Diabetes Talking

Question:

I was a discus thrower for the NC STATE track team and in Martial arts. i workout all the time. If your son gets high during exercise it’s because the liver& muscles release glycogen for energy at the start. If there’s enough insulin on board the level will come down as physical activity continues, if not levels may rise. Ketones may be present. Also even if ketones do not show it does’nt mean they are not there. It takes a while for them to pass through the urine. If ketones are below medium the danger is very low. Your son just may need a few drops of insulin during the game.  It’s fine to take extra with dinner to adjust just be aware of post-exercise hypoglycemia. Whatever you do don’t let your son give up. There are many succesful pro athletes with type 1.

Response:

My son is Type I, NPH/R; 11 years old..  Lately after a real tough/long soccer game/practice his BG’s are soaring to high 200’s to even low 300’s.  I conveyed my concerns to his nurse practioner and she told us not to worry, that it was the body’s way of increasing needed energy for the the exertion required as well as the increased endorphins in his system.  As long as he is not showing a trend we should check ketones and carry on.  I’m still a little concerned because usually after these games we have a meal which has the potential of putting him even higher (he will use an extra unit or two of humalog in these circumstances) and I feel we are putting him in a bad situation.   Any comments, suggestions?

In addition to my comments in the FAQ, I would caution you to be very careful with humalog and exercise.  Exercise induced insulin efficiency increases last for some time after exercise and the extremely sharp peak of humalog can cause unexpected postprandial hypoglycemia in this circumstance.  Be cautious and sneak up on the increased dosages with increased postprandial testing. — Charly Coughran

Response:

To Bill…… Thanks for all your help.  You’re right, I’ll have to read it once or twice, sleep on it and read it again! We’ve only been doing this a year and I feel like there is so much out there to keep up with. Ben is a wonderfully responsible kid but would much rather be playing soccer than anything else (can’t imagine why – oh to be 11!) so I feel like I need to find and show him all the alternatives available.  When we go to his Doc (endo also) we usually have an armful of questions and ideas to discuss.  The care team is really great but you are right, they don’t remember or even have the time to educate you on every alternative.  We must do our own research and decide what will work for us and then approach the health care team with our ideas.  We are fortunate in that this team is very open and responsive to whatever works for us.  I just wasn’t happy with the answer I got  about his BG’s simply because I KNOW that high BG’s no matter how frequent or infrequent signal a problem. This NG is priceless because of people like you – thanks! Joanne Mom of Ben –  TypeI

Response:

read the exercise section of the faq (by charly coughran).  sleep on it and then read it again. Where do I find that?  Sorry – still kinda new =)

the www version of the FAQ and other documents via the URL    http://www.faqs.org/faqs/diabetes/ other sources are    http://www.cis.ohio-state.edu/hypertext/faq/usenet/diabetes/top.html    ftp://rtfm.mit.edu/pub/faqs/diabetes/ the exercise section is in part 1.  but i suggest you get all 5 parts as it is the single most useful document i’ve come across. Q: why do you have your young son using Humalog? We actually started using it sometime last summer (he’s just been diagnosed a year now) because we were looking for more flexibility for visits to friends houses, eating at odd times and sports (at odd times).  He was able to go to a 2pm birthday party and not feel "wierd" as he put it.  Why?

