Microsoft word - exercise & bg control article pdf.doc

Last month, I saw two very different clients To understand what it takes to control blood sugar during active situations, we need to go back to the basics. Blood sugar regulation involves a complex interaction between the who has type-2 diabetes. Anthony’s wife likes factors that raise blood sugar: carbohydrates in to drag him outside for 45-minute walks after the diet and stress hormones (causing insulin dinner. “It’s good for him to help him lose resistance and extra glucose production by the weight,” she said. “But he keeps getting low on liver); and factors that lower blood sugar: the way home. I give him extra food, but it just insulin and oral diabetes medications, and defeats the whole purpose. Maybe we should sensitivity). A change in one requires a change in something else in order to keep the balance The other was a teenage girl, Liz, whose father expressed concern over how her diabetes is affecting her swimming performance. “We competes,” he explained. “Trouble is, she goes low during practice, so we give her extra carbs. Then she goes way up high for the meets, so she gets tired and doesn’t swim well. And if we cover the high, she winds up low during the night or even the next day. Up and down. Up Factors That Raise Blood
Factors That Lower
Two very different people with two very similar Blood Sugar
problems: difficulty controlling blood sugar levels during physical activity. Managing blood sugar levels during physical activity is important not only for preventing hypoglycemia, but also for improving physical performance: research has shown that strength, speed, flexibility and stamina are all impaired by high blood sugar levels. It is not usually dangerous to exercise Physical activity can actually effect blood sugar with a high blood sugar level (as long as you are in work a number of ways. Muscle cells are one not spilling ketones), but performance will be of the main targets for insulin, whether it is influenced by even moderately elevated blood insulin your body produces or insulin that you inject. With increased activity, muscle cells become much more sensitive to insulin. This Diabetes Self Management, September/October, 2006 Copyright 2006, Gary Scheiner MS, CDE – Integrated Diabetes Services LLC enhanced insulin sensitivity may continue for maximal level over a period of 20 minutes or many hours after exercising, depending on the more) will promote a blood sugar drop due to extent of the activity. The more intense and enhanced insulin sensitivity and accelerated prolonged the activity, the longer and greater the With enhanced insulin sensitivity, insulin exerts a greater force than usual. A unit that usually When exercise is going to be performed within covers 10 grams of carbohydrate might cover 15 an hour or two after a meal, the best approach is or 20. A unit that normally lowers the blood usually to reduce the mealtime insulin or oral medication. If you take insulin and plan to exercise at a time that you do not normally take Some forms of physical activity, most notably rapid-acting insulin, you would be best served high-intensity/short duration exercises and by consuming extra carbohydrate prior to the competitive sports, can produce a short-term activity. Also, note that for activities lasting rise in blood sugar levels followed by a delayed less than 2 hours, we only reduce the rapid- drop. This is due primarily to the stress acting insulin. It is not usually helpful to reduce hormone production or “adrenaline rush” that intermediate-acting or long-acting insulin unless your activity is going to last for more than 2 Let’s take a look at these two different situations When adjusting mealtime insulin, both aspects (the dose to cover food and the dose to cover a high reading) are made more effective by Aerobic Activities
exercise and need to be reduced. To accomplish this, I like to use an activity “multiplier”. Most daily activities (including yardwork,
Essentially, this means that you calculate your cleaning, shopping, filing, playing, sex, and mealtime insulin as usual (based on the food and anything else that has us using our muscles for the blood sugar level), and then multiply the more than a few minutes) and aerobic exercises
dose by a factor that results in a lower dose: (activities performed at a challenging but sub- Activity Short Duration Moderate Duration Long Duration
Low intensity (relatively easy)
Moderate intensity
High intensity (very challenging)
Diabetes Self Management, September/October, 2006 Copyright 2006, Gary Scheiner MS, CDE – Integrated Diabetes Services LLC For example, if I take a leisurely 20-minute bike When Snacks Are Needed
ride after dinner (I consider it “low intensity”), I multiply her dinner insulin dose by .90, which Under certain conditions, extra food intake will reduces the dose by 10%. If I plan a much more be necessary to prevent hypoglycemia during intense 90-minute ride up and down hills (which exercise. For example, when exercise is going I consider “high intensity”), I would multiply to be performed before or between meals, my dinner dose by .50, which reduces my dose reducing the insulin at the previous meal would only serve to drive the pre-workout blood sugar very high. A better approach would be to take What about Anthony, whose wife likes to take the normal insulin dose at the previous meal, him out for those 45-minute, moderate-intensity and then snack prior to exercising. If you walks? If Anthony takes rapid-acting insulin at engage in exercise soon after you have already dinner, he should try reducing his insulin by taken your usual insulin/medication, snacking 33% (multiply his usual dose by .67). Not only will this help him to avoid hypoglycemia, but it hypoglycemia. Also, during very long-duration will also enable him to lose more weight since endurance activities, hourly snacks may be excess insulin tends to promote weight gain. Medication Changes
