Sherri Shafer, Registered Dietitian, Diabetes Management Part 5: Exercise Considerations

Sherri Shafer, Registered Dietitian, Diabetes Management Part 5: Exercise Considerations

November 12, 2019 0 By William Morgan


Hello. Next, we’re gonna talk about exercise
considerations for people with diabetes. The objectives are to name
two ways a person with type 1 diabetes can reduce the risk of having
hypoglycemia related to exercise. Explain why hypoglycemia can happen as
much as 24 hours after strenuous exercise. List four benefits of exercise for
a person with type 2 diabetes and two exercise recommendations for
a person who has peripheral neuropathy. So again, exercise is one of
the variables that needs to be considered when you’re looking at managing web
glucose in somebody with diabetes, especially a type one. Needing to figure out what their
dose should be whether they’re exercising or not. It’s an addition to counting the carbs and
dosing their insulin. So let’s first look at what happens in
your body if you don’t have diabetes and everything’s working as it should. Normal metabolism during exercise is that
there will be an increase in counter regulatory hormones, such as glucagon,
epinephrine, cortisol, growth hormone. When the body starts to move and
starts to exercise, the liver is gonna mobilize fuel for
those activities. So your gonna have
gluconeogenesis as needed and you’re gonna have glycogenolysis
of what’s already stored. There’s also gonna be a release of free
fatty acids from adipose tissue and increase of glucose uptake by the muscles. The more strenuous activity,
the more glucose that’s disposed or the longer the duration,
the more glucose that’s disposed. There at the same time will be
a reduction in insulin production. So if you don’t have diabetes, you will
again, orchestrate this perfect hormone balance between the hormones
that are raising blood sugar and insulin, which are lowering it. So that during exercise, somebody without diabetes is not
going to get a low blood sugar. Now let’s look at what happens with
somebody specifically with type one diabetes who has not had insulin and
that could be a teenager who just decided to take a vacation from injections
that day and didn’t inject, that could be somebody on an insulin pump who’s had
a malfunction and doesn’t realize it. It could be somebody that forgot
their long acting insulin shot. So what you will have is the same
increase in counter regulatory hormones, which will mobilize
glucose from the liver and mobilize free fatty acid
from adipose tissue. But without the insulin, the muscle
uptake of glucose is impaired greatly. Fats are not metabolized properly and
you have ketone synthesis increase. The net result is hyperglycemia and
ketosis and you can’t take somebody in this situation and have them run in
place to try to lower their blood sugar, it’ll just drive more ketone production. So you can check for ketones with,
as you can see on here, this is a urine dipstick
against the color coding. The darker the color,
the higher the ketone level and they can check their blood glucose
with a blood glucose monitor. They also have ketone monitors. So the precautions for somebody with type
one diabetes to catch this before it happens is to check blood
glucose before exercising. And if they have a surprise 300 and
they’re not sure why, hey should check for ketones. An example, on a pump, somebody has a 300. The pump has a memory of
when the last dose was. The person can look at it and
say, oh, I’m 300, because I forgot to bolus this for lunch. But if they did bolus for lunch and
it’s an hour later and their 300, you have to start thinking,
maybe the pump didn’t deliver the insulin. So checking for ketones lets you know if
your insulin isn’t there or isn’t working and if somebody has ketones, they should
not exercise until that’s resolved. Also if somebody doesn’t have ketones,
maybe they’re checking urine ketones. Remember, that’s a delayed picture, you have to accumulate the ketones
in the bladder before they show up. They might still have ketones in the
blood, but not showing up in the urine yet or they might not have ketones. They might just have high blood sugar. But when you have the increase
kinda regulatory hormones, that 300 can turn to 350 can turn to 400. So if you’re that high, you probably need
to take a little insulin if you have type one diabetes and
wait to start your exercise. The difference here and what becomes confusing is we’re really
looking at two totally different diseases. If you’re looking at someone with type 2
diabetes who has insulin resistance and their blood sugar is 300,
