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Clinical Nutrition 3 > Exercise and Diabetes > Flashcards

Exercise and Diabetes Flashcards

1
Q

What are the standard exercise recommendations for adults?

A

-150 minutes/week of mod-vig activity with no more than 2 days off in a row and strength training 2-3x/week

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2
Q

What are the standard exercise recommendation for youth?

A

-60 mins/day of mod-vigorous activity, with 3+days/week strength building activities

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3
Q

What are 5 benefits of exercise in diabetes?

A
  • Weight management, increase LBM
  • Reduced CVD risk factors (lower BP, better lipid profile)
  • Improved insulin sensitivity
  • Psychological benefits
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4
Q

What are the 4 challenged of exercise in diabetes?

A
  • Injury
  • Impact on A1C varies
  • Hypoglycemia
  • Hyperglycaemia
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5
Q

What is the number 1 reported barrier for exercise for those with diabetes?

A

Hypoglycemia

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6
Q

Discuss exercise impact on overall A1C management

A

-Exercise may have a beneficial effect, however the beneficial effect may be mitigated by attempts to avoid hypoG

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7
Q

(T/F) Exercise in diabetes is the most beneficial, and poses the least risks to T1DM

A

F

T2DM

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8
Q

When can hypoG occur during exercise?

A
  • Immediate-during or right after exercise

- Delayed “lag effect”

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9
Q

When can delayed hypoG occur after exercise?

A

-6-15 hours after exercise, with an average of 7-11 hours after activity, and usually overight

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10
Q

BG trends after aerobic exercise? What are the main variables?

A
  • Trends down

- Intensity, duration, I:G ratio, fitness, initial glucose concentration

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11
Q

BG trends after mixed exercise? What are the main variables?

A
  • Trends upwards (with anaerobic) and downwards (with aerobic)
  • Same as aerobic, plus lactate concentration and counterregulatory hormones
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12
Q

BG trend after anaerobic exercise? What are the main variables?

A
  • Trends upwards

- Same as mixed, but intensity and number of intervals and I:G ratio is not considered

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13
Q

When a healthy person exercises, how does insulin concentrations change?

A

Naturally, they will physiologically decrease allowing us to maintain a stable blood sugar
-In diabetes, we need to mimic this physiological mechanism

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14
Q

Discuss the dysregulation which occurs leading to hypoglycemia in exercise in diabetes?

A

1) Absence of physiological decrease in insulin secretion
2) Increased absorption of insulin from subcutaneous area (due to increased blood flow)
3) Increased transport of glucose transport into the muscle, and diminished hepatic glucose production’
4) Hypoglycemia
5) Blunting of counter-regulatory hormones in patients with T1D

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15
Q

Discuss the trends seen in Glucose Infusion Rates (GIR) to maintain euglycemia

A
  • There are biphasic glucose requirements
  • We will require more glucose to maintain euglycemia right after exercise to avoid early hypoG risk
  • We will require more glucose ~10 hours later in order to avoid late hypoG risk
  • GIR is inversely proportional to BG levels
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16
Q

During sleep and after exercise, how are those with T1DM affected? (4)

A
  • Have increased glucose requirements (incr. insulin sensitivity, glycogen restoration)
  • Impaired counter-regulation
  • Relative excessive circulating insulin
  • Absence of CHO intake
  • –> Strategy could be to have small 15-20 g CHO snack prior to bedtime
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17
Q

Discuss 5 factors which can affect the BG response to exercise

A
  • Duration/intensity
  • Type of activity
  • Metabolic control
  • BG at time of exercise
  • Timing/type of insulin and timing/type of food
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18
Q

If we are going for a run, and inject insulin into our legs how may this affect glucose levels?

A

-May encourage a quicker onset of hypoG due to increased blood flow to the legs

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19
Q

A patient presents with recurring hypoglycemias after exercise (which she corrects with extra snacks) and is finding this counterintuitive to her weight-loss goals, what could we recommend to control BG and encourage weight-loss?

