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Exercise, Pumps & Continuous Monitors

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  1. Exercise, Pumps & Continuous Monitors Diabetes Exercise & Sports Assoc. Colorado Springs June 29, 2007 John Walsh, P.A., C.D.E. North County Endocrine 700 West El Norte Pkwy Escondido, CA 92126 (760) 743-1431 The Diabetes Mall www diabetesnet.com (619) 497-0900 jwalsh@diabetesnet.com Healthcare Across Borders - September 2003

  2. Highlights • Phys Ed • ExCarbs • Pump Settings • DIA and BOB • Continuous Monitors • Future Devices • Wrap Up Healthcare Across Borders - September 2003

  3. Polar Heart Monitor • Devices like the Polar Heart Monitor provide invaluable information about cardiac function during exercise Optimum cardiac function Healthcare Across Borders - September 2003

  4. Glucose Monitor • Devices like BG meters and continuous monitors provide invaluable information about energy flow during exercise BGs for optimum energy flow Healthcare Across Borders - September 2003

  5. Insulin Pump • Once BG data is available, precise insulin adjustments can be made with a pump to optimize fuel flow during exercise BGs for Optimum energy flow Healthcare Across Borders - September 2003

  6. Result: Entry to cells Glucose release Fat release Your Insulin Controls Access To Fuel • When INSULIN is LOW • More stored glucose and fat is released into blood, but • Less glucose enters muscle cells from blood BG Tiredness, lack of energy Healthcare Across Borders - September 2003

  7. Result: Entry to cells Glucose release Fat release Your Insulin Controls Access To Fuel • When INSULIN is High • Less stored glucose and fat is released into blood, but • More glucose enters muscle cells from blood BG Tiredness, lack of energy Healthcare Across Borders - September 2003

  8. Result: Entry to cells Glucose release Fat release Your Insulin Controls Access To Fuel • When INSULIN is Optimum • Right amounts of stored glucose and fat are released • And glucose entry into muscle cells is appropriate BG Energy and performance Healthcare Across Borders - September 2003

  9. When Your Insulin Levels Need To Change • The LONGER you exercise, • The MORE INTENSE you exercise, and • The LESS TRAINED you are, • The MORE you need to lower your insulin Healthcare Across Borders - September 2003

  10. What’s The Right Starting Glucose For Exercise? • The glucose you have at the time • Beyond that • < 70 glucose, Gatorade, or other fast carbs • 70-100 carbs • > 100 ? Powerbar • > 180 ? insulin • > 300 Insulin, check ketones • Some competitive and anaerobic sports may require insulin, no matter the starting glucose BOB plusBG trend from cont monitor gives critical info Healthcare Across Borders - September 2003

  11. Fuel Type Shifts As Intensity Rises (work, HR, or intensity) Healthcare Across Borders - September 2003

  12. Intensity Affects Fuel Preference Glucose Portion As intensity rises, so too does the percentage of glucose required for exercise Healthcare Across Borders - September 2003

  13. Muscle Glycogen As Glucose Shock-Absorber • More muscle glycogen (training) means: • Larger glucose stores can minimize a fall in BG during exercise • After large meals, more glucose is absorbed to minimize rise in BG During exercise, stored glucose is removed from blood and glycogen. After exercise, glucose stores must be rebuilt by removal of glucose from the blood over several hours. Healthcare Across Borders - September 2003

  14. ExCarbs Healthcare Across Borders - September 2003

  15. How Many Calories You Need Is Known • The number of calories you burn during exercise was determined decades ago. • To get calories, you only need to know: • Your weight • Type of exercise and intensity, such as running at 8 mph • How long you will exercise Healthcare Across Borders - September 2003

  16. Exercise Calories Can Be Converted To ExCarbs • To determine ExCarbs, how many carbs you need for exercise, you need to know: • What percentage of your calories come from carbs (more intense = higher carb %) • And that your insulin level is appropriate Healthcare Across Borders - September 2003

  17. Are Your Basals And Boluses Appropriate? • Is your A1c between 6% and 7%? • Is your meter average between 120 and 150? • Do you have frequent lows? • Does your BG go below 50? Healthcare Across Borders - September 2003

  18. Once Known, ExCarbs Can Be: • Eaten as carbs • Used to lower a high BG * • Used to lower boluses or basal rates * • * If your carb and correction factors are accurate © Pumping Insulin, 2006 Healthcare Across Borders - September 2003

  19. ExCarbs – The Carbs You Need For Exercise • Carla weighs 150 lbs. and will need 68 grams of carb for her 1 hour run at 5 mph © Pumping Insulin, 2006 Healthcare Across Borders - September 2003

  20. ExCarbs Conversions • Carla’s 68 grams of ExCarbs: • can be eaten as free carbs • can be converted into insulin to reduce carb boluses orbasal rates • 68 gr / 14 gr per u (Carla’s carb factor) = 4.9 units • or used to lower a high blood sugar • 1 u for each 65 mg/dl above 100 mg/dl (Carla’s corr factor) © Pumping Insulin, 2006 Healthcare Across Borders - September 2003

