6/7/2018

1

Kathleen Dunn, RN CDE

Jason Pelzek, RN CDE

Ksenia Tonyushkina, MD

Baystate Pediatric Endocrinology

June, 2018

Ksenia Tonyushkina, MD

6/7/2018

2

Objectives What does it mean to live with T1DM?

Why exercise is important?

Exercise physiology: effects of various sports and durations

What do we teach about blood sugar (BG) control around sports?

How can a school nurse help to get ready for afternoon sports?

How can a coach help on the field?

Questions

Case 16 y.o. wrestler with T1DM for 10 years

Diabetes control depends on whether he is in the season

Weight fluctuates +/- 8lbs

Checks BG occasionally

Hates feeling «low»

Uses insulin pump, disconnects pump for sports

Does not think his coach needs to know about his DM

6/7/2018

3

What is Diabetes?

Type 1 diabetes

Pancreatic destruction by immune system

Insulin-dependent

Type 2 diabetes

Due to insulin resistance

Can be managed by insulin and/or oral medications

• Serious, potentially life-threatening condition resulting form inability to regulating blood sugar levels.

Goals for Therapy Normal growth and development

A1C <7.5%

Minimize hypo-/hyperglycemia/ketosis

Reduce risk of long term complications

Allow full participation

Provide care without overly interfering with social, academic, emotional development

6/7/2018

4

What does it mean to live with T1DM?

6-8 times/day

365 days/yr

3000+ x/year

Every meal

Every snack

3-6 times/day

365 days/year

4-6 times/day

365 days/yr

Insulin Pumps

6/7/2018

5

Continuous Glucose Monitors (CGM)/Sensors

New school orders will have guidelines on how to deal with the sensor data

Hybrid Closed Loop System “Artificial pancreas”

Insulin pump + CGM + “algorithm”

“Algorithm” automatically adjusts insulin rate based on CGM data

Patients are still required to bolus for meals

6/7/2018

6

What does it mean to live with T1DM?

Peer influence - fear of not fitting in

Depression: 15-30%

Disordered eating:

15% mid-teen females to 30% late teen young adults restrict insulin

Why exercise is important? Exercise

Lowers BG levels

Helps maintain proper weight

Helps feeling better

Improves self-esteem

Allows for making friends, connections, helps to “fit in”

6/7/2018

7

How can a school nurse or coach help a student with T1DM to stay healthy ?

Make sure they do not feel “different”

Help recognize and treat hypo-/hyperglycemia

Motivate to take better care to improve performance

Exercise Physiology and Practical Approach

Kathleen Dunn, RN CDE Jason Pelzek, RN CDE

6/7/2018

8

BG goes down during physical activity, true or false?

BG increases during physical activity, true or false?

BG drops after physical activity for up to 12 hours, true or false?

How Does Physical ActivityAffect the Blood Sugar?

Exercise and Blood Sugars

Exercise

6/7/2018

9

Blood Glucose & Exercise

Blood Sugar Considerations during Exercise

Exercise is a very effective way to lower a high BG

If a person is not physically fit; BG might drop rapidly

BG levels might increase during exercise due to “excitement” hormones

Insulin might work faster – of injection site is close to a working muscle

6/7/2018

10

Exercise Physiology

Muscles can uptake glucose without insulin during the exercise -> BG drops

“Hungry” muscles continue to uptake glucose after the exercise to replenish the stores -> BG drops

Intensity, duration, and exercise types, affect BG differently

Everybody responds differently to the same physical activity – monitoring BG levels before, during, and after exercise is essential to identify patternsEverybody responds differently to the same physical activity – monitoring BG levels before, during, and after exercise is essential to identify patterns

Physical Activity ModerateVigorous

Hiking

• Light gardening/ yard work

• Dancing

• Golf

• Cycling (<10 mph)

• Walking (3.5 mph)

• Weight lifting (general light

workout)

• Stretching

• Running/ jogging (5 mph)

• Cycling (>10 mph)

• Swimming (slow freestyle laps)

• Aerobics

• Walking (4.5 mph)

• Heavy yard work

• Weight lifting (vigorous effort)

• Basketball (vigorous)

6/7/2018

11

Practical Approach:What is our Goal for Kids with DM?

Participation in sports

- Minimize hypoglycemia and hyperglycemia

Optimal sports performance

Case Study A 14 year old reports to the nurses office for lunch. She

participates in track after school. Student mentions her blood sugars have been dropping frequently at practice.

As a school nurse, can you help your student prevent the troubles with “lows” at practice?

No, it is too early to think about her sports now.

Yes, I need more data

6/7/2018

12

Blood Sugar Management

Before During After

Before

6/7/2018

13

BEFORE:Preparation for Exercise2-3 hours before 30-60 min before

Nutrition: Fuel your body

- Complex carbs and protein

Insulin:

- Adjust insulin dose based on the desired BG range before exercise (120/150-/180mg/dL)

- Decrease bolus insulin/ basal rate

Recheck BG before sports

Is BG in the range?