A
  • Suggest to decrease bolus insulin at meal prior to exercise (start with higher BG)
  • Go over how many CHOs are really required after exercise (15-20 g CHO)
  • Recommend small snack after exercise only if not eating in the next hour
  • Suggest anaerobic/sprint after exercise to increase BG and avoid hypoG
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20
Q

A patient presents with recurrent post-exercise hyperglycemia, followed by nocturnal hypoglycemia (injecting insulin after exercise to combat high BG). The patient would like to gain muscle and wants to avoid hypoGs as it affects his performance the next day. Why does this happen? What are your recommendations? The patient is on an insulin pump

A
  • He is finishing his exercise with anaerobic exercise, therefore BG are high, and he is then overcompensating for high BG by injecting insulin after exercise and then later at dinner, causing nocturnal hypoG
  • We can recommend patient to do an aerobic cool own to bring BG levels down. The aerobic exercise will increase the demand for glucose.
  • We should also investigate if the patient is suspending their insulin pump, and ensure they are doing so appropriately
  • Advise patients that bolus insulin is usually not req. after exercise, and our BG will naturally come down
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21
Q

Both _____ and ____will increase glucose uptake into skeletal muscle

A
  • Insulin

- Muscle contration

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22
Q

Discuss the increased insulin sensitivity and muscle glucose uptake during exercise

A
  • Usually we will require insulin to signal GLUT4 transporters to the membrane for glucose uptake
  • However, during muscle contraction, GLUT4 will be brought to the membrane with less insulin, and there will be an increased flow of blood bringing glucose into the cells
  • Therefore, we will require less insulin during exercise
  • In diabetes, we need to mimic this mechanism
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23
Q

What is the decline in plasma glucose in DM during exercise associated with?

A

-Impaired glucose production (as elevated insulin levels will suppress glycogenolysis and gluconeogenesis) alongside increased glucose uptake (normal mechanism of insulin, enhanced by increased insulin sensitivity with muscle contraction)

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24
Q

Discuss post-exercise glucose uptake

A

remains elevated for hours to replenish muscle glycogen stores

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25
Q

After exercise, why do our glucose requirements remain elevated?

A
  • The receptors are still sensitized, and we need to replenish our muscle glycogen stores
  • Therefore, there is a risk of hypoglycemia later on
  • Recommend snack after exercise
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26
Q

What does aerobic exercise without adjusting insulin cause?

A

Variable drop in glucose, which may cause hypoglycemia

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27
Q

(T/F) In non-diabetic patients, blood sugar will drop in aerobic exercise as there is increased utilization of glucose in muscles

A

F

Blood glucose will remain relatively constant, as in healthy individuals our insulin secretion will decrease, therefore the increase uptake of glucose in the muscles is counteracted by hepatic glucose output

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28
Q

In T1DM with no insulin adjustment in aerobic exercise, what is the average change in blood glucose over 75 minutes? What is a key concept?

A
  • Approx. 3.6 mmol/L decrease, where 40% will become hypoglycemic
  • There is a large variability, some will drop more and some will drop less
  • requires trial and error
  • Sometimes, will not have the same response twice to the same exercise, therefore hypoG is hard to predict
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29
Q

(T/F) In trained, T1DM patients with good physical fitness, they will see no glucose drop after aerobic exercise

A

F, the glucose drop is still present in patient with high fitness

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30
Q

What is considered aerobic exercise which can drop BG in T1DM/

A

~60% of VO2 max

31
Q

(T/F) Similar to the glucose drop after aerobic exercise in fit, diabetic patients - exercise also does not improve insulin sensitivity and lipid use

A

F

  • fat utilization increases with exercise duration
  • this is enhances by lowering insulin levels and training (insulin will suppress lipolysis)
32
Q

What will increase insulin sensitivity, and lower daily insulin requirements? How may parameters be adjusts in an insulin pump to accomodate for this?

A
  • Training

- If more insulin sensitive, we need to adjust ISF and ICR

33
Q

ICR adjustments in trained, insulin sensitive patients?

