Sports & Pumping: Finding the Right Mix

1. Sports & Pumping: Finding the Right Mix Rick Philbin, MBA, M.Ed., ATC

2. Advanced Pump Management • Insulin Action • Basal Insulin Regulation • Bolus Regulation • Physical Activity Adjustment • DKA Prevention • Temporary Basal Rates • Insulin - Prolonged Boluses • Alternate Basal Patterns

3. Profiles of Human & Analog Insulins Humalog, Novolog, Apidra (up to 4hrs) Regular (6–10 hours) NPH (12–20 hours) Detemir (Up to 24 hours) Plasma Insulin Levels Glargine (20–26 hours) Hours 4 2 6 8 12 14 16 18 20 22 24 0 10 Adapted from American Diabetes Association. Diabetes in the Latino Population. Available at: http://www.diabetes.org/uedocuments/LatinoSlidesAugust05.ppt. Diabetes Core Curriculum Workshop

4. Basal Insulin Regulation • Basal Insulin’s One And Only Job Is To Hold Blood Glucose Levels Steady In the Absence of Confounding Influences* * Food, Exercise, Bolus Insulin, Unusual Hormonal Conditions (illness, rebounds, menstruation)

5. Physical Activity Adjustments

6. Physical Activity Adjustments Meal Bolus Adjustment* • Low Intensity Cardio  25% • Mod. Intensity Cardio  33% • High Intensity Cardio  50% • Competitive/Anaerobic ??? * If activity is after meal • Basal • Adjustment** •  Basal rate 50% • Start basal reduction 1 hr pre-activity ** For activities lasting > 90 Min.

7. Carbohydrate Replacement Per 60 Minutes of Activity 50 lbs 100 lbs 150 lbs 200 lbs 250 lbs Skating 7-10g 14-20g 20-30g 28-40g 35-50g Gymnastics 8-12g 17-23g 25-35g 34-46g 42-57g Soccer 13-17g 27-33g 40-50g 54-66g 67-82g Physical Activity Adjustments • Snacking to prevent low (examples)

8. Where do you carry it during exercise? Can you play contact sports? How often do you change the infusion site? Should you give yourself a bolus of insulin for a high glucose reading? How can you adjust your basal delivery of insulin depending on your glucose readings? Stay connected or not?

9. Physical Activity Adjustments Alternatives to Disconnection:  Wear It! (Sport Pack, Bum Bag, Backpack Harness) • Re-Connect hourly & bolus 50% of missed basal rate

10. DKA Prevention Causes of insulin deficiency in Pump Therapy • Malabsorption (site problems) • Insulin Spoilage • Tubing or infusion set clogs • Leaks where the cartridge connects to the tubing • “Tunneling”/Leakage at the infusion site • Air pockets in the tubing • Dislodgement of the canula from beneath the skin • Improper or insufficient priming • Extended pump suspension or disconnection

11. Temporary Basal Rates • High-Fat Food

12. Temporary Basal Rates • Illness

13. Temporary Basal Rates • Extended Inactivity

14. Temporary Basal • Menstrual Cycles

15. Temporary Basal Rates • Prolonged Activity

16. Temporary Basal Rates Prevention of (Delayed-Onset Hypoglycemia)

17. Temporary Basal Rates • Alcohol

18. Definition: Insulin on BoarD(IOB or BOB) The amount of insulin still active at a given time after a bolus

19. 30% Rule is Where it Started Pumping Insulin, Walsh J, Roberts R

20. Benefits of IOB • Decreased risk of stacking insulin • Less chance of hypoglycemia • Decreased risk of intentionally running high due to fear of hypoglycemia • May improve A1c

21. Prolonged Boluses • Description: Normal/Standard Boluses are delivered within a few minutes; peak is approx. 1 hr, duration approx. 4 hours Prolonged boluses are delivered over a period of a couple of hours; peak is delayed/blunted and duration is extended.

22. Dangers of Dehydration • *Fatigue *Loss of coordination *High Blood Sugar • *Increased risk of heat illness, heat stroke and even death

23. Monitor Fluid Loss • Two ways: • Weigh in before practice and after practice • 3 cups of fluid per pound lost • Check the color of urine (lemonade v. apple juice) 1 - 3 = Optimally Hydrated 4 - 6 = Slightly dehydrated should drink more 6 - 8 = Dehydrated, must drink more

24. Fluids and Exercise • Hydration is very important • Non-caffeinated beverages (non-diuretic) • Cool water is best • Consider using diluted sports drink if CHO supplementation is needed • Make sure fluids are available along planned route • Thirst mechanism may be unreliable • Don’t wait until thirsty • High blood sugars can be worsened quickly by dehydration

25. Fluid Guidelines • Before • Drink 12 to 20 oz -- 2-3 hours before • During • Drink 6 to 12 oz every 15-20 minutes • After • Drink 150% of sweat losses • Drink 3 cups (24 oz) for every 1 lb weight lost through sweat • Two gulps are about 3 ounces • Replace 70% of what you have lost before next practice *Guidelines from American Dietetic Association & American College of Sports Medicine , 2007

26. Case Study… What Changes Can Be Made? • Female soccer player wearing an insulin pump • Frequent weekend tournaments up to three games a day • BG ok on Saturdays but struggles with low BGs on Sunday

27. Athletes with Type 1 Diabetes

28. Athletes With Type 1 Diabetes • Adam Morrison, NBA basketball • Chris Dudley, NBA basketball • Jay Leeuwenburg, NFL football • Kris Freeman ,U.S. XC ski team • Gary Hall, Jr., Olympic Gold swimmer • Missy Foy, Ultra distance runner • Doug Burns, Bodybuilding • Travis Pesco, Olympic wrestler • Will Cross, Explorer • Phil Sutherland, Cyclist • Michelle McCann, LPGA Golfer • Bill King, Marathoner