  21. Translate Intensity & Duration Into Extra Carbs Or Bolus Or Basal Reduction • Table 23.9 translates exercises with different intensity and duration into combinations of likely carb intakes and bolus or basal reductions Carla’s run after breakfast was between moderate – so she lowered her breakfast bolus by 30%, ate an extra 12 grams of free carb before her run and 26 grams afterward © Pumping Insulin, 2006 Healthcare Across Borders - September 2003

  22. ExFactors • Enter into pump: • Exercise intensity (1-7 scale) • Exercise duration (15-480 min) • Current level of fitness for that activity (1-5 scale) • Given this info, pump can calculate carb intake and insulin reduction you need for this activity, while accounting for any BOB Future Pump Feature Healthcare Across Borders - September 2003

  23. Bolus Reduction • Reduce bolus before short, planned exercise and during any long exercise • Ideal for exercise lasting less than 60 to 90 minutes and which takes place shortly after a meal • For premeal exercise, consider some extra carbs with a bolus reduction in the meal that follows Healthcare Across Borders - September 2003

  24. Temporary Basal Reduction • Short, large basal reductions can be used right before short activities • 80% reduction for 30 min • or 60% for 1 hr • Smaller reductions for exercise lasting longer than 90 min • Max reduction usually 50% • Reduce basal an hour or so before activity starts • After long exercises, glucose may fall for 12 to 36 hrs • Temp basal reduction may be needed AFTER activity • More glucose needed during this time to rebuild glycogen stores basal basal Healthcare Across Borders - September 2003

  25. Disconnect Bolus • Disconnect for up to 2 hours for sports, sauna, etc. • User estimates time off pump • Pump offers to give up to 50% of missed basal as disconnect bolus • Alarm reminds user to re-connect at set time • On reconnecting, pump determines basal missed and offers to supply the missing basal amount Current Feature Healthcare Across Borders - September 2003

  26. Pump Settings For Improved Control Healthcare Across Borders - September 2003

  27. When Major Control Problems Occur, Adjust Your TDD • Raise your TDD: • With a high A1c or a high average BG on your meter • Lower your TDD • For frequent lows • If both highs AND lows occur – which comes first? • Keep basals and carb boluses balanced as you adjust your TDD TDDtoo low or too high? Healthcare Across Borders - September 2003

  28. Adjust The TDD For A High Avg. BG or A1cExample: someone with a TDD of 35 units and few lows. A1c = 9%, so more insulin is needed: about 3.2 units. © Pumping Insulin, 2006 Healthcare Across Borders - September 2003

  29. Basal Tips • 50% Rule: basals usually make up 40 to 65% of an accurate TDD • Basal rates will be similar through the day, such as between 0.45 and 0.7, or between 1.0 and 1.4 • Adjust basal rate in small steps – 0.05 to 0.1 u/hr • Change basals 3 to 8 hours before need arises Healthcare Across Borders - September 2003

  30. Check Your Carb Boluses • Does your carb factor work for large carb meals (over 80 grams)? • Are you counting carbs accurately? • Do you bolus at least 20 min before meals with a normal glucose? Healthcare Across Borders - September 2003

  31. Most Carbs Much Faster Than “Rapid” Insulin One hour after a meal, half of a meal’s glucose rise has occurred, but 80% of rapid insulin activity remains Time over which most meals affect the BG % bolus activity remaining Take Home: Bolus 15 to 30 minutes before meals Use extended and boluses sparingly. From Pumping Insulin Healthcare Across Borders - September 2003

  32. Timing Is Everything • Figure shows rapid insulin injected 0 min, 30 min, and 60 minutes before a meal • Normal glucose and insulin profiles are shown in the shaded areas Healthcare Across Borders - September 2003

  33. Therapy Effectiveness Scorecard • Screen 1 : • Average BG • BG tests per day • BG standard deviation • Screen 2: • Carbs per day • TDD • % of TDD as correction boluses • % of TDD as carb boluses • of TDD as basal rates Healthcare Across Borders - September 2003

  34. Exposure And Variability One day’s BG results with usual meals and insulin. The DCCT proved that exposure to high blood glucose was damaging. New emphasis is on glucose variability. Variability or Swing = SD from PC or meter Exposure or Average = A1c or avg. BG from meter Healthcare Across Borders - September 2003

  35. Therapy Scorecard Screen 1 14 Day Average: BG 146 mg/dl Tests 3.5/day Std Dev 53 mg/dl • Overall controlAdequate testingBG variability – aim for less than half of avg BG Healthcare Across Borders - September 2003

  36. Therapy Scorecard Screen 2 14 Day Average: Carbs 206 g TDD 48.58 u Meal 38.07% Corr 4.95% Basal 56.98% • Boluses taken? Low carb?Guides therapy – A1c, lows, etcCarb bolus %Corrections less than 8% of TDD?Is basal at least 40-45% of TDD? Healthcare Across Borders - September 2003

  37. Check Correction Bolus % Regularly • When correction boluses make up over 8% of TDD • Raise your basal rates or carb boluses • Or stop skipping carb boluses • Move half of the excess units above 8% into basal rates or carb boluses, whichever is smaller, or into both if basals and carb boluses are balanced Note: Paradigm pumps give correction bolus % as a % of total bolus dose, not the TDD. Do not use this percentage here! Healthcare Across Borders - September 2003

