EXTOD Healthcare Professionals South Conference

EXTOD Healthcare Professionals South Conference
Face-to-face
Engineers’ House, Bristol
Fri 6 Sep 2024 08:30-17:20


EXTOD Healthcare Professionals South Conference is delivered by EXTOD and organised by SBK Events. 


This unique forum is created to equip Diabetologists, Diabetes Specialist Nurses, Dietitians and Paediatricians with the knowledge, inspiration and practical understanding to support your type 1 patients to undertake safe and effective exercise.


Choose between this one-day condensed forum taking place in Bristol on Friday 6th September or the National, two-day full conference taking place in Edinburgh on Tuesday 26th and Wednesday 27th November


Please click on the EXTOD courses tab for details of further courses available.

Featuring evidence-based presentations, case study led workshops and invaluable lived experience

Attending this EXTOD day will provide you with current, evidence-based knowledge on managing Type 1 diabetes for exercise. You will also be able to speak with experts in the field and leave with practical advice and clear strategies to use with your patients with T1D in a clinical setting.

A unique opportunity for sharing ideas, networking and peer learning

If you have limited time and EXTOD South is geographically closer to you, then this condensed forum will be able to offer you excellent targeted content in one day.

Featuring case study led presentations on:

  • The challenges someone with Type 1 diabetes faces when exercising
  • The elite female athlete
  • Exercise setting for each pump / closed loop system and how to use these settings for exercise

Plus discussion driven workshops on:

  • Assessment and starting advice for exercise
  • Basic insulin changes to improve glucose control around exercise
  • Special circumstances: Low carb diets, hot and cold weather adaptations
  • Getting the most out of a continuous glucose monitor when exercising
  • Using dietary intake to improve glucose control around exercise
  • Using exercise to control glucose around exercise
  • Managing race /event day: what to do prior, on the day and postrace management
  • Dealing with multisports and how to plan changes

Invitation to sponsor

This interactive event is a great opportunity for providers of diabetes technology and treatments to support healthcare professionals. To find out more about all the engagement and branding opportunities available in the full sponsorship package, please email Sarah Kemm or call Sarah on 01732 897788.

Supported by JDRF and the Diabetes Research and Wellness Foundation

SBK Healthcare would like to thank JDRF and DRWF for supporting this educational conference.


          


