1. Sports & Diabetes Francesca Annan RD

2. Sport important for health and wellbeing – and having fun!

3. Having diabetes means you have to think -What do you think will happen to my blood glucose during exercise?

4. The “CEO” of your own body
Phil Southerland – founder Team Type 1

5. Exercise & Diabetes “Rules”
We all have “rules” – some will be about diabetes, some will have come from our diabetes team, some we may have worked out for ourselves
Exercise & diabetes management often means re writing the rules
So be prepared to change and adapt to manage exercise
Everything about exercise is challenging – increased levels of sport can make diabetes management more challenging

6. Introduction
Look at how you can manage blood glucose before, during and after exercise
Develop a “checklist” to use to work out how to manage your exercise
Look at how much you should be eating and drinking
Question time – discuss your exercise and requirements.

7. Can you copy the pancreas when you exercise?
Liver – glucose store
Blood glucose levels maintained by liver in response to changes in insulin and glucagon levels.
Blood glucose levels during exercise are controlled by a complex system of ‘feedback’ and ‘feedforward’
Pancreas – blood glucose measurement and insulin or glucagon production

8. What happens during exercise?
Knowing how these energy systems work will help you to “think like a pancreas” and get the most from your pump
During exercise you need to supply “fuel” to your muscles & brain
Muscles need energy in the form of ATP to contract – all exercise uses ATP for energy
You use different energy systems to make ATP during exercise

9. What happens during exercise?
To exercise the body activates a number of complex pathways.
The aim of these pathways is to produce glucose for use by the muscles and brain during exercise
You store glucose in your liver and muscles as glycogen. During exercise you convert this store to glucose to use as energy

10. What happens during exercise
What happens next is very important. If you want to carry on jumping or run or do any kind of exercise you need to provided the muscles with energy.
ATP is the energy source your muscles need.
Everybody stand up, now jump up and down twice
You just made your muscles contract so you could jump.
To do that you needed an instant energy source
That energy source is called ATP
We all have a small supply of ATP in our muscles to provide the instant energy to start exercise

11. Aerobic and Anaerobic Exercise

12. Anaerobic exercise
Examples include sprinting (track, bike or swimming), weight training, basketball.
These types of exercise do not use blood glucose as a major fuel source during the activity, they use stored energy.
They will often increase blood glucose levels during activity

13. Aerobic exercise
The aerobic energy system uses glycogen stored in the muscles & liver, glucose from the blood and fats for fuel.
Aerobic exercise which lasts for longer than 30 minutes may lower your blood glucose levels.

14. Exercise effects
So at the beginning of any exercise the body works to provide glucose to the muscles (and brain).
In diabetes you are not able to change the amount of insulin present in the body.
This means you may have too much or even too little insulin when you exercise

15. What does insulin do?
Insulin allows glucose to move from the blood into tissues.
If insulin levels are high the liver cannot turn glycogen stores into glucose for muscles to use for fuel
If insulin levels are low the liver can over produce glucose, which the muscles cannot use.

16. Making adjustments for exercise with your exercise checklist
What type of exercise?
Pump on or off?
Last insulin injection or bolus
How long does the exercise last for?
When did you last eat or drink?
What is your blood glucose level?

17. What type of exercise
Anaerobic Exercise
Aerobic exercise
Anaerobic exercise only uses fuel sources within the muscle. This means that during exercise the blood glucose level will rise.
Aerobic exercise uses glucose for fuel, so your blood glucose level may fall during this type of exercise

18. Exercise types
Anaerobic activities
Aerobic activities
Short bursts of fast movements
Usually strength and power sports
Sprinting
Basketball
Some racquet sports
Golf swing
Longer duration activities
Usually endurance sports
Running
Cycling
Swimming
Hill walking
Many sports are a mixture of both types of activity e.g. team games like football, rugby, hockey

19. If you use an insulin pump Pump on or pump off?
If you remove your pump during exercise will you run out of insulin?
This is more of a problem during anaerobic exercise
If you have your pump on will you have too much insulin?
This is more of a problem during aerobic exercise
For either option you need to check your blood glucose level during exercise to know what is happening.

20. How long does your exercise last for?
For the first 30minutes of any exercise you will use stored energy sources, so exercise that lasts under 30minutes may not effect blood glucose.
Exercise that lasts longer than 60minutes will have a much greater effect on your blood glucose levels – ideally you should check your blood glucose every minutes during exercise to find out what happens

21. When did you last eat or drink
Eating 1-3 hours before any exercise (60mins or more) will top up your stores
It may also mean that you need to make insulin adjustments – depending on your insulin action time
If you eat and bolus 1-2hours before exercise you will need less insulin 25-75% less and you should always use a normal bolus 15minutes before eating.
Ideally you should have at least 1g carbohydrate per kg body weight before exercise lasting 60minutes or longer