they might find that going out and doing a walk is gonna help lower that,
because exercise lowers insulin resistance and the contracting muscle helps
pull in and clear glucose. So, a type two who’s not at risk so
much for diabetic ketoacidosis may go out and
exercise. So when you’re having this
discussion with a patient who’s starting an exercise program,
you want to screen for complications. Or if you know of
preexisting complications, we wanna make some advice
tailored to that person. If you have somebody with
peripheral neuropathy, maybe they don’t feel their feet so well. One of the complications of that can
be that they don’t position their foot correctly when they’re walking or
running and that can damage a joint
called sacral joint syndrome. And you wouldn’t want something who
doesn’t feel their feet to be on a stair master pounding and putting their foot in
the wrong position under the strain and stress of their weight,
that could cause problems. You wouldn’t want that
person out walking and getting blisters or problems with
their feet that might not heal. So something off the feet like
stationary biking, swimming, a rowing machine or walking low impact
aerobic activity is probably fine. Think of somebody who has
background retinopathy. You don’t want to be a heavy weight
lifter, the machines at the gym with too much weight where you’re bearing down
and increasing intraocular pressure. Something low impact aerobics,
walking, swimming, biking, those sorts of things are fine. If you have somebody with
peripheral vascular disease, they’re maybe uncomfortable, their legs,
it’s difficult for them to get around. But upper body exercises with light
weights or stretch bands, something like a stationary bike, slow might
work fine for them or pool exercises. Anybody who you think is at risk for cardiac events should have
an exercise stress test. So exercising safely, the first step is
checking blood glucose, especially for type 1s to see where they’re at and
they need to keep the meter and the supplies handy through
the duration of their activity. Their meter can’t be in the locker,
if they’re on the football field for the next three hours. Hypoglycemia is a risk, so
that person needs to carry everything they would need to treat or
even to prevent that low blood sugar. If you know that your child is starting
soccer and that’s a big difference from being sedentary previous months,
then medications will probably need to be reduced to accommodate that
increase in activity without causing lows. Hydration is important whenever blood
sugar levels are significantly elevated, that’s having the kidneys remove
glucose through increase urination causes dehydration. And when you add exercise,
especially in heat and perspiration, that increases fluid needs as well. We want proper foot care, especially for somebody who has
diminished sensation in their feet. So you don’t need to tell an eight year
old, newly diagnosed kid that there’re problems with their feet and
they shouldn’t be barefoot. Now that child doesn’t
have any complications, they can run around like any other kid. It’s somebody who’s had
long duration diabetes and does have diminished sensation or issues
with circulation that needs to be very careful about not ending up with a wound
in their foot that doesn’t heal. When blood sugar is high, bacteria love
it and then infections can fester. And that’s what leads to
the potential amputations. So it’s important to also have medical ID. If something happens you want to be
recognized as somebody that has diabetes. So the most common risk with
exercise is low blood glucose. And that’s because
the muscles are taking up and burning glucose through
the whole activity. And depending on the activity, you may
be depleting glycogen stores as well. So, to prevent that,
you can make adjustments to insulin and to carbohydrate intake. So consider somebody who’s gonna eat
lunch, take their rapid-acting insulin, and knows they’re gonna go out and
play basketball right after. Maybe it’s a kid whose PE
class is right after lunch. Or maybe it’s an adult
who’s planning an activity in the early afternoon after the meal. If you know that’s coming,
you can take a smaller dose for that meal, because the insulin
will last about four hours. It peaks in 30 to 90 minutes. If you’re gonna be exercising during that
time, the sheer activity of the muscles contracting facilitate that insulin
action and you actually need less. You need insulin, but less. However, if its gonna be four or
more hours roughly since you ate and took that rapid acting insulin and
you’re gonna go out and do a bike ride,
