1. Exercise & Busy Kids Smart Pumps & Sports Rick Philbin, MBA, MED, ATC Sports Program Coordinator, CWD Board Member, Diabetes, Exercise, & Sports Assoc. Board Member, Diabetes, Exercise, & Sports Assoc. Regional Manager, Animas Corporation

2. A Typical Blood Sugar Response Joslin Medical Publication

3. Effect of Exercise on Blood Sugar Levels Effect of Exercise on Blood Sugar Levels Joslin Medical Publication Lacking insulin With insulin No diabetes

4. Exercising After Food

5. Know the Action of Your Insulin Glargine (no peak) NovoLog

6. 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

7. 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

8. 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

9. Key Elements Dose –Amount of decrease or increase percentage Duration for temporary adjustment Test often to see a pattern

10. What to do with the Pump? Pre-exercise meal boluses may be reduced as much as 50% depending on when exercise will take place 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

11. 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

12. 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

13. 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)

14. Variables Blood flow differences –Activity –Site selection Abdomen is fastest ~34 min* Deltoid, Femoral, Gluteal about the same (rapid- acting) –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.

15. Competition?

16. 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.

17. 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?

18. 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

19. Definition: Insulin on Board (IOB) The amount of insulin still active at a given time after a bolus.

20. The 30% Rule Pumping Insulin, Walsh J, Roberts R

21. Benefits Decreased risk of stacking insulin –Less chance of hypoglycemia Decreased risk of intentionally running high due to fear of hypoglycemia –Improved HbA1c

22. Challenges One size doesnt 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

23. 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 dont want to take away the benefit of exercise by being hyperglycemic.

24. 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

25. 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

26. 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)

27. 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 rapid- acting 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

28. Healthcare Team Involvement 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 like- cant, stop, and dont)

29. Diabetes, Exercise & Sports Association (DESA) http://www.diabetes-exercise.org 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

31. THANK YOU FROM THE BOTTOM OF MY PANCREAS!