8:30
Registration and refreshments
9:00
Welcome
Parth Narendran, Diabetes Research Unit and the Type 1 Diabetes Clinical Service Lead, University of Birmingham and The Queen Elizabeth Hospital
9:10
The challenges someone with Type 1 diabetes faces when exercising
  • Effect of different physiology
  • Variability of glucose response to exercise
  • Effect of insulin levels
  • Physiological changes post exercise
  • Effect of diabetes complications
Dr Matt Cocks, Exercise Physiology Lecturer, Liverpool John Moores University and Dr Katie Hesketh, Exercise Physiologist, University of Birmingham will discuss the following therapies: exercise, diet, finger and continuous glucose monitors, insulin, insulin pumps and closed loop systems
9:50
The elite female athlete
Elite female athletes will explain the problems they have with exercise and the solutions they have come up with
10:30
Networking break
10:50
Workshops 1a – 1e
These workshops will be run twice in the morning.
Choose your first morning workshop from the following:
1a - Assessment and starting advice for exercise
  • Key medical questions to ask
  • What to look out for on examination
  • Contraindications to exercise
  • Starting advice
Parth Narendran, Diabetes Research Unit and the Type 1 Diabetes Clinical Service Lead, University of Birmingham and The Queen Elizabeth Hospital and Barbara Hudson, Clinical Nurse Specialist in Diabetes, University Hospital Birmingham NHS Foundation Trust will discuss the following therapies: history taking, complications, injections sites, insulins, glucose monitors, glucose targets
1b - Basic insulin changes to improve glucose control around exercise
  • Simple advice for making insulin changes before and after exercise
Claire Foster, Diabetes Dietitian and Giorgio Carrieri, Lead Nurse, Children's Diabetes Team, Somerset NHS Foundation Trust will cover: insulin, insulin pumps and closed loop systems.
*Recommended for first time attendees*
  • 1a - Assessment and starting advice for exercise
  • 1b - Basic insulin changes to improve glucose control around exercise
If this is your first time attending EXTOD day then we would suggest picking the above workshops as these will give you a good grounding.
1c - Special circumstances
  • Low carb diets, hot and cold weather adaptations
Rob Andrews, Associate Professor, University of Exeter and Honorary Consultant Physician, University of Exeter and Manyee li, Specialist Diabetes Dietitian, Queen Elizabeth Hospital will discuss the following therapies: exercise, diet, insulin (all modalities), glucose monitoring
1d - Dealing with multisports
  • How to plan changes in someone doing a variety of sports across the week
Anne-Marie Frohock, Lead Paediatric Diabetes Dietitian, Oxford University Hospitals NHS Foundation Trust and Francesca Annan, Lead Paediatric Diabetes Dietitian, Alder Hey Children's NHS Foundation Trust will discuss the following therapies: diet and insulin (MDI, Pumps) and close loop system
1e - Getting the most out of a continuous glucose monitor when exercising
  • Pros and cons of CGMs for exercise
  • Glucose targets before, during and after exercise
  • Carb calculators for carb intake for different exercises
John Pemberton, Diabetes Dietitian, Birmingham Women's and Children's Hospital NHS Foundation Trust and Alistair Lumb, Consultant in Diabetes and Acute General Medicine, OCDEM, Oxford University Hospitals NHS Foundation Trust will cover all types of continuous glucose monitors
11:45
Workshops 1a – 1e
Choose your second morning workshop from the following:
1a - Assessment and starting advice for exercise
1b - Basic insulin changes to improve glucose control around exercise
1c - Special circumstances
1d - Dealing with multisports
1e - Getting the most out of a continuous glucose monitor when exercising
12:35
Lunch and networking break
1:30
Exercise setting for each pump / closed loop system and how to use these settings for exercise
In groups attendees will be introduced to each Pump / closed loop system and be talked through features for exercise and how to use. At the end you will receive a summary sheet of the pros and cons of each system and recommendations for which system might suit different people
2:45
Workshops 2a-2e
These workshops will be run twice in the afternoon.
Choose your first afternoon workshop from the following:
2a - Using dietary intake to improve glucose control around exercise
  • Overall dietary needs
  • Food and fluid for exercise
  • Carbohydrate loading
Claire Foster, Diabetes Dietitian, Somerset NHS Foundation Trust and Manyee li, Specialist Diabetes Dietitian, Queen Elizabeth Hospital
2b - Using exercise to control glucose around exercise
  • Role of warm up and warm downs
  • Sprints and ease off to control glucose
Parth Narendran, Diabetes Research Unit and the Type 1 Diabetes Clinical Service Lead, University of Birmingham and The Queen Elizabeth Hospital and Barbara Hudson, Clinical Nurse Specialist in Diabetes, University Hospital Birmingham NHS Foundation Trust
*Recommended for first time attendees*
  • 2a - Using dietary intake to improve glucose control around exercise
  • 2b - Using exercise to control glucose around exercise
If this is your first time attending EXTOD day then we would suggest picking the above workshops as these will give you a good grounding
2c - Managing race /event day
  • What to do in week before event
  • Preventing high glucose on the day
  • Race planning and postrace management
Rob Andrews, Associate Professor, University of Exeter and Honorary Consultant Physician, University of Exeter and Giorgio Carrieri, Lead Nurse, Children's Diabetes Team, Somerset NHS Foundation Trust will discuss the following therapies: psychological approaches, exercise (training), diet, Insulin (all modalities), glucose
2d - Dealing with multisports
  • How to plan changes in someone doing a variety of sports across the week
Anne-Marie Frohock, Lead Paediatric Diabetes Dietitian, Oxford University Hospitals NHS Foundation Trust and Francesca Annan, Lead Paediatric Diabetes Dietitian, Alder Hey Children's NHS Foundation Trust will discuss the following therapies: diet and insulin (MDI, Pumps) and close loop system
2e - Getting the most out of a continuous glucose monitor when exercising
  • Pros and cons of CGMs for exercise
  • Glucose targets before, during and after exercise
  • Carb calculators for carb intake for different exercises
John Pemberton, Diabetes Dietitian, Birmingham Women's and Children's Hospital NHS Foundation Trust and Alistair Lumb, Consultant in Diabetes and Acute General Medicine, OCDEM, Oxford University Hospitals NHS Foundation Trust will discuss all types of continuous glucose monitors
3:35
Networking break
3:50
Workshops 2a – 2e
Choose your second afternoon workshop from the following:
2a - Using dietary intake to improve glucose control around exercise
2b - Using exercise to control glucose around exercise
2c - Managing race /event day
2d - Dealing with multisports
2e - Getting the most out of a continuous glucose monitor when exercising
4:40
Pulling it all together
  • Summary of all that has been learnt on the day into simple rules of three
Rob Andrews, Associate Professor, University of Exeter and Honorary Consultant Physician, University of Exeter will discuss the following therapies: exercise, diet, finger and continuous glucose monitors, insulin, insulin pumps and closed loop systems
5:20
Close of day