hmmm, giving an appropriate answer to this is NOT going to be easy, so please bear with me and you might even read this post a second time after you’ve slept on it. the bottom line for me is that i now use regular insulin as my preferred meal insulin.  i once used Humalog %100 in my pump for 10 months.  but i now only use it for 1) quick b/g corrections (maybe 2 or three times/week) and 2) for evening meals.  for breakfast and lunch i use regular insulin.  and before exercise, i’ll sometimes take 1 or 2 units of regular insulin, but never Humalog before exercising. btw, if my b/g is a bit high before a meal, i’ll eat the protein and fat part of the meal and carry some of the carb food to be eaten an hour later.  or if my a.m. b/g is really high, i’ll carry the carb foods and eat less food for that day.  i’ll also take a bit of extra insulin if my b/g is high, but only 1 or 2 extra units. (my current daily total insulin is about 28 units). so if i were going to a 2pm birthday party, i’d probably take a shot of Humalog to cover the food there.  :) being a t1 diabetic is an exercise in not being normal. perhaps the t2’s (on meds or on insulin) would say the same? but they generally don’t have to micro-manage the b/g like t1’s have to. at best, a well controlled t1 can have a half normal life and live a full and complication free life. either the proper use of mdi -or- the proper use of a pump give a t1 at least some reason to smile.  :)   and when i got my pump 8 years ago, it was a revelation.  i went from nothing normal to half normal overnight. i recently tried mdi for the first time ever (for about 3 weeks) and was very favorably impressed.  i HATE having this pump attached to myself all the time. best summary statement defining diabetes & self-management, is this:     [ comes from the Joint Task Force into the implementation      ]     [ of the St Vincent Declaration ( British diabetic Association ]     [ and UK Department of Health)                                 ]  "Diabetes (Type 1 *OR* Type 2) is a chronic disease carrying the risk   of multiple, disabling, yet potentially preventable complications…"  "There is probably *NO* other disease in which the patient can   contribute *MORE* to the success of management nor one in which   there is such a fine line between invalidity and a life of   effective normality…" Speaking strictly for myself, my medical team is presently myself and my Doctor (an Endo).  My Doc, excellent as he is, is presently no more than 49% of my medical team.  *I* am presently 51% of the team [ my Doc would probably say that it's more like 70%  <g ] so is there is punch line to all this?   yes, there is indeed.  my current doc in enamored with Humalog.   so if i were to go by his input, i’d still be using Humalog. because your son is young, he’ll be tremendously influenced by the commercial advertising, and what others in his peer group think, etc etc etc.  it is critically important to you and him that *YOU* keep in mind that your doc and other specialists think/recommend won’t necessarily be either the best answer, and especially not a complete set of alternatives. but when it comes to ideas, mhd is the best place on planet earth.  the data isn’t "dumbed down."  the trick is to figure out what has merit and what doesn’t. so am i saying don’t use Humalog?  no.  i’m saying that this is something that primarily both you and your son will need to figure out. Q: what is his insulin regimen?  i.e. which insulin(s) and what are the   total units and the individual shot totals? Currently he takes 5R and 11N before breakfast and 5R and 5N before supper.  If his BG is over 300 he takes a unit of humalog.  On Friday and Saturday nights (or any night before a day off)  he splits his doses (R at supper and N around 10pm) so he can sleep a little later in the morning.

if your son doesn’t have a rising b/g before arising, you might want to consider going to Lilly’s Humulin UL as the background insulin.  using NPH tends to result in more hypos.  there are frequent posts here on this subject.  and of course, you’d want to discuss this option with your doc. Q: is your son using a pump?  or mdi?  if mdi, pen or syringe? He’s using a syringe.  He just got a couple of pens to try but he’s been reluctant (don’t really know why but haven’t pushed him) to use them.  He’s been seriously thinking about a pump and may do a trial weekend this summer to see if he likes it.  We are still in the "gathering of info" stage of the pump decision, although most people I’ve "spoken" with think it’s the best thing they’ve ever done. Thanks for your help. Joanne Mom of Ben, Type I

there’s a stiff learning curve with using a pump.  plus the extra expense. my own recent 3 weeks of doing mdi really opened my eyes.  if i didn’t already have my pump, i’d have to have terrific insurance coverage or i’d just not bother with it.  otoh, many pumpers will be quick to tell you that’s it’s worth every penny, even if you have to pay for it yourself. iow, no easy answer on this one. best wishes,  bill  t1 40y pumper 8y

Response:

To Bill – read the exercise section of the faq (by charly coughran).  sleep on it and then read it again.

Where do I find that?  Sorry – still kinda new =) Q: why do you have your young son using Humalog?

We actually started using it sometime last summer (he’s just been diagnosed a year now) because we were looking for more flexibility for visits to friends houses, eating at odd times and sports (at odd times).  He was able to go to a 2pm birthday party and not feel "wierd" as he put it.  Why? Q: what is his insulin regimen?  i.e. which insulin(s) and what are the   total units and the individual shot totals?

