everyone for joining tonight. And what I wanna do is we published a position statement on the care of the athlete and active person with diabetes. And I'd like to acknowledge my co-authors before I start. You'll see references throughout the paper and slides that are not referenced are from the position statement themselves. Today, I'd like to talk to you about the list of benefits of exercise for type one and type two diabetes, why people should exercise and explain the effects of exercise at different glucose levels. So part of the importance of a diabetes talk is actually an exercise sociology talk. And we'll go into a fuel usage during exercise. We'll describe the methods to prevent exercise complications, identify the symptoms of hypoglycemia, which are important, state the treatment of hypoglycemia. And then I'll give you some resources to look at at the end. That's where we'll cover. Here we go. So athletes and active people with diabetes can participate at all levels. And this involves people from weekend warriors, professionals, Olympic athletes, people have even climbed Mount Everest with diabetes and needing insulin for type one diabetics. So, you know, we advocate that people with type one diabetes should be encouraged and educated by medical professionals to allow a safe participation in all forms of physical activity, consistent with individual's desires and goals. And the reason we say that is that there's a lot of fear in type one diabetics and families to not do exercise and activity for the fear of hypoglycemia. And so part of this is you can help. You know, physical activity provides many benefits, not just for hemoglobin A1C, but for cardiac reasons. And so there's an extension of life in type one diabetics, not necessarily for the drop in hemoglobin A1Cs, but for the reduction in cardiac risk. So barriers to exercise are often, as I said, fear of hypoglycemia, loss of glycemic control in sufficient time, like most people, facilities or motivation, and a general scarcity of knowledge around exercises management. And so hopefully you as a physician can help guide people as you take care of them. In the United States, approximately 192,000 people have type one, have diabetes, and 167,000 of type one and 20,000 type two. Type one prevalence is high, you know, at the younger age, and then of course it's type two, diabetes increases as people get older, it drops. And overall, type two diabetes is 90% of people with diabetes, which is around 13.7 million people. That's a lot of people out of our 333 million people. One thing that I want to point out to you when you look at what is the prevalence of type one diabetes in people who are 19 and younger, that's about 3.2 per 1,000 people. And our college athletes in one of our studies that I did, looking at the Colonial Athletic Association, what we saw was there was a 3.42 per 1,000. So there seems to be no difference in the general population as in the athletic population, and type one diabetes shouldn't prevent people from being able to exercise and be active, especially even at high levels. As you're probably aware, because you graduated med school, that type one diabetes is a chronic problem related to the absence of insulin, and type two diabetes is by far more prevalence, and it's more of a resistance to insulin, and often will have elevated insulin production. There are different combinations of the two, and there are other forms, such as glucocorticoid-induced diabetes and gestational diabetes, which I'm not going to get into tonight. Some of the things you need to think about as you're managing, and I want to make sure we're all on the same page, is that euglycemia, with activity, insulin decreases and counter-regulatory hormones go up, and we maintain euglycemia. Hypoglycemia is not necessarily too little glucose, but what it is is an overabundance of insulin, and you have an increase in insulin and an increase in counter-regulatory hormones. Whereas an under-insulinized state, you end up with hyperglycemia, and so you have too little insulin. So those are the things you need to kind of think about as you manage people, that when they are at a lower state, they have a situation where they're having too much insulin, we need to gauge for that, and we'll see that as we go along. Another point that I need everybody to be kind of aware of is the GLUT4 receptors. So GLUT4 receptors are located in adipose tissue and striated muscles, cardiac and skeletal muscles, and they are a non-insulin dependent, so they react to activity, and they are part of the system with insulin, but they are very important for type 2 diabetics, they get upregulated with exercise. And so these are something that you need to be aware of, GLUT4 receptor, and GLUT means glucose transport. So, you know, as we educate and talk to people about exercise and diabetics with exercise, we need to keep in our mind that we should be good examples of exercise, and, you know, we should be out walking, should be active ourselves as physicians. Physical activity has both acute and chronic