1. SPORTS & PUMPING: FINDING THE RIGHT MIX Rick Philbin, MBA, M.Ed., ATC

2. ADVANCED PUMP MANAGEMENT  Insulin Action  Basal Insulin Regulation  Bolus Regulation  Physical Activity Adjustment  DKA Prevention  Temporary Basal Rates  Insulin - Prolonged Boluses  Alternate Basal Patterns

3. PROFILES OF HUMAN & ANALOG INSULINS DIABETES CORE CURRICULUM WORKSHOP 0 2 4 68 10 12141618202224 Plasma Insulin Levels Regular (6–10 hours) NPH (12–20 hours) Hours Glargine (20–26 hours) Humalog, Novolog, Apidra (up to 4hrs) Detemir (Up to 24 hours) Adapted from American Diabetes Association. Diabetes in the Latino Population. Available at: http://www.diabetes.org/uedocuments/LatinoSlidesAugust05.ppt.

4. BASAL INSULIN REGULATION Basal Insulin’s One And Only Job Is To Hold Blood Glucose Levels Steady In the Absence of Confounding Influences* * Food, Exercise, Bolus Insulin, Unusual Hormonal Conditions (illness, rebounds, menstruation)

5. PHYSICAL ACTIVITY ADJUSTMENTS Activity Within 2 Hrs After Meal Activity Before or Between Meals Short Duration (<90 Minutes)  Mealtime Bolus Snack Prior to Activity* Long Duration (>90 Minutes)  Mealtime Bolus  Basal Rate Snack hourly  Basal Rate Snack hourly

6. PHYSICAL ACTIVITY ADJUSTMENTS Meal Bolus Adjustment*  Low Intensity Cardio  25%  Mod. Intensity Cardio  33%  High Intensity Cardio  50%  Competitive/Anaerobic ??? * If activity is after meal Basal Adjustment**   Basal rate 50%  Start basal reduction 1 hr pre-activity ** For activities lasting > 90 Min.

7. PHYSICAL ACTIVITY ADJUSTMENTS Snacking to prevent low (examples) Carbohydrate Replacement Per 60 Minutes of Activity 50 lbs100 lbs150 lbs200 lbs250 lbs Skating 7-10g14-20g20-30g28-40g35-50g Gymnastics 8-12g17-23g25-35g34-46g42-57g Soccer 13-17g27-33g40-50g54-66g67-82g

8. STAY CONNECTED OR NOT? Where do you carry it during exercise? Can you play contact sports? How often do you change the infusion site? Should you give yourself a bolus of insulin for a high glucose reading? How can you adjust your basal delivery of insulin depending on your glucose readings?

9. PHYSICAL ACTIVITY ADJUSTMENTS Alternatives to Disconnection: Wear It! (Sport Pack, Bum Bag, Backpack Harness) Re-Connect hourly & bolus 50% of missed basal rate

10. DKA PREVENTION Causes of insulin deficiency in Pump Therapy  Malabsorption (site problems)  Insulin Spoilage  Tubing or infusion set clogs  Leaks where the cartridge connects to the tubing  “Tunneling”/Leakage at the infusion site  Air pockets in the tubing  Dislodgement of the canula from beneath the skin  Improper or insufficient priming  Extended pump suspension or disconnection

11. TEMPORARY BASAL RATES High-Fat Food DurationAdjustmentNotes 8:00+60% Start After Meal

12. TEMPORARY BASAL RATES Illness DurationAdjustmentNotes 24:00+80% Repeat as Needed

13. TEMPORARY BASAL RATES Extended Inactivity DurationAdjustmentNotes Varies (>3 hrs) +40% Great for long trips!

14. TEMPORARY BASAL Menstrual Cycles DurationAdjustmentNotes 12:00 +50% (pre) Start at night 12:00 -30% (post) Start at night

15. TEMPORARY BASAL RATES Prolonged Activity DurationAdjustmentNotes Minimum 2 hrs. -50% Start 1-2 hours prior

16. TEMPORARY BASAL RATES Prevention of (Delayed-Onset Hypoglycemia) DurationAdjustmentNotes 6-10 hours -50% Base timing on experience

17. TEMPORARY BASAL RATES Alcohol DurationAdjustmentNotes 2 hrs per drink -50% Begin after drinking

18. DEFINITION: INSULIN ON BOARD (IOB OR BOB) The amount of insulin still active at a given time after a bolus

19. 30% RULE IS WHERE IT STARTED Pumping Insulin, Walsh J, Roberts R

20. BENEFITS OF IOB Decreased risk of stacking insulin  Less chance of hypoglycemia Decreased risk of intentionally running high due to fear of hypoglycemia  May improve A1c

21. PROLONGED BOLUSES Description: Normal/Standard Boluses are delivered within a few minutes; peak is approx. 1 hr, duration approx. 4 hours Prolonged boluses are delivered over a period of a couple of hours; peak is delayed/blunted and duration is extended.

22. DANGERS OF DEHYDRATION *Fatigue *Loss of coordination *High Blood Sugar *Increased risk of heat illness, heat stroke and even death

23. MONITOR FLUID LOSS Two ways: Weigh in before practice and after practice  3 cups of fluid per pound lost Check the color of urine (lemonade v. apple juice) 1 - 3 = Optimally Hydrated 4 - 6 = Slightly dehydrated should drink more 6 - 8 = Dehydrated, must drink more

24. FLUIDS AND EXERCISE Hydration is very important  Non-caffeinated beverages (non-diuretic)  Cool water is best  Consider using diluted sports drink if CHO supplementation is needed  Make sure fluids are available along planned route Thirst mechanism may be unreliable  Don’t wait until thirsty High blood sugars can be worsened quickly by dehydration

25. Before  Drink 12 to 20 oz -- 2-3 hours before During  Drink 6 to 12 oz every 15-20 minutes After  Drink 150% of sweat losses  Drink 3 cups (24 oz) for every 1 lb weight lost through sweat  Two gulps are about 3 ounces  Replace 70% of what you have lost before next practice Fluid Guidelines *Guidelines from American Dietetic Association & American College of Sports Medicine, 2007

26. CASE STUDY… WHAT CHANGES CAN BE MADE? Female soccer player wearing an insulin pump Frequent weekend tournaments up to three games a day BG ok on Saturdays but struggles with low BGs on Sunday

27. ATHLETES WITH TYPE 1 DIABETES

28. Adam Morrison, NBA basketball Chris Dudley, NBA basketball Jay Leeuwenburg, NFL football Kris Freeman,U.S. XC ski team Gary Hall, Jr., Olympic Gold swimmer Missy Foy, Ultra distance runner Doug Burns, Bodybuilding Travis Pesco, Olympic wrestler Will Cross, Explorer Phil Sutherland, Cyclist Michelle McCann, LPGA Golfer Bill King, Marathoner