Currently he takes 5R and 11N before breakfast and 5R and 5N before supper.  If his BG is over 300 he takes a unit of humalog.  On Friday and Saturday nights (or any night before a day off)  he splits his doses (R at supper and N around 10pm) so he can sleep a little later in the morning. Q: is your son using a pump?  or mdi?  if mdi, pen or syringe?

He’s using a syringe.  He just got a couple of pens to try but he’s been reluctant (don’t really know why but haven’t pushed him) to use them.  He’s been seriously thinking about a pump and may do a trial weekend this summer to see if he likes it.  We are still in the "gathering of info" stage of the pump decision, although most people I’ve "spoken" with think it’s the best thing they’ve ever done. Thanks for your help. Joanne Mom of Ben, Type I

Response:

Thank you Mark for your excellent insight and information.  I am very grateful for your response and will most definately take it to our next visit. He usually does do an extra unit or two of humalog when he gets home and prepares for dinner but it looks like it may be more beneficial to do this right after practice. Thanks again. =) Joanne Stroud Mom of Ben, Type I (N,R & Humalog)

Response:

My son is Type I, NPH/R; 11 years old..  Lately after a real tough/long soccer game/practice his BG’s are soaring to high 200’s to even low 300’s.

This problem involves the interaction of insulin and exercise, and is apparently not well understood in the health community, in spite of published research articles on the subject. I experience this myself after intense exercise if I do not increase my insulin level appropriately during that time, and disagree with your health provider that this is not a problem as long as your son is not producing ketones. That sure is a lousy way to run a railroad (or manage diabetes!). The problem is, I think, best understood if you ask a question about normal exercise physiology (in non-diabetics): what happens to blood glucose and blood insulin levels after intense exercise in non-diabetics? As you can see from the two articles given below, insulin levels increase dramatically while glucose levels increase moderately. Now ask the question, how much would those glucose levels increase if the insulin levels did NOT increase normally? The answer is obvious: they would increase dramatically, just as you have seen in your son, and in the diabetic subjects in the following articles. And that is not good, for all sorts of reasons (more details later if you would like). The solution (to shorten up a very long story)? Take some fast-acting insulin immediately after the exercise. This may sound rather strange, but not if you consider where his BGs are running during this time – over 300. This insulin helps the body recover from the exercise in many ways, such as restoring the glycogen that was burned up during the exercise. This get subject gets very detailed and I can provide more information if you would like. In the mean time, you might take these two references to your health provider/doctor as this problem is not unique to your son. Mark Haberman Title: Hyperglycemia after intense exercise in IDDM subjects during      continuous subcutaneous insulin infusion. Authors: Mitchell-T-H.  Abraham-G.  Schiffrin-A.  Leiter-L-A.      Marliss-E-B. Journal: Diabetes-Care.  1988 Apr.  11(4).  P 311-7. Abstract:  Exercise is conventionally considered a modality for      improvement of glycemia in diabetes. We have found that a      short period of intense exercise (80% VO2max) in normal lean      subjects produces sustained postexercise hyperglycemia 20%      above basal with a corresponding 100% increase in plasma      insulin. In people with insulin-dependent diabetes mellitus      (IDDM) incapable of this insulin response, it was predicted      that postexercise hyperglycemia would be of greater magnitude      and/or duration. To investigate this possibility, the effects      of the same intense exercise (80% VO2max) were studied in 8      IDDM subjects (2 on 2 occasions) in the postabsorptive state      with continuous