benefits, providers should be aware of these to assist athletes as they become both safe and effective and they can do these things. So what about exercise for prevention of diabetes? Well, there's a 6% decrease in age-adjusted risk for every 500 calories per week of exercise in a 1991 study, and exercise at least once a week decreases the risk of developing diabetes. So exercise in and of itself will help to decrease the probability of type 2 diabetes. And how's that? It increases insulin sensitivity. So we talked about type 2 diabetes having a problem with insulin sensitivity and so we're making insulin, and therefore exercise is beneficial for them both as preventive and as treatment. What about over time? Well, the effects get better over time as we see here with this line going down, the more weeks duration of exercise that is systematic review shows that you get a downward trend and you get a stronger effect more weeks of people who are participating in exercise and reduction of diabetes. So we see that exercise stimulates the uptake of glucose and improves insulin sensitivity, reduces body fat and increases sense of wellbeing. It's one of those things we should be pushing for. I'll know that we need to emphasize and push towards decreasing sedentary activity, especially in type 2 diabetics. And we want to help them and really kind of decrease prolonged sitting, have them get up to light activity every 30 minutes, which can be helpful for diabetes. And these are grade, our normal kind of grades where C is there's good evidence, not super strong, grade A is there's outstanding evidence, because we're aware. And this is all from the Diabetes Care 2016 publication. Physical activity in type 1 diabetes, youth and adults with type 1 diabetes can benefit from being physically active and activity should be recommended to all type of people with type 1 diabetes. Blood glucose response activity in all people with type 1 diabetes are highly variable. So you really need to make an individual plan and adjustment and we'll see that as we go along. So what else do we know? Well, we know that exercise in type 1 diabetics doesn't improve hemoglobin A1Cs as obviously as it does in type 2 diabetics. There's numerous studies where the aerobic exercise does not make a big dent because the problem isn't insulin sensitivity, it's the fact that the type 1 diabetics don't have insulin. So it's more of an adjustment of their insulin to match the exercise. We do note that the studies that do show improvements in hemoglobin A1C type 1 diabetics really seem to add resistance exercise seems to be more effective. We'll talk about that. Major benefit from exercise is reduction in cardiac risk factors and that's why we should be recommending exercise to our type 1 diabetics. So the training effects in type 2 diabetics, you get acute exercise, you get insulin sensitivity, endogenous glucose production and improvement in fasting glucose. With exercise training, we see this over time that insulin sensitivity and endogenous glucose production improvements. And so the longer periods of time, you get more and more effects and stronger duration effects, but you also see effects initially with acute exercise. So a combination of aerobic and resistance exercise training may be more effective in improving blood glucose control than either alone. This is especially effective in the type 2 diabetics. This combination of aerobic and resistance exercise is better than each individual one. Mild forms of exercise, including Tai Chi and yoga, see in our position statement, do have effects and yoga in itself has been shown to have an effect. There are mixed results, but more studies have come out since this 2010 paper showing that yoga can be helpful in diabetes as well. Also in your older type 2 diabetics, so people with type 2 diabetes who want to stay active, yoga can also be helpful for balance. So some exercise physiology. When we're in our light exercise phase at 25% VO2 max, there's a very small portion that comes from the muscle glycogen portion. Whereas as we get into moderate exercise and into severe exercise or vigorous exercise, we see a larger part of a muscle glycogen formation. And so the fuels used during exercise really makes a difference in how you take care of your athletes, whether they are weightlifters, whether they are sprinters, whether they are long distance runners, soccer players, it all depends on where they're going to sit in that realm of vigorous and moderate exercise through their activity. So blood glucose uptake in the muscle occurs in two ways, insulin mediated and contraction mediated. They're two max separately, but additively using GLUT4 and thus active insulin levels affect blood glucose response by exercise by decreasing blood glucose levels more. And so you get this effect of glucose comes through, you get the insulin receptor here, and then it upregulates glucose transport through, and then also GLUT4 comes to the surface with exercise and AKT. And so there is an effect of exercise contraction, muscle contraction, not only