120-150-180mg/dL

Check BG every 60 min or if felling/ looks “LOW”

Student’s Bag on the Field

Treatment of lows, snack, water and low sugar sports drink

Glucose meter

Infusion sets

Insulin pen

6/7/2018

14

Blood Sugar Targets and Interventions

VIGOROUS

physical activity (>1hr)

MODERATE physical activity (<1hr)

BG goal 150-180 mg/dl

BG <80mg/dl: treat BG and then eat a 30g snack

BG 80-120mg/dl: eat a 30g snack

BG 120-150mg/dl: eat a 15g snack

BG 150-180mg/dl: no snack needed

BG >180mg/dl: use ½ correction

BG goal 120-150mmg/dL

BG <80 mg/dL: treat BG and then eat a 15g snack

BG 80-120mg/dl: eat a 15g snack

BG 120-180mg/dl: no snack needed

BG >180mg/dl: use ½ correction

Case: “Low” BG at Dismissal –Nurse Intervention 16 year old M

Well controlled T1DM x6y

Basketball practice at 3:30 pm

BG at 11:30 pm= 110 mg/dl

Full coverage for lunch

BG at 2:30 pm=55

Treat his low with 15 grams of snack and re-check in 15 min.

Provide another 15 grams of mixed carb snack

- May require more based on next BG

Check 30 min before practice

Don’t forget to re-check after treating lows

6/7/2018

15

“Highs” and “Lows”

“High” “Low”

If BG>300mg/dL -> check ketones.

If ketones are moderate-large – do not exercise. Take insulin and drink water.

If BG is low- > treat with 4oz of Gatorade, juice, sugar tabs.

Follow up with mixed snack to prevent future low BG

If you are hungry and eat more snacks or a meal, cover with insulin!!!

Case: “High” BG at Dismissal –Nurse Intervention 14 year old female

Managed on insulin pump

Soccer at 5:30 pm

BG at 11:30 pm= 240 mg/dL

Full coverage for lunch

BG at 2:30 pm=305mg/dL

Trouble shoot

Test ketones

Administer insulin, correct to target

Check 30 min before game

6/7/2018

16

During Exercise

During Exercise

Plan and communicate with athlete

Check BG every 60 min

you might need an extra 15g snack for every additional hour

Stay hydrated

Drink water if BGs are steady, switch to Gatorade if BG drops

Recognize symptoms of hypoglycemia & hyperglycemia

6/7/2018

17

Hypoglycemia

Treatment of Low Blood Sugar

BG below target (<80mg/dL)

• 4 glucose tablets • gel tube• 4 ounces (1/2 cup) of

juice or regular soda (not diet)

• 8 ounces of energy drink

15 g Snack • Fresh fruit• Peanut butter crackers • Mini bags of cookies• ½ sandwich 4-5 whole grain crackers or pretzels Small granola bar 6 saltine crackers

30g Snack 1 banana or a small fruit 1 whole grain English muffin or small

(2oz) whole grain bagel ½ cup cereal with 1 cup milk ½ cup yogurt or trail mix

6/7/2018

18

Case: “Low” BS on the Field -Coach Intervention 16 y.o. boy feels dizzy,

pale and shaky

What is going on?

BS = 62 mg/dl

Treat with 4 oz juice and recheck in 15 min

“rule of 15”

30 gm snack, back to sports

Don’t allow kids to participate in sports with persistent low BS

Check BS?

Juice, how much?

Hyperglycemia

6/7/2018

19

Hyperglycemia and Exercise

BG > 250mg/dL -> ketones are produced

Symptoms of ketones:

- nausea, stomach pain, vomiting

Exercising with ketones is contraindicated

Exercise with hyperglycemia but without ketones may lower BG

Case: “High” BG on the Field -Coach Intervention 14 y.o. girl feeling tired,

complaining of stomach pain

What is going on?

BG now = 388 mg/dl

BG at lunch = 298 mg/dl

Headache since morning

Suspect ketones

Call family

• No sports with moderate to high ketones• You can fix mild ketones

Does she have a pump?

Check BG?

Ask about her lunch BG?

6/7/2018

20

After Exercise

After the Exercise

Check blood sugar

Refuel your body

BG lowering effect from exercise lasts for up to 12 hours

- Afternoon sports versus nighttime sports

- If BG is low: treat & have a 15g snack to help recovery, recheck in 15 min- If BG is high: correct conservatively

6/7/2018

21

Pumps and sports Before:

- take less insulin, decrease the basal rate

During: - try to wear your pump during activity

- for contact sports you may disconnect for 60-90 minutes

• After: - reconnect your pump

- decrease the basal rate

- use a temp basal rate

Summary

Everyone is different!

Most teens have their own strategies

Nurses can promote success on the field by ensuring BGs are in range at dismissal

Frequent (hourly) snacks for longer practices

Be aware of signs of “lows” and “highs”

Make every effort to encourage sports participation!!!

6/7/2018

22

Thank you!!