SPORTS & PUMPING: FINDING THE RIGHT MIX

Rick Philbin, MBA, M.Ed., ATC

The Pump Club Insulin Pump

ADVANCED PUMP MANAGEMENT Insulin Action Basal Insulin Regulation Bolus Regulation Physical Activity Adjustment DKA Prevention Temporary Basal Rates Insulin - Prolonged Boluses Alternate Basal Patterns

The Pump Club Insulin Pump

PROFILES OF HUMAN & ANALOG INSULINS

D I A B E T E S C O R E C U R R I C U L U M W O R K S H O P

0 2 4 6 8 10 12 14 16 18 20 22 24

Plas

ma

Insu

lin L

evel

s

Regular (6–10 hours) NPH (12–20 hours)

Hours

Glargine (20–26 hours)

Humalog, Novolog, Apidra (up to 4hrs)

Detemir (Up to 24 hours)

Adapted from American Diabetes Association. Diabetes in the Latino Population.

Available at: http://www.diabetes.org/uedocuments/LatinoSlidesAugust05.ppt.

BASAL INSULIN REGULATIONBasal 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)

PHYSICAL ACTIVITY ADJUSTMENTS

Activity Within 2 Hrs After Meal

Activity Before or Between Meals

Short Duration(<90 Minutes)

Mealtime Bolus Snack Prior to Activity*

Long Duration (>90 Minutes)

Mealtime Bolus Basal RateSnack hourly

Basal RateSnack hourly

PHYSICAL ACTIVITY ADJUSTMENTSMeal 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.

PHYSICAL ACTIVITY ADJUSTMENTSSnacking to prevent low (examples)

  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

STAY CONNECTED OR NOT?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?

PHYSICAL ACTIVITY ADJUSTMENTSAlternatives to Disconnection:

Wear It! (Sport Pack, Bum Bag, Backpack Harness) Re-Connect hourly & bolus

50% of missed basal rate

DKA PREVENTIONCauses 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

TEMPORARY BASAL RATESHigh-Fat Food

Duration Adjustment Notes

8:00 +60% Start After Meal

TEMPORARY BASAL RATES

Illness

Duration Adjustment Notes

24:00 +80% Repeat as Needed

TEMPORARY BASAL RATES

Extended Inactivity

Duration Adjustment Notes

Varies (>3 hrs) +40% Great for long trips!

TEMPORARY BASAL

Menstrual Cycles

Duration Adjustment Notes

12:00 +50% (pre) Start at night

12:00 -30% (post) Start at night

TEMPORARY BASAL RATESProlonged Activity

Duration Adjustment Notes

Minimum 2 hrs. -50% Start 1-2 hours prior

TEMPORARY BASAL RATES

Prevention of (Delayed-Onset Hypoglycemia)

Duration Adjustment Notes

6-10 hours -50% Base timing on experience

TEMPORARY BASAL RATES

Alcohol

Duration Adjustment Notes2 hrs per

drink-50% Begin

after drinking

DEFINITION: INSULIN ON BOARD(IOB OR BOB)

The amount of insulin still active at a given time after a bolus

30% RULE IS WHERE IT STARTED

Pumping Insulin, Walsh J, Roberts R

BENEFITS OF IOB

Decreased risk of stacking insulin

Less chance of hypoglycemiaDecreased risk of intentionally

running high due to fear of hypoglycemia

May improve A1c

PROLONGED BOLUSESDescription:

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.

DANGERS OF DEHYDRATION

*Fatigue *Loss of coordination *High Blood Sugar*Increased risk of heat illness, heat stroke and even death

MONITOR FLUID LOSSTwo ways:Weigh in before practice and after practice3 cups of fluid per pound lostCheck the color of urine (lemonade v. apple juice)

1 - 3 = Optimally Hydrated4 - 6 = Slightly dehydrated should drink more6 - 8 = Dehydrated, must drink more

FLUIDS AND EXERCISEHydration is very importantNon-caffeinated beverages (non-diuretic)Cool water is bestConsider using diluted sports drink if CHO supplementation is needed

Make sure fluids are available along planned routeThirst mechanism may be unreliableDon’t wait until thirstyHigh blood sugars can be worsened

quickly by dehydration

BeforeDrink 12 to 20 oz -- 2-3 hours beforeDuringDrink 6 to 12 oz every 15-20 minutesAfter 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

Fluid Guidelines

*Guidelines from American Dietetic Association & American College of Sports Medicine , 2007

CASE STUDY… WHAT CHANGES CAN BE MADE?

Female soccer player wearing an insulin pumpFrequent weekend tournaments up to three games a dayBG ok on Saturdays but struggles with low BGs on Sunday

ATHLETES WITH TYPE 1 DIABETES

ATHLETES WITH TYPE 1 DIABETESAdam Morrison, NBA basketballChris Dudley, NBA basketballJay Leeuwenburg, NFL footballKris Freeman ,U.S. XC ski teamGary Hall, Jr., Olympic Gold swimmerMissy Foy, Ultra distance runnerDoug Burns, BodybuildingTravis Pesco, Olympic wrestlerWill Cross, ExplorerPhil Sutherland, CyclistMichelle McCann, LPGA GolferBill King, Marathoner