CME INDIA Presentation by Dr. N. K. Singh, MD, FICP, Director – Diabetes and Heart Research Centre, Dhanbad, Jharkhand, India. Editor, www.cmeindia.in.

Based on a presentation at D-TECON 2022, Jaipur – 3rd August.

In order for man to succeed in life, God provided two means, education and physical activity. Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise can save it and preserve it. —Plato 400 B.C.

Generate a live Exercise Prescription first

• “Similar to a drug, exercise has to be prescribed in modality, dose, frequency, with not only a pathology but also a personalized patient approach. New data are needed to make this new science not only evidence-based and personalized, but also a precision approach.”- American College of Sports Medicine.
• This concept was known to Susruta.

CMGU is the mantra in exercise

• It works also in type 1 diabetes

Why Type 1 and Exercise intricacies differ

• Type 1 diabetes is a challenging condition to manage for various physiological and behavioural reasons.
• Regular exercise is important, but management of different forms of physical activity is particularly difficult.
• People with type 1 diabetes tend to be at least as inactive as the general population, with a large percentage of individuals not maintaining a healthy body mass nor achieving the minimum amount of moderate to vigorous aerobic activity per week.
• Regular exercise can improve health and wellbeing, and can help individuals to achieve their target lipid profile, body composition, and fitness and glycaemic goals.

Health care professionals can lack the knowledge and skills or simply don’t allocate time to address these challenges in a busy clinic setting.

• The success of the healthcare professional(HCP) in assisting patients with effective exercise plans is likely to be improved by the understanding of some of the basic physiological principles of exercise and diabetes.
• In a research paper, it was found that most participants believed that HCPs did not necessarily know how to manage diabetes and physical activity, which meant it was difficult for them to obtain accurate information and meaningful advice (1).
• One type 1 patient revealed: “I was shocked when I first got diabetes, how hard it was to find that information (about physical activity) what to do and how to practically manage your diabetes. I found it very hard to get that specific advice. [Male; age 45].”

Fact of the matter: Winging it

• The phrase ‘wing it’ was frequently used when participants described how they managed their diabetes and physical activity.
• Participants explained that they often improvised and discovered what worked for them through trial and error, with minimal input from HCPs. (1)

Not Dead Yet

• Not Dead Yet tells the inspirational story of Phil Southerland’s battle with Type 1 diabetes.
• His race against disease is testimony – From Diagnosis to Dominance.
• Phil Southerland beat all odds and turned his diagnosis and his passion for cycling into a platform. 
• When Phil Southerland was seven-months-old, he lost ten pounds in a week.
• His body was limp and his breathing slowed to what his mother called a “death rattle.”
• Phil displayed the youngest case of diabetes on record in the world at that time.
• Blindness, kidney failure and death were all predicted for him by age twenty-five.
• Decades later now, not only is Phil alive and well but also is the founder of Team Type 1 – his team of championship cyclists.
• He has become health and fitness role model for people the world over.
• He has taken the most challenging endurance events in the world, including winning the Race Across America – a grueling 3,000-mile endurance competition – twice.
• Many of the guidelines for Type 1 diabetes and exercise emerged from his athletic activities.

Amazing benefits of exercise in T1 DM

Credit: Credit: Francesca Cannata ,Gianluca Vadalà  , Fabrizio RussoJ et al. Funct. Morphol. Kinesiol. 2020, 5, 70; doi:10.3390/jfmk5030070

Children and young people with T1D must overcome specific challenges related to managing diabetes and exercise.

These challenges include:

1. Maintaining stable blood glucose levels before, during and after exercise fear of hypoglycemia especially on the nights after exercise.
2. Health professionals can play a key role in assisting families to overcome these challenges as physical activity confers many benefits for individuals with T1D including.
3. Improved glycemic control, cardiovascular function, blood lipid profiles and psychological well-being.

Patterns of physical activity in young people differ from adults and therefore they merit a different management approach.

• Responsibilities for diabetes management change over time, with a transfer of responsibility.
  from parents and caregivers to the increasingly independent young person
• In young children, physical activity is usually unplanned, based- around play and often varies from day to day.
• In this young age-group it can be difficult to make planned adjustments of insulin or carbohydrate, and caregivers need to be equipped to problem solve as challenges arise.
• Older children and adolescents may be engaging in more structured exercise such as school sports and extra-curricular activities which may involve competition.
• This planned exercise provides an opportunity for sequential review and refinement of exercise strategies.

Exercise management for young people with T1D is complex and one approach does not fit all.

