Exercise as it relates to Disease/Preventing hypoglycemia in type 1 diabetics during and after exercise

Definitions Type 1 Diabetes Type 1 diabetes is a chronic disease in which the beta cells of the pancreas are destroyed and cannot produce insulin, the hormone that is responsible for the uptake of glucose from the blood.Powers, S.K., Howley, E.T. (2009). Exercise Physiology: Theory and applications to fitness and performance 7th edition. Mcgraw-Hill Companies, Inc. New York Type 1 diabetes accounts for around 10 to 15% of all diabetics with over 16 million people worldwide diagnosed with the disease.Guelfi, K.J., Jones, T.W. & Fournier, P.A. 2007, "New insights into managing the risk of hypoglycaemia associated with intermittent high-intensity exercise in individuals with type 1 diabetes mellitus: implications for existing guidelines", Sports Medicine, vol. 37, no. 11, pp. 937-946 Regular insulin injections are required to increase the amount of glucose extracted from the blood and utilized within the body for energy. Hypoglycemia Hypoglycemia is a state of low blood glucose in which circulating blood glucose levels drop below 3.5 mmol/l.Cryer, P.E., Davis, S.N. & Shamoon, H. 2003, "Hypoglycemia in diabetes", Diabetes care, vol. 26, no. 6, pp. 1902 Hypoglycemia may occur as a result of excessive insulin dosages, low glucose intake eg: missing a meal or not eating enough carbohydrates and/or participating in prolonged or unplanned exercise.Guelfi, K.J., Jones, T.W. & Fournier, P.A. 2007, "New insights into managing the risk of hypoglycaemia associated with intermittent high-intensity exercise in individuals with type 1 diabetes mellitus: implications for existing guidelines", Sports Medicine, vol. 37, no. 11, pp. 937-946 Severe hypoglycemia can lead to seizures,coma and death. Symptoms of hypoglycemia include:Cryer, P.E., Davis, S.N. & Shamoon, H. 2003, "Hypoglycemia in diabetes", Diabetes care, vol. 26, no. 6, pp. 1902. Shaking, Trembling & Quivering Abnormal Heart Beat Anxiety & Arousal Paleness & Sweating Increased Appetite Tingling & Numbness Increased Body Temperature Weakness & Fatigue Confusion Behavioural changes Involuntary Crying Exercise Complications Participation in exercise generally increases the risk for type 1 diabetics to develop hypoglycemia during exercise and up to 24 hours after completion.Ertl, A. & Davis, S. 2004, "Evidence for a vicious cycle of exercise and hypoglycemia in type 1 diabetes mellitus", Diabetes/metabolism research and reviews, vol. 20, no. 2, pp. 124-130 The body becomes more sensitive towards insulin causing insulin to be utilized at a greater rate, this can lead to an abrupt drop in blood glucose levels. In healthy individuals the body has mechanisms that counteract this problem these are known as counterregulatory responses. Healthy counterregulatory responses to lowering blood glucose levels show a decrease in insulin production and an increase the production and release of glucose. In type 1 diabetics these counterregulatory responses are diminished as the body is not able to decrease the amount of synthetic insulin administered via injections, glucose raising responses are also weakened in type 1 diabetics.Briscoe, V.J.B.V.J., Tate, D.B.T.D.B. & Davis, S.N.D.S.N. 2007, "Type 1 diabetes: exercise and hypoglycemia", Applied Physiology, Nutrition, and Metabolism, vol. 32, no. 3, pp. 576-582 In saying this individuals should not be limited in regards to sport participation and can partake in exercise with simple manipulations of insulin injections, carbohydrate intake and exercise intensity while regularly monitoring blood glucose levels to help maintain adequate blood glucose control.Powers, S.K., Howley, E.T. (2009). Exercise Physiology: Theory and applications to fitness and performance 7th edition. Mcgraw-Hill Companies, Inc. New York Exercise Recommendations Insulin Administration As mentioned above type 1 diabetics have impaired counterregulatory responses to exercise and therefore are unable to lower the amount of synthetic insulin circulating within the body, therefore it is important to reduce the amount of insulin injected to offset this problem. The total amount of insulin reduced relies on many factors these include: duration and intensity of exercise, blood glucose and insulin levels and environmental factors.Toni, S., Reali, M.F., Barni, F., Lenzi, L. & Festini, F. 2006, "Managing insulin therapy during exercise in type 1 diabetes mellitus", Acta Biomed, vol. 77, no. suppl 1, pp. 34-40 General guidelines for insulin administration prior to exercise involve:Rabasa-Lhoret, R., Bourque, J., Ducros, F. & Chiasson, J.L. 2001, "Guidelines for premeal insulin dose reduction for postprandial exercise of different intensities and durations in type 1 diabetic subjects treated intensively with a basal-bolus insulin regimen (ultralente-lispro)", Diabetes care, vol. 24, no. 4, pp. 625.Toni, S., Reali, M.F., Barni, F., Lenzi, L. & Festini, F. 