insulin receptors. So physical activity increases glucose uptake into muscles, and it's balanced by the liver, which makes glucose production. And so there's this greater reliance on carbohydrate to fuel, and these are important. I think this is what we want to look at as we take a look at our, and we increase our VO2 max, we get into this area of moderate exercise where we start using up more and more of our muscle glycogen, and we have less of our plasma-free fatty acid being used. When we do exercise and do duration of exercise, it's going to make a difference to whether or not we get into the overproduction, and when we use our creatine phosphate and use that system. So sprint athletes really pay forward their glucose usage, and they don't need necessarily that insulin adjustment, and we'll show you that on a table that you can use. So insulin-stimulated blood glucose into skeletal muscle predominates at rest, and it's paired in type 2 diabetics, so people with type 2 diabetes. And while muscle contraction stimulates blood glucose transport via a separative mechanism, it's not impaired by insulin resistance. So GLUT4 is really important for type 2 diabetics, and so muscle contraction, muscle activity is very important to control blood glucose for type 2 diabetics. So physical activity can result in an acute improvement in insulin action, lasting up to two to 72 hours. Why is that important? Because when we're taking care of our athletes and we see that they have fresh first-year person comes to school, and they start doing an activity at a new level, they're going to have this increased insulin action, and so that when they are more likely to develop hypoglycemia, we need to be aware of changes in exercise and activity to match that and note that the hypoglycemia can occur, especially in the overnight period of time, in our athletes who are changing from one to another. So muscle and glucose. Both aerobic and resistance training improve insulin action, blood glucose control, and fat oxidation and storage of muscles, and resistance exercise enhance delta muscles. So the more muscle glycogen, you know, the more muscle, the more muscle glycogen, and you get more stores of glucose removed from the blood, and after exercise, you have more places to deliver that glucose to, and therefore, you know, the muscle acts as a glucose sink, and this is why we think that when we see athletes who do resistance training with type 1 diabetes, they have better chance of lowering the hemoglobin A1c because the muscle acts as a sink. It pulls more muscle, more place for the glucose to come out of the bloodstream and be stored in the muscle itself. How about sprinting and glucose? So short-burst exercises, less than two minutes, they use our ATP and creatine phosphate, and so for a lot of you out there who've heard people talk about using creatine, it's those short-burst activities that it benefits because that's when you're using that phosphate to be pulled off and be redistributed to the cyclic ATP. So you get this feed-forward control, immediate rise in glucose, but increased insulin sensitivity. Longer exercise uses glucose, and normally with exercise, and this is something for you to keep in mind, and it's often one of those questions that's asked is what happens to insulin when a person normally exercises and does a longer activity of an hour, like a soccer match? Their insulin will decrease. So a person without diabetes, their insulin normally will decrease with their activity, and so when you're taking care of someone with type 1 diabetes, you need to match that. Their bolus insulin will decrease, and so therefore, you should match that for them. This year, I always find this an interesting table as it looks at the ATP creatine phosphate, and you can see why people can sprint that 100 and 200, start to fade off in the 400, and people sit in the 400, 800, and then once you get up into the 1500s and above, you get a different type of athlete. So some insulin is needed to moderate the effects of glucose rise in hormones with activity, and so you need some, and so having no insulin can be detrimental in these cases. The other thing to keep in mind when you're taking care of athletes is that some practices happen in the morning, and so cortisol and gorathormone are higher during the morning exercise, and so there's gonna be more insulin resistance. So these period of times, you may find that you have an athlete who practices, I'm gonna continuously say soccer, but soccer in the afternoon, and they're fine, and then they come up in the morning, their insulin numbers are higher. That's because their counter-regulatory hormones are different, and they may need to make adjustments for morning exercise. So hormone release is intensity-dependent, so this is one of those ones where we get to stress. Game time, a little different than practice, and so sometimes glucose numbers can rise with those counter-regulatory hormones during games and intense championships and things like that. So high-adrenaline activity, sports with intense