subcutaneous (abdominal) insulin infusion      (CSII). When the preexercise plasma glucose was normal (n = 6,      86 +/- 4 mg/dl), there ensued a postexercise hyperglycemia to      127 +/- 7 mg/dl (P less than .001) sustained for 2 h      postexhaustion. Plasma free immunoreactive insulin (IRI) was      1.43 +/- 0.12 ng/ml before exercise and did not change      postexercise. When mean preexercise plasma glucose was 149 +/-      9 mg/dl (n = 4), it rose progressively throughout the 2 h of      recovery to 229 +/- 28 mg/dl (P less than .025). A small but      statistically significant decrease in free IRI occurred during      the last 80 min of recovery. Hyperglycemia in the diabetic      subjects was not explained by abnormal or differing responses      of glucagon or catecholamines. Thus, with intense exercise,      diabetic control deteriorates rather than improves. Therefore,      different therapeutic strategies may be required for intense      compared with moderate exercise in IDDM patients. Title: Hyperinsulinemia prevents prolonged hyperglycemia after      intense exercise in insulin-dependent diabetic subjects. Authors: Sigal-R-J.  Purdon-C.  Fisher-S-J.  Halter-J-B.  Vranic-M.      Marliss-E-B. Journal:  J-Clin-Endocrinol-Metab.  1994 Oct.  79(4).  P 1049-57. Abstract: Hyperglycemia with accompanying hyperinsulinemia occurs after      brief, greater than 85% maximum oxygen consumption exercise to      exhaustion in normal subjects and persists up to 60 min of      recovery. To determine the importance of endogenous insulin      secretion during and after intense exercise, responses to      exercise of lean fit male post-absorptive insulin-dependent      diabetes mellitus (IDDM) subjects, aged 18-34 yr, were      compared with those of control subjects (C; n = 6). Three iv      insulin protocols were employed: hyperglycemic (HG; n = 7) and      euglycemic (EG1; n = 6) with constant insulin infusion, and      euglycemic with doubled insulin infusion during recovery (EG2;      n = 6). Overnight iv insulin was adjusted to achieve prolonged      euglycemia (5.4 +/- 0.3 mmol/L) or hyperglycemia (8.6 +/- 0.3      mmol/L) before exercise. This allowed for comparisons between      HG and EG1 (constant infusion) and between C and EG2 (to      approximate physiological hyperinsulinemia by doubling the      infusion rates at exhaustion for 56 +/- 7 min during      recovery). Subjects exercised to 89-98% of their individual      maximum oxygen consumption for 12.8 +/- 0.3 min. Glycemia      increased to maximum values at 6 min of recovery (9.8 +/- 0.5      in HG, 6.9 +/- 0.4 in EG1, 7.3 +/- 0.3 in EG2, and 6.9 +/- 0.4      mmol/L in C). Whereas in EG2 and C, glucose returned to      resting values in 50-80 min, it remained elevated at 120 min      recovery in HG and EG1. During exercise,      [3-3H]-glucose-determined glucose production increased      markedly and exceeded disappearance in all groups, but less so      in the HG subjects than in the other groups. An early recovery      decline in glucose production did not differ among groups, but      MCR (rate of glucose disappearance/glycemia) were markedly      lower in HG and EG1, in whom plasma free insulin remained      unchanged from 15 min of recovery onward (MCR, 1.6-1.9 vs.      2.3-2.8 mL/kg.min in C). Doubling the insulin infusion rate in      EG2 restored the MCR response to that of C subjects. In      summary, constant insulin infusion is insufficient to prevent      prolonged postexercise hyperglycemia in IDDM subjects, even      when provided at a rate sufficient to maintain normal resting      glycemia and glucose turnover. The finding that increasing the      rate of insulin infusion restored plasma glucose to normal in      IDDM subjects suggests that the postexercise increase in      insulin levels observed in normal subjects is essential to      return plasma glucose to resting levels. Therefore, special      strategies, differing from those for less strenuous exercise,      are required for the management of insulin therapy in IDDM      during and after intense exercise.