A
  • ICR should increase, as we require less insulin

- 1 unit of insulin will cover more g of CHO

34
Q

ISF adjustments in trained, insulin sensitive patients?

A
  • ISF should increase, as our BG levels are more responsive to insulin
  • 1 unit of insulin will decrease BG by more mmol
35
Q

Discuss the mechanism in which anaerobic exercise will increase BG and potentially cause hyperglycemia and increase insulin needs during recovery?

A
  • A release of stress hormones (cortisol, epi, norepi) have two actions: (1) to increase hepatic glucose output and (2) decrease skeletal muscle glucose uptake.
  • We want to keep blood glucose high to fight the stressor
  • Muscles will perform glycogenolysis, producing lactic acid which can further aggravate gluconeogenesis
  • In healthy individuals, this also happens but we can respond by increasing insulin to avoid hyperG
  • In diabetes we want to mimic this mechanism
36
Q

Which kind of exercise results in a more stable blood glucose profile in T1DM?

A

Resistance Trainign

37
Q

How can we prevent hypoglycemia with exercise

A
  • Use short duration sprinting, or short-duration anaerobic exercise
  • Will be used to counter the rapid fall in glycemia due to moderate-intensity exercise in T1DM
38
Q

Discuss how short sprinting for hypoG prevention is desirable within the context of weight-loss

A

-Intermittent high intensity exercise will facilitate burning kcals, to maintain BG, while reducing CHO intake

39
Q

When may the use of short-sprints to counteract hypos be ineffective?

A
  • In over-insulinised individuals
  • If repeated high intensity training, especially if mixed with aerobic exercise, could results in a significant reduction in BG
40
Q

What are two ways to prevent hypoG by using short-sprints?

A
  • We could start our exercise with sprinting to prevent hyperG during exercise
  • We could finish our exercise with sprinting to prevent hypoG later in the day
41
Q

BG hyperglycaemic?

A

> /= 14 mmol/L

42
Q

blood ketones to be considered ketotic?

A

> /= 1.5 mmol/L

43
Q

If prior to exercise a patient is hyperglycaemic and ketotic, what would we expect their insulin levels to be? Should we exercise?

A
  • Insulin deficient
  • This level of hyperglycaemia, ketones and dysregulation will not be corrected by aerobic exercise
  • Do not exercise until hyperglycemia and ketone are restored with insulin
44
Q

If mildly hyperglycaemic (8-14 mmol/L), should we administer insulin prior to exercise?

A

No, try a mild 10-15 minute aerobic warm up

45
Q

After exercise, we should always _____

A

Cool down for ~20 minutes with aerobic, easy intensity exercise in order to decrease BG (note that BG should be high before engaging in this cool-down)

46
Q

If after cool-down, patient remains hyperglycaemic (>/= 12.2 mmol), how should be proceed?

A

Conservative insulin correction

47
Q

In mild, aerobic exercise (~25% Vo2 max) what is the suggestion for bolus dose decrease if 30min and 60min?

A
  • 25%

- 50%

48
Q

In moderate aerobic exercise (~50% Vo2 max) what is the suggestion for bolus dose decrease if 30min and 60min?

A
  • 50%

- 75%

49
Q

In heavy aerobic exercise (~70-75% Vo2 max) what is the suggestion for bolus dose decrease if 30min and 60min?

A
  • 75%

- NA

50
Q

In intense aerobic exercise or anaerobic exercise (>80% Vo2 max) what is the suggestion for bolus dose decrease if 30min and 60min?

A
  • No recommendation in reduction

- N/A

51
Q

When are suggestions to reduce bolus rates useful?

A

Only when the exercise is PLANNED, because the peak action of the insulin is 2-3 hours later, therefore we need to plan

52
Q

What is the effect of pump disconnection on basal insulin levels?

A
  • Disconnection/suspensions during 30 minutes of exercise will eliminate basal pulses for 30 minutes
  • Therefore, the insulin will be begin again after the pump is reconnected, caution if patient ends the exercise with low blood glucose
53
Q

(T/F), when we discontinue the insulin pump during exercise, this means that our blood glucose levels are immediately “safe” from excess insulin causing hypoG

A

F

During exercise, we will still be receiving the effects of the previously injected insulin, however insulin will trend downwards. This means the dip in insulin will occur AFTER the exercise, which may prevent post-exercise hypoglycemia

54
Q

How should we adjust the basal insulin does?