bursts, sprinting of any type, heavy weightlifting, scary activities such as high-end gliding, downhill skiing, intense competition, mental stress. What about endurance? People finishing running a marathon or 10K. Extended exercise results in decreased blood glucose levels if any insulin is on board, and pre-exercise, shorter rapid-acting insulin doses will likely need to be lowered, and so you need to match that, and so it's important that you make an adjustment to the insulin levels when someone is doing these extended endurance exercise activities and that there's monitoring in place. So aerobic versus anaerobic activity, there is a metabolic difference. Blood glucose is easier to maintain during short, intense exercise. Longer-duration activities generally necessitate greater regimen changes and monitoring, and increased muscle mass improves insulin sensitivity overall. So this one's interesting. What you see is that, you know, this is resistance exercise here in the diamonds, and you get this drop, but not nearly as much drop as aerobic, and then you can get a nice level versus fluctuation versus control. So you will see that aerobic exercise will get a drop much more than things like resistance exercise. You'll get a nice, steady, stable after, where you might get fluctuations with your aerobic exercise. What can you do about this? Sometimes people look at, like, what can be done about that, and what happens when we do sprints exercise, so these intermittent, high-intense intermittent exercise, versus, like, a moderate exercise, and what we see is a drop in glucose in moderate exercise, and sometimes a late drop in the glucose levels, whereas those sprints, where people are doing four-second sprints every two minutes, almost like a Tabata-type program, you end up with a drop, but not nearly as much as the moderate aerobic exercise, and then stable post-exercise. So these are the things that you need to be aware of, how exercise affects glucose levels and insulin levels, so that you can prescribe these things better, and understand what different levels of exercise, how they use glucose, so that you can have a better understanding of how to adjust. So now let's talk about exercise in people with diabetes. So pre-exercise clearance is generally unnecessary. Now, this is different than, like, a decade ago. So for asymptomatic individuals to do low or moderate intense physical activity, not exceeding the demands of brisk walking or everyday living. So moderate exercise is a brisk walk with purpose. So we're talking, you know, the four miles per hour kind of walk, which is enough to get us our benefits. So if we're looking at cardiac benefits, a brisk walk is enough to get people cardiac benefit 150 minutes a week with the extension of expected life. So you as a physician, what should you ask? Which questions do you need to be aware of when you're taking care of your patient with diabetes? So does the athlete notice performance changes at different level of glucose? So asking your athletes about that, what are the attitudes, abilities, and willingness of the athlete's teammates and coaches to assist them in diabetes management? This is important because with you're sending somebody out and if they're gonna exercise and they don't have support for people willing to have help with check, you may need to talk to the coaches. You may need to talk to not only the athletic trainer on the team, but the assistant coaches, knowing that this person may need a moment to check their glucose levels to make sure they're fine. And that not panic. A lot of times I see people are panicked. People with diabetes have dealt with it a lot. They're usually very good at managing their glucose levels. And you get a lot of people, coaches, and athletic trainers who are very worried about ending up having somebody with hypoglycemia. So education may be there if the attitudes and abilities and willingness of the athlete's teammates and coaches aren't there. Do the athletes routinely monitor their blood glucose or they use the general gestalt of how their body feels? So this is an important question to ask someone. Do you regularly monitor or do you just use your kind of general feel? If they're using their general feel, they're more likely to fall into a period of hypoglycemia. And so really talk to them and negotiate about when they end up at a new level of activity and are gonna be doing vigorous exercise or is it moderate that this is the period of time that you really wanna start to do some blood glucose check, especially prior to exercise and during exercise. And then how do they notice, how much does it vary with life stresses and mealtimes, changes in training regimens and competitions, et cetera? So the rationale for screening and patients has been historically bet on the risk of acute cardiac event. And they found that for low and moderate exercise, the benefit of exercise outweighs any chance of cardiac risk. So who should get it? Anybody who says they have chest pressure, chest pain, people who wanna go from sedentary to a vigorous