there’s no insulin to reduce. But you could add carbohydrates
to prevent the low. So a small snack perhaps. One nice thing about being on an insulin
pump is you can reach right down and you can turn down your basal rate. If you’re running at 0.8 unit per hour
you can say I wanna 50% reduction and turn it down then and there. Whereas somebody injecting a long-acting
insulin cannot do that and may need to add carbs. So when people are on insulin
to carbohydrate ratios and you know that they have regular activity
on Tuesdays and Thursdays that’s pretty strenuous, the doctors will
sometimes give a different ratio. So for example, if you have
somebody who takes one unit for every 15grams of carbohydrate. If they ate 60 grams, that’s 4 units. If that person on a sedentary
day had a different ratio, say 1 for every 10 grams,
60 grams is 6 units. So by just having a different ratio, it gives them a way to calculate their
dose on a sedentary versus active day. In some cases doses are reduced
by 20 to 50% for activities. Let’s look at this slide. The blue lines are showing
a rapid acting insulin. It could be any of the ones
that are out there. The green line is the long acting insulin. This is just a visual of
what I just spoke about. In the first arrow, you’re seeing exercise during a time
when the insulin in very strong. I would reduce the dose, maybe at 20,
25, or it depends on the exercise, but reducing the dose there. Whereas later,
the one that’s occurring around 5 PM, there’s no rapid acting insulin on board,
it’s just the long acting. You can make that decision about
whether you need a snack or not based on your blood sugar. So if the blood sugar’s 180,
you don’t really need a snack, that exercise will help
clear some of that glucose. However, if you’re 100 and
you’re gonna go for a 3 mile jog, you’re probably gonna need
some carbohydrate for that. So carbohydrate tips are for
unplanned exercise, add carbohydrates as needed
to prevent low blood glucose. Eat carbohydrates before,
perhaps during and after activity as needed
to prevent hypoglycemia. So you have somebody at a swim
meet whose gonna be swimming for several hours, they might be drinking
a four ounce juice every hour. They don’t want something
heavy in their stomach. So that is a time and a place where small
amounts of juice through a longer activity can actually mitigate a low. Keep carbohydrates handy as snacks,
as needed. But also, if your blood sugar is below
100 and you’re about to exercise, the first carbs that go in should
be rapid carbs to bring you up. And then maybe something,
a granola bar, it could be anything, that’s gonna digest more over time
can be followed after the juice. So why might exercise
actually raise blood glucose? And sometimes people say, I can’t believe
it, I pulled him off the basketball court, I checked his blood sugar,
it was higher than when he started. Well, if you’re in the middle
of a heated game and you’ve got all this adrenaline, your
heart’s racing and you’re competitive, it may be that you’re catching that
mobilization of glucose from the liver. And the blood glucose looks higher
because of that mobilizing substrate. If you’re gonna give a correction,
maybe the blood glucose is 300, if you’re gonna give a correction, be a little
bit careful about how much you give. You might not use your
normal correction ratio. Because they’re gonna go back in,
they’re gonna burn off more glucose. And when the game is entirely over, the glucose is gonna shift back
somewhat to the muscles and the liver. And so
you don’t wanna give an over correction. Beware of delayed hypoglycemia. The muscle contraction during exercise
will increase GLUT4 transporters at the cell’s surface and
make it much easier to clear glucose. That transport system,
that insulin sensitivity, that improved transport of glucose will persist for
a while after the activity is over. That’s a great thing for
a type 2, to have that ongoing benefit of exercise that lasts for
awhile after their activity. But for a type 1, it could also lead
to a shifting back of glucose and a hypoglycemia. And that can happen immediately after,
or it could happen hours and hours after the activity, depending
on how much glycogen was depleted and then replenished. So we want to shift gears and
talk about type 2 for a second. We want to encourage exercise,
it is along with diet control and weight control, the therapy for
type 2 diabetes, is to get people moving. And if they’re doing anything, just get
them to walk to the corner and back. Start with something manageable and
build on that. Say, can you do 5 minutes a day? In a week would make it 10 minutes. So the idea here is that exercise
