogue)
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Abdomen in the morning because faster absorption
covers breakfast
Thighs/buttocks in evening because slower absorption
protects from nocturnal hypoglycaemia
Analogue insulins
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NPH: thighs and buttock because absorption slowest
Soluble: abdomen because absorption fastest
Site does not affect absorption rates
Massaging site not recomended
29yr old accountant. Diagnosed 3yrs.
Little exercise to date. Humulin M3 bd insulin regime.
Abdominal lipohypertrophy. No complications. No troubling
hypoglycaemia. Wants to start cycling at weekends
 Would
you change the insulin regime at
outset? If so, to what and why?
 Where should she inject and with what
needle length?
 Do absorption rates differ according to
site of injection and if so, how?
 What is the recommended technique for
insulin injection?
Insulin injection technique
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Resuspend cloudy (NPH and pre-mixed) insulins – how?
Disinfection required?
Prime needle – how?
Single use needle
Inject through clothing?
Count to 10 after pushing in plunger
42yr old shop assistant. Diagnosed 37yrs.
Previous long history of poor control. HbA1c now
73mmol/mol. Had retinopathy previously requiring laser.
Microalbuminurea. Basal bolus insulin regime. Wants to run
the 5K
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Should he run the 5K?
What advice would you give him if he insisted
on participating?
What exercise advice would you give him if
he had no complications but wanted to run
the marathon?
What exercise advice would you give
someone with
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Neuropathy
Autonomic neuropathy
Prevous MI
ADA position statement 2015
 Vigorous
or resistance exercises may be
CI in patients with proliferative retinopathy
or severe non-proliferative retinopathy
due to risk of haemorrhage or
detachment
 No evidence that vigorous exercise
increases rate of progression of diabetic
kidney disease (though watch out for any
associated IHD).
42yr old shop assistant. Diagnosed 37yrs.
Previous long history of poor control. HbA1c now
73mmol/mol. Had retinopathy previously requiring laser.
Microalbuminurea. Basal bolus insulin regime. Wants to run
the 5K
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Should he run the 5K?
What advice would you give him if he insisted
on participating?
What exercise advice would you give him if
he had no complications but wanted to run
the marathon?
What exercise advice would you give
someone with
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Neuropathy
Autonomic neuropathy
Prevous MI
Criteria for Recommending Graded
Exercise Stress Testing
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Age >40 years
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Age >30 years and:
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with or without cardiovascular disease risk factors other than diabetes
Type 1 or 2 diabetes of >10 years' duration
Hypertension
Cigarette smoking
Dyslipidemia
Proliferative or preproliferative retinopathy
Nephropathy, including microalbuminuria
Any of the following, regardless of age
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Known or suspected coronary artery disease, cerebrovascular disease,
and/or peripheral vascular disease
Autonomic neuropathy
Advanced nephropathy with renal failure
42yr old shop assistant. Diagnosed 37yrs.
Previous long history of poor control. HbA1c now
73mmol/mol. Had retinopathy previously requiring laser.
Microalbuminurea. Basal bolus insulin regime. Wants to run
the 5K
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Should he run the 5K?
What advice would you give him if he insisted
on participating?
What exercise advice would you give him if
he had no complications but wanted to run
the marathon?
What exercise advice would you give
someone with
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Neuropathy
Autonomic neuropathy
Prevous MI
ADA position statement 2015
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Peripheral neuropathy.
Risk of skin breakdown, infection, Charcoat joint
destruction
 Daily foot review, good footwear
 Non weight bearing exercise if injury/ulcer
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Autonomic neuropathy.
Hypo unawareness, impaired thermo regulation,
postural hypotension,
 HR monitors of exercise intensity unreliable
 Higher risk of cardiovascular death - exercise
test before increasing physical activity
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36yr old businessman. Diagnosed 15yrs.
Moderate control. HbA1c now 67mmol/mol. Basal
bolus insulin regime. Has recently taken up squash in
evenings. Troubled by night hypos following squash.
 What
further information would you need
to provide useful advice?
 Consider the different scenarios and how
you would address them (I will role play
during discussion)
36yr old businessman. Diagnosed 15yrs.
Moderate control. HbA1c now 67mmol/mol. Basal
bolus insulin regime. Has recently taken up squash in
evenings. Troubled by night hypos following squash.
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How does he currently manage his diabetes for
exercise? How much CHO does he take?
Does he eat before or after the squash game?
If he eats after sport, does he take his normal or
reduced insulin?
Is he troubled by hyper glycaemia after
squashand if so how does he treat it?
How is he detecting the nocturnal hypo’s? Are
these severe or does he wake up?