program, and vigorous is running. So somebody who wants to run a 10 minute mile or faster, those people need to have a check. And individuals who are increasing from sedentary is more vigorous. I highly recommend that individuals with type 1 diabetes get diabetic retinopathy checks before resistance. So anybody who's gonna Valsalva, anybody who's going to do heavy weightlifting, where they may end up having to Valsalva while they lift, you're not supposed to do, but people do. Getting retinopathy checks and getting a digital dilated retinal examination can be very important and should be done. So training effects, so we said blood training, blood glucose use, and fat use increases, thus less muscle glycogen used after two to three weeks of training. And so you may get a change in your need for insulin as the person gets better and better affected with their training. So as you go from middle school to high school, high school to college, or JV to varsity, these big changes and you're now moving to a new level, you're gonna have an adjustment as they get their training effects over four weeks and they make these adjustments that you're gonna need to be aware that they'll need to make adjustments to their insulin levels as they decrease their blood glucose use. So regular exercise improved blood glucose control, lower insulin doses needed, we talked about this just before. And we talked about morning, so mornings you may need to have more insulin. So you need to monitor and know when they are having troubles with their glucose levels. Stress, so as we do activities like the start of a triathlon, which is a free for all, and there can be a lot of stress involved as you get your head dunked under the water. It's important to be aware of the fact that stressful situations like exams, et cetera, can affect glucose control. I've seen this and I keep this in my presentation, but I personally have not noticed and having taken care of athletes with diabetes, I've not noticed a big difference in the second half of the menstrual cycle in teens and women, but it's there because of testosterone. And so hypoglycemia, moderate aerobic exercises improve blood glucose and insulin action. And so transient hyperglycemia can follow intense physical activity, but you can get a drop in glucose levels for at least 24 hours after exercise. So it's really important to monitor, and I have people who are jumping from one level to the other monitor at night. This is where continuous glucose monitors are quite helpful. And could be useful. So hypoglycemia, shaking, sweating, anxious, dizziness, hunger, fast heartbeat, impaired vision, weakness and fatigue, headache and irritability. What's the difficulty? Most of these things are when you're running really hard and you're fatigued from practice and near exhaustion. Anyhow, these can show up. So there's a little difficulty in being able to differentiate those things. Obviously, the one that I've always found is irritability. And some people are always irritable. Ask my fellows. And then shaking. So those things are ones that really kind of stick out to me. Hypoglycemia is serious, but avoidable condition. So have an emergency action plan and practice it. Get your emergency action plan and practice it. Hypoglycemia can occur during exercise or early after exercise. So seen more often in unchanged insulin dosing and also with sulfonylureas prior to exercise. The other medications really aren't, you know, associated with this hypoglycemia, but SLG2s, they can enhance this with the insulin and sulfonylurea. So they can amplify that. GLPs have a direct connection. And exercise actually can make GLP2s might work better. So GLP, sorry, one, sorry, I said two, work better. So there's some new studies showing that exercise with those can make those more effective. Hypoglycemia and blood glucose is the most immediate risk during and after exercise. You really need to have access to simple carbs and a gluco emergency kit are very important. All your diabetics should have a gluco emergency kit. All your diabetics should have a gluco emergency kit and preferably two, one for their athletic trainer if they're in college or at a high school with an athletic trainer or their coach, if they're not with an athletic trainer and then one for them. And I've had numerous athletes who, you know, end up going out drinking because they're in college and they end up with hypoglycemia. And it's great that they had one there. I had at least one where a roommate gave them glucogon. So it's important that roommates know about it as well. Most common following long duration or repeated bouts of high intensity exercise for delayed onset hypoglycemia caused by a combination of enhanced glucose action and muscle glycogen repletion. As we talked about, can happen delayed, but usually six to 12 hours. So evening exercise, it's the highest risk for hypoglycemia overnight. So evening exercise, highest risk for hypoglycemia overnight. And I say that twice because I saw that on the CAQ recently. So what is one of the interesting things that