is a treatment for type 2, because it decreases insulin resistance. That’s their defect. It increases glucose uptake, that’s gonna
help control their blood glucose levels. It also mobilizes and burns fat. Helps with weight management. It improves lipids. So exercise can raise HDL levels and
help lower triglyceride and LDL. It improves cardiovascular fitness. And people who exercise tend to
have have lower blood pressure. So it improves hypertension. 70 some percent of adults with
type 2 diabetes are hypertensive. 80% or so are overweight. So this exercise can help across
the board with many of their problems. It reduces stress in for
everybody who has diabetes. That’s a life-long condition, and
that can lead to depression, and anxiety, and stress. And exercise does help manage that. It can be as simple as walking for
people with type two diabetes, it doesn’t have to be
a big exercise regimen. So the prescription would
be aerobic activity and the surgeon general says,
we should all get 30 minutes a day. Kids should get an hour a day. We wanna start with something
manageable and work their way up, but the diabetes association guidelines say
that it should be at least 150 minutes of moderate activity a week or
it could be 75 minutes of more vigorous, racquetball or something more
vigorous activity a week, but not more than two days
without exercise at all. And resistance exercise is
a great component for somebody, especially like an elderly person
who is not leaving the home. Doing those three pounder,
five pound weights or a Sit and Be Fit program on TV or
a stretch band or somebody that is out of the house could be
using weights as part of their routine. So when you have limited mobility
like a lot of our elders do have, we wanna find suitable activities
that they can do in their home for safety reasons for some people and
upper body exercises are a good fit. You can get DVDs to do at home, there’s television programs they can
tune into Sit and Be Fit is one of them. Some pools offer services for
the handicapped. The water’s a little warmer. it can help lower people in, but
there’s always stationary cycles or something like that people
have in their homes. Food requirements go up. A lot of elderly people are type 2. Get used to high blood glucose. We talked earlier about
hypoglycemia unawareness, where type one’s might get used
to lows and not have symptoms. People that run in the 200s and 300s also kind of regulate to thinking
that’s their new norm, so they could be running around with blood sugars in the
250 to 400 range every day and feel fine. And that makes them get dehydrated,
so one of the common admissions for elderly with diabetes is dehydration. The other problem with that is if they’re
not testing their blood sugar and they don’t know they’re that high, they don’t know they have complications as
a risk until they have the complications. So, it’s imperative to
check blood glucose levels. So, increase fluids. Those shouldn’t be juices
unless somebody’s low, so reserve that for treating hypos. Monitor the effect of
exercise on blood glucose. So for a type 1, that data is critical for
learning how to self-manage. Giving a little more carb, a little less
insulin til they get the right pattern for that activity. But for a type 2, it’s very motivating to
see a blood glucose of 220, for example, before your walk and
coming back from a half an hour walk. Having a glass of water, relaxing,
letting that shift back happen and then seeing that the blood
glucose is now 140. It’s just a nice reinforcement
that exercise helps with their glucose sensitivity and
then adjust medications. If you have a type 2’s on oral agents, because their blood sugars require that
and then they start exercising regularly. They might need their doses reduced. We don’t want them getting low, coming
home and eating to treat the low that’s sorta counter productive to being
out there and trying to lose weight. So in summary, exercise offers
health benefits to everybody. That includes people with type 1 and
type 2. It definitely helps people with type 2, because it gets at the root
of their insulin resistance. But for people with type one,
it’s an extra variable. It’s actually one more layer to the
complexities of trying to get the right dose of insulin for the right amount of
food and the right amount of activity. So they need to learn how to adjust
their medications to mitigate that hypoglycemic issue. But people with type 2, the insulin resistance will benefit by
the increase in insulin sensitivity. So, it’s an important part
of managing type 2 diabetes.