Response:

What is his bg level before the game? If it’s high beforehand and he exercises it will increase automatically He always checks before the game and it’s fine, he will also check halfway into practice or at halftime and usually a snack is in order.  His snack is usually 2 orange quarters and some watered down gatorade, he will also try to drink water as much as possible.  What’s wierd is that this has been his routine until the last couple of weeks when we noticed the highs.  He hasn’t changed his snack……could the body all of a sudden decide that oranges and gatorade aren’t working??  Then what ?  He’s a very physical player and usually plays the entire game (may sit out for 5 min break each half) so I’m confused as to what’s happening.

to jksmt, read the exercise section of the faq (by charly coughran).  sleep on it and then read it again. Q: why do you have your young son using Humalog? Q: what is his insulin regimen?  i.e. which insulin(s) and what are the    total units and the individual shot totals? Q: is your son using a pump?  or mdi?  if mdi, pen or syringe? cheers,  bill  t1  40y  pumper 8y ps- ted is also a pumper.

]My son is Type I, NPH/R; 11 years old..  Lately after a real tough/long soccer ]game/practice his BG’s are soaring to high 200’s to even low 300’s.  I conveyed ]my concerns to his nurse practioner and she told us not to worry, that it was ]the body’s way of increasing needed energy for the the exertion required as ]well as the increased endorphins in his system.  As long as he is not showing a ]trend we should check ketones and carry on.  I’m still a little concerned ]because usually after these games we have a meal which has the potential of ]putting him even higher (he will use an extra unit or two of humalog in these ]circumstances) and I feel we are putting him in a bad situation.   Any ]comments, suggestions? ] ]What is his bg level before the game? If it’s high beforehand and he exercises ]it will increase automatically. Problem there is that he doesn’t have enough ]background (actually basal) insulin to get the glucose out of the bloodstream ]into his cells. i think ted only has this partly correct.  the fact that the son’s b/g rises does in fact indicate that the plasma insulin level is not quite high enough to cover basal requirements.  if it were adequately high, then the b/g would drop, even if the b/g were 300 when the exercise started.  however, things get a lot more confusing after one has competed for more than an hour. btw, this is my own experience.  i don’t like starting exercise when my b/g is 300.  the times that i’ve done this, i’ve made absolutely sure that my insulin level was at least high enough to cover my basal AND NO MORE because once exercise starts you become MORE EFFICIENT with the insulin that is in your blood!! ]I’d suggest testing him sometime before a game and give him a small shot to ]correct a high in time for it to be in effect, which is minimal with Humalog, ]but at least 15 to 30 minutes beforehand to give it a chance to bring down ]the high.  He may also need a small snack to support the activity. ]Ted Quick using Humalog before exercise may not be such a good idea.  far better to one of the slightly slower regular insulins.  the Humalog is mighty peaky. again, read the exercise part of the faq.  the possible problem is that when Humalog is most active (varies from one person to the next), the drop in b/g is very, very quick. also, a soccer game lasts how long?  i remember seeing posts by some diabetics that Humalog is "gone within 2 hours."  how long is a shot of Humalog last for your son?

Response:

What is his bg level before the game? If it’s high beforehand and he exercises it will increase automatically

He always checks before the game and it’s fine, he will also check halfway into practice or at halftime and usually a snack is in order.  His snack is usually 2 orange quarters and some watered down gatorade, he will also try to drink water as much as possible.  What’s wierd is that this has been his routine until the last couple of weeks when we noticed the highs.  He hasn’t changed his snack……could the body all of a sudden decide that oranges and gatorade aren’t working??  Then what ?  He’s a very physical player and usually plays the entire game (may sit out for 5 min break each half) so I’m confused as to what’s happening.

Response:

My son is Type I, NPH/R; 11 years old..  Lately after a real tough/long soccer game/practice his BG’s are soaring to high 200’s to even low 300’s.  I conveyed my concerns to his nurse practioner and she told us not to worry, that it was the body’s way of increasing needed energy for the the exertion required as well as the increased endorphins in his system.  As long as he is not showing a trend we should check ketones and carry on.  I’m still a little concerned because usually after these games we have a meal which has the potential of putting him even higher (he will use an extra unit or two of humalog in these circumstances) and I feel we are putting him in a bad situation.   Any comments, suggestions?

What is his bg level before the game? If it’s high beforehand and he exercises it will increase automatically. Problem there is that he doesn’t have enough background (actually basal) insulin to get the glucose out of the bloodstream into his cells. I’d suggest testing him sometime before a game and give him a small shot to correct a high in time for it to be in effect, which is minimal with Humalog, but at least 15 to 30 minutes beforehand to give it a chance to bring down the high. He may also need a small snack to support the activity. Ted Quick

Response:

My son is Type I, NPH/R; 11 years old..  Lately after a real tough/long soccer game/practice his BG’s are soaring to high 200’s to even low 300’s.  I conveyed my concerns to his nurse practioner and she told us not to worry, that it was the body’s way of increasing needed energy for the the exertion required as well as the increased endorphins in his system.  As long as he is not showing a trend we should check ketones and carry on.  I’m still a little concerned because usually after these games we have a meal which has the potential of putting him even higher (he will use an extra unit or two of humalog in these circumstances) and I feel we are putting him in a bad situation.   Any comments, suggestions?

Response: