What have we learned over the last decade Ian Gallen Jephcott Symposium 9 th May 2012 Diabetes and exercise Ian Gallen Challenges in the management SRs diabetes prior to 2000 Olympic games ID: 621814
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Slide1
Olympic diabetes What have we learned over the last decade?
Ian GallenJephcott Symposium9th May 2012Slide2
Diabetes and exerciseIan GallenSlide3
Challenges in the management SR’s diabetes prior to 2000 Olympic games
How to give insulin treatment with high enough energy intakeHow to give basal insulin and avoid hypoglycaemia during exerciseHow to avoid nocturnal hypoglycaemiaIdentify and treat excessive fatigueRestore pre-existing performance Slide4
Effect of exercise on blood glucose
Differences between types of exercise
Timing, type and quantity of carbohydrate
What to do with bolus insulin dose
What to do with basal insulin dose
Nocturnal hypoglycaemia
Causes and treatment of fatigue
How to use insulin pump treatment
What did we need to know?Slide5
What do we need to know
Effect of exercise on blood glucoseDifferences between types of exerciseTiming, type and quantity of carbohydrateWhat to do with
insulin doseNocturnal
hypoglycaemia
How to use insulin pump treatment
Slide6
Glucose metabolism during exercise
McConell et al. 1994Slide7
What is different about exercise in diabetes?
Food storageAthletes require high energy intake of high glycaemic index foods. Usually excessive background insulin levels Endocrinology of exerciseAbnormal glucagon responseAbnormal portal insulin regulation of gluconeogenesis and ketogenesis
Impaired catecholamine response
Diabetic complications
Autonomic neuropathy/microvascular diseaseSlide8
Data from Buckinghamshire Hospitals Diabetes Sports clinic
18:00
00:00
03:00
06:00
09:00
15:00
12:00
21:00What Happens to Blood Glucose in Exercise in Type 1 Diabetes? Exercise22.216.711.10.05.603:0006:0009:0015:0018:0012:0021:0000:0015/01/2006mmmol/Lmmmol/L24/11/2005
22.2
16.7
11.1
0.0
5.6
03:00
06:00
09:00
15:00
18:00
12:00
21:00
00:00
Exercise
10.0
3.9
06/10/2005 (Thu)
Glucose - mmmol/L
22.2
16.7
11.1
0.0
5.6
Cycling
AerobicsSlide9
Trends in Glucose Production and Use in
T1DM During Prolonged Aerobic Exercise
Glucose use
Blood glucose
60 min training run
Meal
Counter-regulatory
hormone responseGlucose productionSlide10
Ian Gallen
Trends in Glucose Production and Use in T1DM During Short Intense Exercise
30 min exercise
Meal
Rest
Counter-regulatory
hormone response
Glucose productionGlucose useBlood glucoseSlide11
Effect of high or low intensity exercise on
blood glucose in T1DMSlide12
Blood glucose and metabolite response
during exercise in T1DMSlide13
Glucose levels during and following different
forms of exercise
Aerobic first
Resistance first
Aerobic first
Resistance firstSlide14
Hypoglycaemia is frequent following aerobic and resistance trainingSlide15
Effects of exercise on blood glucose
Aerobic exercise causes blood glucose to fall rapidlyAnaerobic exercise cause blood glucose to riseAerobic exercise increases risk of nocturnal hypoglycaemiaIntermittent high intensity exercise protects against hypoglycaemia during exercise, but is more likely to cause nocturnal hypoglycaemiaTeam sports have variable effect on glucose depending on position and intensity of playSlide16
Carbohydrate supportSlide17
Why not just start with a high glucose? Some mathematics
Available free glucose space is 20% lean person total weight1mm/l measured glucose is 0.18g free glucose or total 2.5g in 70 kg personThus raising bg to 15mmol/l, will only provide 25g readily available glucose.At 60%VO2 max glucose oxidation typically 130
μmol/kg/min.Thus approximately 2g/min or 12 minutes! Slide18
Strategy 2 Taking extra glucose whilst exercising
“Using the mouth to do the liver’s job”
Effect of Carbohydrate Ingestion on the Glycaemic
Response of Type 1 Diabetic Adolescents During Exercise
55.3 g
66.5 g
Perrone C, Laitano O, Meyer F.
Diabetes Care. 2005;28:2537–2538.