people are experimenting and figuring out is that a 10 second sprint at the end of an exercise session. So this is a 20 minute exercise session. Then they did a 10 minute sprint. And they saw that the people who did the 10 minute sprint did not get a drop in their glucose levels post exercise versus people who did vigorous 20 minutes of exercise without the 10 minute sprint did have a drop in their glucose levels over the next two hours. Prior hypoglycemia is very dangerous. So the person who has a hypoglycemic episode the day before for the next 24 to 48 hours, they are at risk because they just dumped all their glucagon. They're at risk for another hypoglycemic event. I will sit the people the next day. If they had a serious enough event where they went hypoglycemic and you needed to treat them, I sit them the next day, just like if you had a concussion or some other type of injury so that they can regain their counter-regulatory moments. Always good to have a glucose source with you. One of the ones that I like having is cake frosting. It comes in those nice little squeezy tubes with a little twist. And I'll make glucose ones like that. And you can just put it in their buccal. You can put it in other places, but it's very useful to have the cake frosting. And then right before it goes expired, you can always use it yourself if you like cake frosting. Remove athletes and activate the emergency medical system. And then if they really are unresponsive, make sure you use a glucagon injection. And when they come back around, they still need to go get monitored. Don't just put them back on the field. Just like somebody had a bad allergic reaction and they get angioedema, you give them epinephrine. It's just to get them to the hospital, not to send them on their way. So continuous glucose monitoring during physical activity is important. So what will happen is as someone that starts exercise, they may get a slight rise in their glucose and then they'll get a drop. And you want to monitor it so that you can measure it and see that drop, catch it before you get to the nadir so that you might need to make an adjustment in their glucose levels. You might need to drop back on the bolus insulin, might need to give them some glucose. So that's where continuous monitor can be helpful. And when they look at continuous glucose monitors, they fall in this 99 to 100% fall into zone A, zone B, which means they're highly reliable to finger stick glucoses. And so these are during high intensity exercise and continuous aerobic exercise. This is a lot different than the ones 10 years ago. So things to keep in mind, they might be inaccurate and very cold and high altitude. So like mountain climbing activities, or if you're going up to Wyoming to play football, you may need to switch over to finger sticks. This is a glucose machine, never used one. Go ask your MA or nurse in your clinic to do one and do a finger stick and measure your glucose levels. Because you may have an athlete you're gonna need to do a finger stick with on the sideline. Don't let that be the first time you ever use the glucose monitor. Highly recommend that you go test it out yourself for the first time. Do a finger stick on the sides, on your finger, sorry, on the tip of your finger, and then squeeze a drop onto a pad and you slide the pad into the machine. And it'll give you your measurement. So when you monitor beforehand, if they're below 90, you want to try to delay exercise, give them some glucose, and then start to drop their bolus. If they're in that 90 to 124, ingest 10 grams of glucose. So an apple is eight calories or 20 grams. So just keep in mind, a cheese sandwich on white bread is around 20. Start glycemia at target level. So 126 to 180 is good for aerobic exercise. Once they're above 180, you're gonna start getting dehydration as you probably remember that all glucose gets filtered through the kidneys and then reabsorbed in the kidney. And that's where the SLV2s block that and pee out glucose, which makes you dehydrated. So that's one of the downsides of that product in athletes. And so the important part here is that when you're in that 182 to 270, really need to be aware that these people can run into problems that the athletes may start climbing. So you need to close monitoring. And then above 270, really want to check for ketones and try to restrict, get their levels down. So hyperglycemia can cure from intense exercise. Once you get up above 250 to 270, it depends on who you read. Then you wanna look, you're in a state of insulin deficiency. You wanna check for ketosis. You wanna start to add your insulin to them and get them down into that more favorable range for exercise. If they're over 300, you should use caution and not to have them exercise until they get into better control so that you are very low on your insulin. And then when you exercise, your counter-regulatory hormones are gonna kick in. You can throw somebody over into a ketoacidosis of type one. Hydration is important. So it's very important to keep hydrated because you can get