  38. Example: Correction Boluses Over 8% 10 Day Average: Carbs 175 g TDD 54.1 u Meal 36% Corr 21% Basal 43% • Move 1/3 to 1/2 of the overage to basals or carb boluses: • 21% of 54.1 = 11.3 units, 8% of 54.1 = 4.3 units • 11.3 u - 4.3 u = 7 units excess • 1/3 to 1/2 of 7 u = 2.3 to 3.5 u to be added to basal rates or carb boluses Over 8% Healthcare Across Borders - September 2003

  39. Weekly Schedule • The user’s basal profile changes automatically for specific days of the week • Different basal patterns and missed meal bolus alerts for each day of the week • No need to remember to change basal patterns or alerts • Great for regular exercise, college classes, shift work, and other routine variations in schedule Current Feature Healthcare Across Borders - September 2003

  40. Duration Of Insulin Action (DIA)Or how long boluses lower the blood sugar Healthcare Across Borders - September 2003

  41. Duration Of Insulin Action Accurate boluses require an accurate duration of insulin action. Glucose-lowering Activity 0 6 hrs 2 hrs 4 hrs Current Feature Healthcare Across Borders - September 2003

  42. Why The DIA Gets Shorted • Pumpers and clinicians often set the DIA too short because: • Recommended boluses do not bring high BGs down (ie, basal rates or carb bolus are too low) • Shortening the DIA seems easier or safer than raising basal rates or lowering the carb factor. • The default DIA may be too short and never gets reset • A low basal rate is hiding true bolus activity Healthcare Across Borders - September 2003

  43. A Short DIA Can Cause Problems • A short DIA hides the true BOB and its glucose-lowering activity. • Hiding bolus activity makes boluses excessive and may cause basal rates to be lowered inappropriately • Set your DIA to your insulin’s action time. • Do not modify the DIA based on control problems. Healthcare Across Borders - September 2003

  44. Recommended DIA Times • Set DIA to 4 hrs or more to calculate BOB and bolus doses accurately Linear Curvilinear Healthcare Across Borders - September 2003 From Pumping Insulin, 4th ed., adapted fom Mudaliar et al: Diabetes Care, 22: 1501, 1999

  45. Bolus On Board (BOB)The glucose-lowering activity that remains from recent boluses An accurate BOB calculation • Prevents insulin stacking • Improves bolus accuracy • Reveals current carb or insulin deficit • Your BOB can be determined only after a BG has been entered into pump! aka: insulin on board, active insulin, unused insulin* * Introduced as Unused Insulin in 1st ed of Pumping Insulin (1989) Healthcare Across Borders - September 2003

  46. Blind Bolusing Also Hides BOB • Only 32.5% of 204,005 boluses from over 500 Cozmo pumps used across the US were accompanied by a BG value. • 2/3 of boluses are given without a BG test • Only 1 of every 7 boluses had both carbs and a BG 67.5% blind boluses Data in preparation for publication Healthcare Across Borders - September 2003

  47. BOB Prevents Insulin Stacking • With a bedtime BG of 173, is there an insulin deficit or a carb deficit? Insulin stacking is common for anyone who gives frequent boluses! Bedtime BG = 173 mg/dl Correction Dessert Dinner 6 pm 8 pm 10 pm 12 am Healthcare Across Borders - September 2003

  48. 1 BG = 173 mg/dl (9.6 mmol) Bolus on board = 0.4 u Correction bolus: 1.2 u Insulin deficit = - 0.8 u Give 0.8 u now? Y or N 2 BG = 173 mg/dl (9.6 mmol) Bolus on board = 4.6 u Correction bolus: 1.2 u Insulin excess = 3.4 u You may need: 37 grams of carb later to prevent a low BG Hypo ManagerFor each BG, pump can show whether an insulin or a carb deficit exists Only after a BG has been entered can a pump determine whether carbs or insulin are needed Helps prevent & treat hypoglycemia and avoid over-treatment Current Feature Healthcare Across Borders - September 2003

  49. Warning: Most Pumps Do Not Subtract BOB From Carb Boluses • Excess BOB is subtracted from correction bolus, but NOT carb bolus • 3 u • + 1 u • – 3 u • = 1 u bolus 3.0U 45 gr 160 3.0U 1.0U3.0U Whenever BOB is greater than correction need, recommended boluses may be excessive for Paradigm, Omnipod, Animas (for BG above target), and Cozmo (if defaults are not changed) Healthcare Across Borders - September 2003

  50. Recommended Boluses Differ Between Pumps Bolus recommendations from different pump for various BGs when BOB = 3.0 u and 30 grams of carb will be eaten • Carb factor = 1u / 10 gr • Corr. Factor = 1 u / 40 mg/dl (2.2 mmol) over 100 mg/dl (5.6 mmol) • Target BG = 100 mg/dl • TDD = ~50 u units BG in mg/dl Healthcare Across Borders - September 2003