CHO 8%
CHO 10%
Recovery
Exercise
Capillary Blood Glucose Concentration (mg/dL)
350
300
250
200
150
100
50
0
Time (min)
-15
0
15
30
45
60
(30)
(60)
(0)
*
*
Data are means ± SD; *p<0.05. Slide19
75g Isomaltulose or dextrose before exercise in T1DM
West et al, 2011Slide20
Strategies for Glucose
Replacement During Exercise
90 minutes aerobic exercise
5 mM
10 mM
5 mM
10 mM
Glucose 60 g
Glucose 20 g20 g20 gGlucose Concentration (mM)Slide21
Insulin dose adjustmentSlide22
Exercise at 50% VO
2
max for 60 min
Baseline plasma glucose (mmol/L)
LP 50% = 8.7
± 1.0
LP 25% = 6.0
± 1.4
Change from baseline in plasma glucose (mmol.L)B030609021015018012054321
0
-5
-4
-3
-2
-1
Time (minutes)
*
Exercise at 75% VO
2
max for 30 min
Baseline plasma glucose (mmol/L)
LP 100% = 8.5
± 1.3
LP 25% = 6.8
± 1.1
Change from baseline in plasma glucose (mmol.L)
B
0
30
60
90
150
180
120
5
4
3
2
1
0
-5
-4
-3
-2
-1
Time (minutes)
*
Ian Gallen
Rabasa-Lhoret R et al.
Diabetes Care.
2001;
24
:625–630.
Reducing pre-exercise meal insulin
Exercise at 50% VO
2
max for 30 min
Baseline plasma glucose (mmol/L)
LP 100% = 10.7
± 0.7
LP 50% = 9.4
± 0.8
Change from baseline in plasma glucose (mmol.L)
A
0
30
60
90
150
180
120
5
4
3
2
1
0
-5
-4
-3
-2
-1
Time (minutes)
*
Exercise at 25% VO
2
max for 60 min
Baseline plasma glucose (mmol/L)
LP 100% = 8.8
± 0.55
LP 50% = 6.1
± 1.3
Change from baseline in plasma glucose (mmol.L)
A
0
30
60
90
210
150
180
120
5
4
3
2
1
0
-5
-4
-3
-2
-1
Time (minutes)
*
% Dose reduction
% Dose reduction
Exercise intensity
(% VO
2
max)
30 min of exercise
60 min of exercise
25
25
50
50
50
75
75
75
-
Data are means ± SEM; *p<0.05 by repeated measures using ANOVA;
LP: lispro.
Slide23
Hypoglycaemia seems to be more common with Glargine than
either NPH or DetemirSlide24
Nocturnal hypoglycaemiaSlide25
Responses of glucose infusion rate (mg/kg{middle dot}min) (A), difference in glucose infusion rate (GIR) between exercise and rest studies (mg/kg{middle dot}min) (B), rate of carbohydrate oxidation (mg/kg{middle dot}min) (C), and rate of lipid oxidation (D) to exercise (solid lines) and rest (dashed lines) studies
McMahon, S. K. et al. J Clin Endocrinol Metab 2007;92:963-968
Biphasic response in glucose requirement with exercise
Increased glucose up take during exercise,
but also late after exerciseSlide26
Copyright ©2006 American Physiological Society
Kraniou, G. N. et al. J Appl Physiol 101: 934-937 2006;
doi:10.1152/japplphysiol.01489.2005
Skeletal muscle GLUT-4 gene expression before (0), immediately after (Post), and 3 h after (3 hrs) exercise at ~40% (Lo) or ~80% (Hi) peak pulmonary oxygen consumptionSlide27
Delayed hypoglycaemia CGMS following exercise in T1DMSlide28
Exercise induced counter regulatory responses are better preserved in women after prior hypoglycaemia. Given similar starting glucose and workload, women are less likely to suffer hypoglycaemia during exercise than menSlide29
The complex interaction between hypoglycaemia and exercise
AN10-551AExercise markedly increases muscle insulin sensitivity by increasing GLUT4 transporters1
Effect from 6-12 hours post exercise lasting 48 hours.Prior hypoglycaemia impairs counter-regulatory response to exercise, and this is proportional to the level of hypoglycaemia
2
.
Prior exercise impairs the counter-regulatory response to hypoglycaemia
2
.