Many factors influence an individual’s glycemic response to exercise:

• Type.
• Intensity.
• Duration of the activity.
• Amount of insulin on board.
• Person’s stress/anxiety levels.
• To further complicate management, even when all these factors are kept constant, an individual’s response to exercise may or may not be predictable on repeated exercise occasions.

Neuroendocrine and metabolic responses to exercise

Individuals without diabetes

• The metabolic responses to different forms of exercise are distinct.
• During aerobic exercise:
  • Insulin secretion decreases.
  • Glucagon secretion increases in the portal vein to facilitate release of glucose from the liver to match the rate of glucose uptake into the working muscles.
• An extended duration of exercise leads to reduced reliance on muscle glycogen as fuel and increased reliance on lipid oxidation and glucose derived from plasma.
• If insulin concentrations do not fall during prolonged aerobic exercise (e.g., walking, jogging, or cycling), the rise in counter-regulatory hormones is less effective in the promotion of hepatic glucose production than when they do fall.

Credit: Cockcroft, EJ, Narendran, P, Andrews, RC. Exercise-induced hypoglycaemia in type 1 diabetes. Experimental Physiology. 2020; 105: 590– 599. https://doi.org/10.1113/EP088219

Credit: Chetty T et al, Front Endocrinol (Lausanne). 2019 Jun 14;10:326

High individual variability exists in the blood glucose responses to different forms of exercise.

Credit: Riddell MC, Gallen IW, Smart CE, et al. Exercise management in type 1 diabetes: a consensus statement. Lancet Diabetes Endocrinol 2017; published online Jan 23. http://dx.doi.org/10.1016

Know the differences

Credit: Credit: Francesca Cannata ,Gianluca Vadalà  , Fabrizio RussoJ et al. Funct. Morphol. Kinesiol. 2020, 5, 70; doi:10.3390/jfmk5030070

Glucose Monitoring Basics

1. Monitoring blood glucose either by self-monitoring (SMBG) or increasingly commonly, real-time continuous glucosemonitoring (rtCGM) and intermittent scanning glucose monitoring, is important for managing glycemia before, during and after exercise.
2. Information gathered from glucosemonitoring allows refinement of future exercise strategies and can inform how different factors and behaviors influence blood glucose levels.
3. Blood glucose levels at the onset of exercise can be used to tailor glycemic management strategies.

Points To Ponder

• Expert opinion suggests that although blood glucose target levels at the start of exercise should be individualized, 126-180mg   is an acceptable starting range for adult patients doing aerobic exercise for up to 60-min duration.
• There are no existing guidelines for target blood glucose levels at the onset of exercise in children.
• Of note, although anecdotal evidence suggests a blood glucose level > 180 may adversely affect exercise performance, studies to date have failed to demonstrate a difference in sports skill performance during acute hyperglycemia compared to normoglycemia.

CGM or SMBG

• CGM provides detailed information on not only glucose levels but trends before, during and after exercise.
• Strategies regarding correction of hyperglycemia and prevention of hypoglycemia can be refined as information obtained from CGM could be regarded as more complete than SMBG.
• What SMBG adds, as a complementary method, is an increased point accuracy as there is a lag time between blood glucose and interstitial glucose levels when glucose levels are changing rapidly, such as during exercise.
• Advancement in CGM technology has made these devices increasingly accurate and user-friendly. Some devices now offer the option of sharing real-time glucose levels with others or “followers.”
• This feature potentially allows parents/caregivers to alert their child to impending hypoglycemia during and after sports and physical activity.

Carbohydrate Intake

• Carbohydrate consumption before, during and after exercise can be used to prevent and treat exercise -mediated hypoglycemia.
•  Factors influencing the amount of carbohydrate intake required to prevent exercise-mediated hypoglycemia include body mass, circulating insulin levels and the type, intensity and duration of exercise.
• The blood glucose level and trend at the start of exercise are other factors to consider and recommendations based on these parameters should be individualized.
• The carbohydrate requirement to prevent exercise-mediated hypoglycemia increases with plasma insulin levels with the pattern of blood glucose response to exercise being highly unpredictable under hyperinsulinaemic compared to near basal insulinaemic conditions.
• Clinical recommendations for carbohydrate intake will vary if the goal is hypoglycemia prevention, weight reduction, improving glycaemic control or optimal exercise performance.
• Increased carbohydrate supplementation, matched with increased insulin doses, is safe and allows the prevention of hypoglycemia during prolonged aerobic activity.
• This strategy has not been explored in the pediatric population. It is important to match insulin dose with extra CHO intake as excessive carbohydrate supplementation without matched insulin may result in hyperglycemia