dehydrated easily, especially if you're starting to climb, if a type one, a patient with type one diabetes starts climbing to the 180s, they're gonna have like across urea and they're gonna have the osmotic diuresis. And so therefore they're gonna become more and more dehydrated. So it's very important to stay hydrated. This is important for everybody but very important for type one, type two diabetes, sickle cell trade, all those ones, these medical conditions, very important to stay hydrated. Hyperglycemia increases risk and one to 2% of body fluids already lost when thirsty. So if you wanna be drinking, whether or not you think you're thirsty or not, you wanna make sure the athlete's doing that. You can use your water bottles and think one mouthful is about an ounce of water. And it's very important to keep hydrated throughout activity, especially for athletes with diabetes. So additional carbohydrate intake after exercise can be helpful and important to prevent the hypoglycemia and also to replenish the muscle glycogen stores. So remember it's type one diabetes. Diabetes is not too much sugar. It's too little insulin. So just like athletes that benefit from post-exercise glucose to restore muscle and decrease delayed onset muscle soreness. So your insulin pump needs to make adjustments. So bolus reduction is needed. Ideal for exercise lasting more than 60 to 90 minutes. And so you wanna decrease that bolus, that amount. And so mild aerobic exercise is a small reduction and moderate is a 50% reduction. Heavy aerobic, so vigorous exercise. You know, the difficulty when we look at like soccer, for instance, like you mentioned, is that it's a walk-run sprint. So most of the time you're actually sitting in that walk range. So most people try the 50% like those types of sports versus like cross-country skiing or where you're sitting in that, or biathlon where you're sitting in that 70, 75% VO2 max frequently. Over here where you say not applicable because if they're doing 60 minutes worth of heavy aerobic they're gonna wear out and won't be able to. No reduction for sprint activities. As we talked about, it's a paid forward mechanism. So disconnect bolus. So often athletes can't wear like swimming. We had Michigan people, so Michigan hat there. And so that bolus, the insulin will drop over time. So you have that insulin level and it has a half-life. And so over the next couple of hours that half-life will go down. You may need to reconnect when it's checked and give yourself a little bit more bolus with adjustments. I keep saying you, but patient. And so it's important to, if you're using a disconnect from the bolus as a way of tapering down your insulin to check the glucose levels with the finger stick or the continuous monitoring, so that you know when you might need to add a little more bolus for a little more insulin as you start to climb, if you become too low in insulin. Because you do need some insulin. Structured lifestyle interventions. Remember, as we said, daily activity is very important for diabetes. And so not only is regular aerobic exercise, but resistance exercise in addition. And that's important for your type two diabetics is that aerobic and resistance. So a combination is the best for reducing hemoglobin A1C. And so there, with type two diabetics, different things like step counters and internet delivered mechanisms can be helpful to help target behavior changes. Here's some internet resources for you. Diabetes.org, food and fitness, and then diabetes.co.uk, exercise for diabetics. Both good internet-based ones. Obviously, we're coming out with our position statement, which should be published very soon in the next couple of months. And I highly recommend that as well. As well as Sherry Kohlberg, if you want to read anything by her, including her books, if you're really interested in diabetes and exercise and diabetes, her books are great. And I always love working with Sherry. So what did you learn today? The benefits of exercise for type one and type two diabetics, that type one really is resistance. Type two exercise plus resistance, even better. More muscles sink, the better. More muscles are good for type one diabetics. The effects of exercise at different glucose levels. Sprint exercises don't need much of an adjustment. When you get into those longer durations, you've got to decrease the bolus. Methods to prevent exercise complications. We talked about that having a plan. Having your EAP is very important or just the action plan, very important. And what were the symptoms of hypoglycemia, including shaking, irritability, sweating, you know, blurred vision, all those things. When they start to come on, you need to start checking blood glucose levels and start the treatment of hypoglycemia. I like the cake frosting too. Those tiny small ones, very useful. And I gave you your websites and good luck. Question.

2nd Edition, CASE 34

2nd Edition

Metabolic Disorders

diabetes

exercise

type 1 diabetes

type 2 diabetes

hypoglycemia

insulin sensitivity

glucose monitoring

lifestyle interventions