The size of the snack depends on the duration and intensity of your workout. The harder and longer your muscles are working, the more diabetes, he may or may not need to reduce or carbohydrate you will need to eat in order to eliminate the dose. Only certain medications maintain your blood sugar level. The amount is can cause hypoglycemia; medications that do also based on your body size: the bigger you not have the potential to cause hypoglycemia should not be changed. Although it is not an exercising, and the more carbohydrate you will “oral” medication, Byetta (exenatide) does not If you take a medication that can cause hypoglycemia, it is usually recommended that you take your usual dose with your first couple of exercise sessions and see what happens. If your blood sugar drops below 80mg/dl during or after exercise, reducing or eliminating the medication might be in your best interest. Check with your doctor before making this type of change on your own. Meds that CAN cause hypoglycemia
Meds that DO NOT cause hypoglycemia
• Sulfonylureas (glipizide, glyburide)
• Metformin (Glucophage)
• Meglitinides (Prandin, Starlix)
• Acarbose (Precose)
• Combinations that contain any of the
• Thiazoladinediones (Actos, Avandia)
Diabetes Self Management, September/October, 2006 Copyright 2006, Gary Scheiner MS, CDE – Integrated Diabetes Services LLC Granted, there is no way of knowing exactly how much you will need, but the chart below should serve as a safe starting point. To use the chart, find your approximate body weight and look down the list to find the intensity of your exercise. The number in the column represents the grams of carbohydrate that you will need per hour of activity. If you will be exercising for half an hour, take half the amount before the activity. If you will be exercising for two hours, take the full amount at the beginning of each Carbohydrate Needed Per 60 Minutes of Physical Activity
100 lbs (45 kg) 150 lbs (68 kg) 200 lbs (91 kg) 250 lbs (114kg) The best way to determine the optimal size and frequency of your snacks is to test your blood sugar before and after the activity. If it holds steady, you have found the magical number of Sports activities in which winning is the carbs to consume. If it is rising, cut back on the number of carbs. If it is dropping, add some more carbs or eat more frequently the next time. Liz, mentioned earlier, was experiencing this exact problem. During swim practices, her blood sugar would drop steadily, requiring extra Anaerobic Activities
snacks. But swim meets caused just the opposite effect. Her blood sugar would rise As mentioned previously, it is not unusual to sharply during swim meets due to the stress and experience a blood sugar rise at the onset of competitive nature of the events, and this would high-intensity/short-duration exercise. This is “adrenaline”. Exercises that often produce a Weight lifting (particularly when using hinder her performance. Once she eliminated Sports that involve intermittent “bursts” the pre-meet snacks and started taking a little extra insulin beforehand, her blood sugars stayed closer to normal, and her performance went to a whole new level. In her first meet Diabetes Self Management, September/October, 2006 Copyright 2006, Gary Scheiner MS, CDE – Integrated Diabetes Services LLC trying this approach, she set a p.r. (personal its own name: Delayed Onset Hypoglycemia. record) and took second place in the 50-meter There are two reasons why this takes place: prolonged, enhanced sensitivity to insulin among muscle cells, and the need for muscle Covering the Highs
cells to replenish their own energy stores (called glycogen) following exhaustive exercise. To determine how much extra insulin to take before an event of this nature, consider how Delayed-onset hypoglycemia is unique to each much your blood sugar normally rises. If it goes individual. The best way to deal with it is to up 200 mg/dl and your sensitivity factor is 50 keep records of when it happens (after what mg/dl per unit (you drop 50 points per unit of types of activities? how many hours later?), and insulin), you would normally need to give 4 then make adjustments to prevent it. For units to prevent the rise. DO THIS AND YOU example, Liz tends to drop low in the middle of activity makes your insulin more potent! Give practices. To fix it, she lowered her pump’s yourself half the normal amount. And give it basal insulin delivery by 40% for 8 hours about half an hour beforehand so that it will following her practices. Those taking injections keep you from being too high when the activity can lower their intermediate or long-acting begins. In Liz’s case, she normally rises about insulin by 20-25%. Anyone taking insulin or an 150 points during a meet, and her usual insulin oral medication that may cause hypoglycemia sensitivity is 25 points per unit. Instead of can have an extra snack prior to the time that the taking 6 units before the meet, she takes 3 units. blood sugar tends to drop. Ideally, the snack should contain slowly-digesting (low-glycemic- The same “half-the-usual-dose” rule applies to index) carbohydrates. Examples include whole fruit, milk, yogurt, peanut butter, pasta or immediately after competitive/high-intensity chocolate (Finally, a therapeutic application for events. Take half the usual “correction insulin” for high blood sugars in these situations. Think Before You Stink
If you are nervous about giving insulin before exercise, check your blood sugar more often Exercise and other daily activities are meant to than usual (perhaps every half hour or so), and have glucose tablets or some other form of fast- effectively during and after physical activity will ensure that you feel good, stay safe and experience, you will develop greater confidence perform your best. Hey, it even worked for and have the ability to fine-tune your correction Anthony. Not only is he walking after dinner without dropping low, he seems to actually enjoy it now. Just don’t tell his wife! Delayed Effects
Editor’s note: Gary Scheiner is a Certified Diabetes Educator and Exercise Physiologist with a private practice specializing in intensive diabetes management Ever finish a workout with a terrific blood sugar and lifestyle modification for children and adults. He level only to go low several hours later or offers his services via phone and the internet to clients overnight? Many aerobic activities (particularly throughout the world. For questions or more those that are long or intense) and most information, you may contact him at anaerobic exercises cause blood sugars to drop gary@integrateddiabetes.com, or call 877-735-3648. several hours later. This phenomenon even has Diabetes Self Management, September/October, 2006 Copyright 2006, Gary Scheiner MS, CDE – Integrated Diabetes Services LLC

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