2006, "Managing insulin therapy during exercise in type 1 diabetes mellitus", Acta Biomed, vol. 77, no. suppl 1, pp. 34-40. Injecting insulin into the subcutaneous fat layer underneath the skin in either the abdomen or non exercising muscle. Lowering the pre-meal insulin dosages by 25-75%. Lowering the pre-meal insulin dosages by 70-80% if exercise is long in duration >90minutes. Lowering the rapid pre-meal insulin dosage by 30-50% if exercise is up to 4hours in duration. Lowering the pre meal insulin dosages by 70-90% in team sports, this may not be necessary if duration is less than 60minutes. As mentioned these are only guidelines, the exact insulin adjustments should be made on an individual basis via the use of a trial and error approach. Carbohydrate Intake Similar to insulin administration, carbohydrate intake should be altered prior to exercise. Insulin becomes more effective as a result of exercise and as previously stated the body is unable to alter the synthetic amount of insulin administered within the body therefore as glucose levels decline insulin levels will not decrease accordingly resulting in an increase in glucose utilization and potential hypoglycemia. This problem can be counteracted by:Coker, R.H., Koyama, Y., Denny, J.C., Camacho, R.C., Lacy, D.B. & Wasserman, D.H. 2002, "Prevention of overt hypoglycemia during exercise", Diabetes, vol. 51, no. 5, pp. 1310. Consuming low glycemic index (GI) foods Consuming a carbohydrate rich snack 3 hours prior to exercise. Consuming extra carbohydrates during prolonged exercise Consuming post-exercise carbohydrates within 30 minutes of exercise completion. Always carrying a carbohydrate rich snack or drink while exercising. Carbohydrate intake recommendations: Exercise stage Carbohydrate (CHO) intake Example's Prior 15g CHO per 30minutes exercise. 1 bannana1/2 cup cooked pasta1 glass fruit juice During 60-80g CHO per 1hour exercise or1g per kg of body weight per 1hour exercise 1 musli/sports bar1-2 sports gels500ml Gatorade/Powerade After 1.5g of CHO per kg of body weight post exercise repeat after 2 hours Multigrain sandwichesPasta/RiceFresh fruitDO NOT drink alcohol Exercise Prescription Exercise can have a major role on blood glucose levels as the body relies mainly on carbohydrates during high intensity exercise for a fuel sourcePowers, S.K., Howley, E.T. (2009). Exercise Physiology: Theory and applications to fitness and performance 7th edition. Mcgraw-Hill Companies, Inc. New York this can cause rapid depletion of blood glucose levels if insulin injection and carbohydrate intake are not modified. General exercise prescriptions to avoid abrupt decreases in blood glucose levels include:Galassetti, P., Mann, S., Tate, D., Neill, R.A., Wasserman, D.H. & Davis, S.N. 2001, "Effect of morning exercise on counterregulatory responses to subsequent, afternoon exercise", Journal of applied physiology, vol. 91, no. 1, pp. 91.Guelfi, K.J., Jones, T.W. & Fournier, P.A. 2007, "New insights into managing the risk of hypoglycaemia associated with intermittent high-intensity exercise in individuals with type 1 diabetes mellitus: implications for existing guidelines", Sports Medicine, vol. 37, no. 11, pp. 937-946 Avoid exercise if an individual has had low blood glucose <5 mmol/l or has recently had a hypoglycemic attack in the prior 24 hours. Avoid exercise if an individual has had an intense training session or competition in the prior 24 hours. Avoid spontaneous and unplanned exercise, especially if insulin has recently been administered. Perform exercise in the morning before insulin administration if able to. Exercise effects on blood glucose regulation:Guelfi, K.J., Jones, T.W. & Fournier, P.A. 2007, "New insights into managing the risk of hypoglycaemia associated with intermittent high-intensity exercise in individuals with type 1 diabetes mellitus: implications for existing guidelines", Sports Medicine, vol. 37, no. 11, pp. 937-946. Intensity Duration % Vo2max Effects on blood glucose Example Medium 30min 40-60% Decrease Running, Cycling High <15min >80% Increase Sprinting Team Sports 30min 40-60% w/ Short sprint's Slight Decrease Rugby, Soccer Blood Glucose Monitoring Self monitoring of blood glucose before, during and after exercise is recommended to distinguish when changes in insulin or carbohydrate intake are needed, monitoring of blood glucose can also provide an insight into the response of blood glucose towards various types of physical activity.Ertl, A. & Davis, S. 2004, "Evidence for a vicious cycle of exercise and hypoglycemia in type 1 diabetes mellitus", Diabetes/metabolism research and reviews, vol. 20, no. 2, pp. 124-130.Powers, S.K., Howley, E.T. (2009). Exercise Physiology: Theory and applications to fitness and performance 7th edition. Mcgraw-Hill Companies, Inc. New York. Further Information American Diabetes Association Diabetes Australia National Diabetes Information Clearinghouse (NDIC) References