A

BEFORE aerobic exercise

55
Q

For patients on MI, how should we suggest adjusting their BG levels prior to exercise?

A
  • Often not routinely recommended to alter, unless the patient often performs steady-state exercise each day (i.e. hiking, walking all day, x-country skiing)
  • If on BID basal, consider reducing one or both of the basal doses by 20%
56
Q

If on BID and long-acting basal, what difficulties may we have in adjusting the basal insulin doses?

A

-We would have to plan 24 hours or more in advance to change the basal rate, therefore we will have to plan ahead

57
Q

For patients on CSII how should we reduce the basal insulin dose before exercise?

A
  • Reduced by 60-80% for exercise over 45-60 minutes

- Dose could be reduced up to 90 minutes prior to exercise

58
Q

If on MDI, how should the basal insulin dose be adjusted AFTER exercise?

A
  • Reduce night-time dose by 20%
  • Encourage increase CHO consumption to prevent nocturnal hypo
  • Test BG during the night
59
Q

If on pump, how should the basal insulin dose be assisted AFTER exercise?

A

-Reduce insulin dose by 20% to 3am
-Encourage increased CHO
consumption
-Test BG during the night

60
Q

What are 4 recommendations to avoid nocturnal hypoG?

A
  • Set alarms to check BG during the night
  • Advise household members on signs of severe hypoG, appropriate use of glucose gels/glucagon
  • Avoid alcohol use following exercise
  • Suggest CGM with the benefits of hypoG
61
Q

Patient self-treated hypoG within 1 hour of planned activity, recommendations?

A
  • Treat hypoG to stabilize BG prior to engaging in activity
  • If glucose increases, OK to exercise and monitoring is necessary
  • May need to retreat as hypoG is more likely to occur
62
Q

Patient has severe hypoglycemia within 24 hours of planned activity, what is your recommendation?

A
  • Exercise should not be undertaken

- Should alert others for potential hypoG

63
Q

Patient presents with hypoG during exercise, what is your recommendation?

A

D/c activity and treat the hypoG

64
Q

(T/F) Disconnection of CSII during a short exercise session has minimal effect on insulin level

A

T

65
Q

BG <5 mmol/L, recommendation before exercise?

A

-Ingest 10-20 g of glucose before exercise and delay exercise until BG >5 mmol/L

66
Q

BG 5-6.9 mmol/L, recommendation before exercise?

A
  • Ingest 10 g of glucose

- Anaerobic and high interval intensity exercise can be started

67
Q

BG 7-15 mmol/L, recommendation before exercise?

A

-Aerobic, anaerobic or high-intensity exercise can be started

68
Q

BG >15 mmol/L recommendation before exercise?

A
  • Check blood ketones and perform low-intensity exercise, or give small dose of insulin
  • Low intensity exercise may be OK if blood ketones are <1.4 mmol/L
  • <1.4 mmol/L, consider small corrective dose of insulin
  • No exercise if >1.5 mmol/L
69
Q

T1Dm should aim to start exercise between _____

A

5-7 mmol/L

70
Q

What else may influence CHO needs and distribution during exercise?

A
  • New/sport or unfamiliar activity (increase CHO needs)

- Training phase of athlete

71
Q

What is a starting point to estimate CHO requirements?

A

4-5 g/kg/day

72
Q

How much CHO may be recommended during runs >60 mins?

A

30 g/hour

-Help with fatigue and hypo prevention

73
Q

Why may exercise in the early AM be optimal?

A

-Recall that we are slightly insulin resistant in the AM, therefore if we exercise after breakfast and before our insulin bolus, we could “decrease” our BG by running

74
Q

(T/F) protein should increase during endurance exercise

A

F

Clinical Nutrition 3 (30 decks)

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