Assessing the patient Exercise and Type 1 Diabetes 2nd National conference NEC, 15 May 2015

What would you ask?  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?  Weight/BMI  HR  BP  Fundoscopy/retinal screening results  PVD – foot pulses  Neuropathy  Foot ulceration  Urinary ACR / serum creatinine  HbA1C  (TFT)  (Coeliac screen)

 1) 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  2) 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  3) 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  Human insulin  NPH: thighs and buttock because absorption slowest  Soluble: abdomen because absorption fastest  Premixed insulin (human or analogue)  Abdomen in the morning because faster absorption covers breakfast  Thighs/buttocks in evening because slower absorption protects from nocturnal hypoglycaemia  Analogue insulins  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  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  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  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  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  Neuropathy  Autonomic neuropathy  Prevous MI

Criteria for Recommending Graded Exercise Stress Testing  Age >40 years  with or without cardiovascular disease risk factors other than diabetes  Age >30 years and:  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  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  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  Neuropathy  Autonomic neuropathy  Prevous MI

ADA position statement 2015  Peripheral neuropathy.  Risk of skin breakdown, infection, Charcoat joint destruction  Daily foot review, good footwear  Non weight bearing exercise if injury/ulcer  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

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.  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?