22. Food & drink during exercise
Should be distributed across the exercise if possible e.g. 10g every 20minutes
Needs to contain high GI carbohydrate so the glucose is available to muscles immediately
Recommended amount = 1g/kg per hour if you have not reduced your meal bolus. Lower insulin levels = less Carbs needed.
For sports performance you need fuel – may need Carbs + insulin
Sufficient fluid to maintain hydration
Sports drinks
Jelly sweets
Jaffa cakes
raisins

23. Food & drink after exercise
Both food and fluid are needed to promote muscle recovery
Try and eat drink within 1hour of finishing exercise. Drink at least 300ml and keep drinking until you no longer feel thirsty. Eat at least 1g/kg carbohydrate mixed with some protein. Milk is the ideal recovery food
Always eat before bed when exercise has been strenuous or > 1hour duration

24. What is happening to your blood glucose level
The more information you have about your blood glucose levels the more in control you will be
If you check your blood glucose before exercise what does this tell you?
If you check 1 hour before, immediately before – what will this tell you?
Before exercise check twice
During exercise/training recommended to monitor every minutes
After exercise monitor more frequently and overb=night
If you are exercising competitively the more you know the better your ability to perform.

25. Pre exercise BG Check your BG before exercise
Below 5 mmol/L – have some extra carbohydrate
Below 7mmol/L and dropping – have some extra carbohydrate
If your BG is above 10mmol/L consider
Type of exercise aerobic or anaerobic
Pump on or off
Extra insulin needed?
If your BG is above 14mmol/L consider
Checking for ketones
Delaying exercise
Correcting BG
Be extra cautious if exercise is anaerobic

26. After exercise………
Exercise can affect your blood glucose levels for hours after you stop.
Why?
You have emptied your muscle and liver stores and you have to replace them – “re fuelling”.
Replacing muscle stores take at least 20hours.
The active muscles are more sensitive to insulin
BUT

27. Highs immediately after exercise?
During exercise you have increased levels of glucagon, adrenaline, cortisol and growth hormone.
All these hormones push your blood glucose levels up.
So when you stop exercise you can see your blood glucose levels rise and then fall.
This happens in athletes without diabetes! Insulin levels rise after exercise – post exercise insulin resistance

28. If you are high after exercise
Check for ketones – some types of exercise can cause ketone production. (usually high intensity/anaerobic activity e.g. Repeated sprints)
High BG without ketones – wait 30minutes and recheck before giving a correction. Use a half correction if needed. Recheck your BG in 1 hour

29. Lows after exercise?
Can happen any time up to hours after exercise, most likely 6-11hours after exercise
Prevention
Reduce insulin post exercise
Increase carbohydrate intake particularly before sleep.
Reduce overnight insulin doses by 20% - most difficult with once daily background insulin
Aim to eat at least 1g carbohydrate/kg weight immediately after exercise and before bed when exercise is longer than 60minutes

30. Exercise, lows & sleep
If you are low before exercise – you are more likely to go low during exercise
If you go low during exercise you are more likely to go low overnight
Basal insulin requirements usually 20% lower between midnight and 3am after strenuous exercise lasting 60minutes or longer
Low blood glucose levels can happen with no symptoms

31. Avoid lows by Adjusting your insulin for planned exercise
Divide background insulin into 2 daily doses
Using a TBR decrease after exercise. The duration of the decrease will depend on when your blood glucose levels fall.
Reduce your ICR and ISF after exercise – you are more sensitive to insulin
Eat or drink enough carbohydrate to replace your stores quickly within 1-2hours of exercise use the 1g/kg rule to work out how much carbohydrate you need

32. Avoid highs by Trying not to exercise with your pump off
Replace missing basal insulin if high at the end of exercise
Use TBR increase for exercise if needed
Inject insulin before or during exercise if needed
Adjust background insulin doses
Distribute your carbohydrate at the right time during exercise
Take bolus insulin with carbohydrate during competition/anaerobic exercise

33. Summary
Check, adjust & eat/drink – before ,during & after any exercise
Accept that exercise management is complex and changes
What works for you may not work for someone else
Remember to eat & drink enough!

34. Your questions?
Blackstone Bay, Prince William Sound, Alaska August 2012

35. Balancing sports & diabetes
CWD November 2012
Francesca Annan RD

36. How to manage your sports?
Exercise adds many challenges to diabetes management
Increased activity levels are not always associated with improved control
Diabetes control will influence sports performance
Achieving sports potential- you can!

37. Food & performance
Providing enough fuel to exercising muscles is crucial for performance and recovery
In young sports competitors inadequate energy = poor growth
Carbohydrate demands of exercise need to met with appropriate insulin adjustment.
If your child is training for a sport they need to eat more carbohydrate

38. Low carbohydrate intakes
Poor growth
Poor adaptation to training
Increased fatigue during exercise (can’t keep up)
Increased frequency of hypoglycaemia post exercise
Low energy levels

39. How to eat during exercise
Taken from
Carbohydrate needs to be distributed across exercise to match muscle uptake of glucose.

40. Sports drinks
When exercise lasts 60minutes or longer – ideal to provide fluid and carbohydrate or fluid & electrolytes