The counter-regulatory response to exercise is relatively preserved in women following hypoglycaemia3.1 Thorell A, Hirshman MF, Nygren J et al. Exercise and insulin causeGLUT-4 translocation in human skeletal muscle. Am J Physiol EndocrinolMetab 1999;277:E733-41.2 Galassetti P, Tate D, Neill RA et al. Effect of antecedent hypoglycaemiaon counterregulatory responses to subsequent euglycaemic exercise intype 1 diabetes. Diabetes 2003;52:1761-9.3 Galassetti,P.; Tate,D.; Neill,R.A.; Morrey,S.; Wasserman,D.H.; Davis,S.N. Effect of sex on counterregulatory responses to exercise after antecedent hypoglycemia in type 1 diabetesAmerican Journal of Physiology - Endocrinology & Metabolism.2004, 287(1):E16-24,Slide30
FatigueSlide31
Robitaille M et al. J Appl Physiol 2007;103:119-124
Fuel oxidation in T1DMSlide32Slide33
Fatigue is common in diabetes - the role of fuel oxidation
Glucose oxidation is increasedEndogenous hepatic glucose production is reducedMuscle glycogen mobilization and derived glucose oxidation increasedExogenous glucose oxidation in increasedGlucose oxidation highest during hyperglycaemiaSlide34
Insulin infusion pumps
Enables normal basal insulin to be markedly reduced or suspended whist performing exercise.with rapid post exercise increase in insulin to deal with post exercise glycogenic peak.and lower post exercise nocturnal basal rate with intermittent exercise patterns.The gold standard for serious athletes where practical.Slide35
Ian Gallen
Prevention of Hypoglycemia During Exercise in Children With Type 1 Diabetes by Suspending Basal Insulin
The Diabetes Research in Children Network. Diabetes Care 2006;29
:2200–2204
Basal insulin continued
Basal insulin stopped
Glucose Concentration (mg/dL)
200
150
100
50
0
Baseline
Rest #1
Rest #2
Rest #3
End
Post 15
Post 30
Post 45
Black dots denote mean values; Boxes denote median, and 25th and 75th percentiles. Slide36
Blood glucose with 1 hour of exercise at 50% VO
2 MAXSlide37
Progress towards an artificial Pancreas?
Combination CSII/CGMS
Automatic low glucose infusion suspend during exerciseSlide38
Automatic low glucose infusion suspend during exerciseSlide39
Are there any other strategies?Sympathomimetics
Endogenous sympathetic stimulationSlide40
The 10-s Maximal Sprint:
Bussau, et al Diabetes Care. 2006. 29, 601. Slide41
20
18
16
14
12
8
10
6
420**50%Exercise 70% VO2 max‡Ian Gallen*‡ Glucose 20g given in 2 subjectsGallen IW, et al. Diabetes Care. 2010;Abstract 1184−PCaffeine (5mg/kg) and Blood Glucose During Prolonged ExercisePlaceboCaffeineGlucose (mmol/L)
-30
0
10
20
30
40
70
Time (min)
n=5Slide42
Ian Gallen
50%
Exercise 70% VO
2
max
‡ Glucose 20 g given in 2 subjects
‡
*
p=0.02The Effect of Caffeine (5 mg/kg) on Blood Glucose During Prolonged Exercise
Time (min)
Placebo
Caffeine
-30
0
10
20
30
40
70
8
6
4
2
0
-6
-2
-4
Gallen IW, et al.
Diabetes Care.
2010;Abstract 1184−P
Glucose (mmol/L)Slide43
What happens to blood glucose with exercise
Differences between types of exercise
Timing, type and quantity of carbohydrate
What to do with bolus insulin dose
What to do with basal insulin dose
Nocturnal hypoglycaemia
Causes and treatment of fatigue
How to use insulin pump treatment
Score card at 10 years!Slide44
Strategy
Advantages
Disadvantages
Reducing preexercise
bolus insulin
Reduces hypoglycaemia during
and following exercise; reduces
CHO requirement
Needs preplanning; not helpful for spontaneous exercise or for late postprandial exerciseReducing preexercisebasal insulinAs aboveAs above, causes pre- and late postexercise hyperglycaemiaTaking extra CHOwith exerciseUseful for unplanned or prolonged exerciseMay not be possible with some exercises; not helpful where weight control important; easy to overreplace causing hyperglycaemiaPre- or postsprintexercise burst Reduces hypoglycaemia during and following sports
Effect limited to shorter and less intense exercise
Insulin pump therapy
Offers flexibility and rapid change in insulin infusion rates postexercise
Expensive; may not be practical
for contact sports (eg, rugby/ football/judo)
Reducing basal insulin
postexercise
Reduces nocturnal hypoglycaemia
May cause morning hyperglycaemia
Summary of Clinical Strategies to Maintain Glycaemic Control With Exercise
Lumb A., Gallen I.W. Curr. Opin. Endo. Diab and Obesity. 2009 16Slide45
Ian Gallen
www.runsweet.comSlide46