The type and timing of carbohydrate ingestion should also be considered

Insulin Adjustment

• Insulin adjustment, along with balanced carbohydrate intake, is a key tool for managing blood glucose levels during and after exercise.
• The degree to which blood glucose levels fall during exercise is dependent on the amount of circulating insulin.
• Reduction in insulin doses to prevent exercise-mediated hypoglycemia is typically required for prolonged (>30 min) moderate intensity exercise, particularly if insulin is above basal levels.
• Insulin pumps allow greater flexibility in adjusting basal rates than injection regimens. The basal dose adjustments are most relevant to patients on insulin pumps, particularly for unplanned exercise, whereas bolus dose adjustment can be applied to most regimens.
• For those on Multiple Daily Injections (MDI), basal dose reduction can reduce the risk of nocturnal hypoglycemia on nights following afternoon exercise. However, this approach may result in hyperglycemia, and if this is the case, should be reserved for when participating in more activity than usual, such as sports camps
• The blood glucose rising effect of sprinting in young people with T1D suggests that this may provide a strategy to reduce hypoglycemia risk during and after exercise.
• A series of studies in young adults with T1D have shown that a maximal 10 s sprint performed before or after moderate intensity exercise can prevent blood glucose levels from falling early after exercise.
• Frequent short sprints (4 s sprints every 2 min) during moderate intensity exercise reduce the decline in blood glucose levels compared to continuous moderate intensity exercise during and early after exercise.
• These strategies have been trialed in clinic-based studies, but real-world data are lacking.

Quick Take Away: Exercise and Hypoglycemia Blues

This Flow chart is very useful

Credit: Cockcroft, EJ, Narendran, P, Andrews, RC. Exercise-induced hypoglycaemia in type 1 diabetes. Experimental Physiology. 2020; 105: 590– 599. https://doi.org/10.1113/EP088219

Ketosis Red Alert

• Low insulin concentrations due to aggressive reductions in insulin administration or a skipped insulin dose can cause hyperglycaemia before and during aerobic exercise, and even mild activity could lead to development of ketosis.

Any role of HIIT In T1DM

• Adults with type 1 diabetes can engage in HIIT and manage blood glucose with appropriate regimen changes.
• For optimal clinical benefit (improved glycaemic control and cardiovascular function), the value of HIIT appears likely to be adjunct to energy restriction, allowing HIIT to certainly make a hit.
• HIT confers superior glycaemic improvement as compared with continuous moderate-intensity training, with a lower time commitment.

Final Points

• Each T1 DM patient is unique.
• Do Access what sort of exercise suits.
• Do encourage Aerobic, Resistance exercises, HIIT  & Yoga.
• Do generate an exercise Prescription.
• Educate first yourself about intricacies of exercise in T1DM… then to your patients.

References:

1. N H Kime, A Pringle, M J Rivett, P M Robinson, Physical activity and exercise in adults with type 1 diabetes: understanding their needs using a person-centered approach, Health Education Research, Volume 33, Issue 5, October 2018, Pages 375–388, https://doi.org/10.1093/her/cyy028
2. Diabetologia 55, 542–551 (2012). https://doi.org/10.1007/s00125-011-2403-2
3. J. Funct. Morphol. Kinesiol. 2020, 5, 70; doi:10.3390/jfmk5030070
4. Chetty T, Shetty V, Fournier PA, Adolfsson P, Jones TW, Davis EA. Exercise Management for Young People With Type 1 Diabetes: A Structured Approach to the Exercise Consultation. Front Endocrinol (Lausanne). 2019 Jun 14;10:326. doi: 10.3389/fendo.2019.00326. PMID: 31258513; PMCID: PMC6587067.
5. Colberg SR, Laan R, Dassau E, Kerr D. Physical activity and type 1 diabetes: time for a rewire? J Diabetes Sci Technol. 2015 May;9(3):609-18. doi: 10.1177/1932296814566231. Epub 2015 Jan 6. PMID: 25568144; PMCID: PMC4604550.
6. Riddell MC, Gallen IW, Smart CE, et al. Exercise management in type 1 diabetes: a consensus statement. Lancet Diabetes Endocrinol 2017; published online Jan 23. http://dx.doi.org/10.1016
7. Cockcroft, EJ, Narendran, P, Andrews, RC. Exercise-induced hypoglycaemia in type 1 diabetes. Experimental Physiology. 2020; 105: 590– 599. https://doi.org/10.1113/EP088219

Discover CME INDIA

• Explore CME INDIA Repository
• Examine CME INDIA Case Study
• Read History Today in Medicine
• Register for Future CMEs

Get CME INDIA Highlights

Curated articles in your inbox.

SUBSCRIBE!

You have Successfully Subscribed!