EXTOD faculty

The content is evidence based and delivered by members of the EXTOD faculty and additional speakers who are all experts in T1D and exercise, including:

Professor Rob Andrews

Associate Professor, University of Exeter and Honorary Consultant Physician
University of Exeter

Professor Parth Narendran

Diabetes Research Unit and the Type 1 Diabetes Clinical Service Lead
University of Birmingham and The Queen Elizabeth Hospital

Giorgio Carrieri

Lead Nurse, Children's Diabetes Team
Somerset NHS Foundation Trust

Dr Matt Cocks

Exercise Physiology Lecturer
Liverpool John Moores University

Claire Foster

Diabetes Dietitian
Somerset NHS Foundation Trust

Anne Marie Frohock

Lead Paediatric Diabetes Dietitian
Oxford University Hospitals NHS Foundation Trust

Dr Alistair Lumb

Consultant in Diabetes and Acute General Medicine
OCDEM, Oxford University Hospitals NHS Foundation Trust

Barbara Hudson

Clinical Nurse Specialist in Diabetes
University Hospital Birmingham NHS Foundation Trust

Manyee Li

Specialist Diabetes Dietitian
Queen Elizabeth Hospital

Dr Katie Hesketh

Exercise Physiologist
University of Birmingham

Mr John Pemberton

Diabetes Dietitian
Birmingham Women's and Children's Hospital NHS Foundation Trust

Francesca Annan

Lead Paediatric Diabetes Dietitian
Alder Hey Children's NHS Foundation Trust

Expected attendees

Join us in 2024 to benefit from this unique and engaging learning environment which will illustrate the practicalities with case study presentations and interactive scenarios of managing exercise in individuals living with diabetes. This special conference is created for, and has been attended in the past by:

  • Diabetologists
  • Diabetes Specialist Nurses
  • Dietitians
  • Paediatricians
  • Sports Physicians
  • Diabetes Specialist Registrars in training

Past attendee feedback

EXTOD National Conference has taken place since 2017, providing attendees with knowledge, inspiration, and a practical understanding of how to support their Type 1 patients to undertake safe and effective exercise. Over 1,200 people have benefited from this unique education to-date, and here are just a few quotes from their experience at the 2023 conference held in Oxford:

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“Great conference, really useful general tips with useful overview of latest research and inspirational speakers. Really appreciated the signposting to available resources”
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“Really good content and informative. Good mix of lecture and workshop”
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“I loved the workshops as opportunities to practice what we had learnt in the lectures. These were great and well run”
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“Excellent content, found it really interesting and have learnt so much”
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“Excellent sessions, a lot packed in and learnt a lot and very inspired by the speakers!!”
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“Speakers were inspiring, extremely knowledgeable and great at sharing their enthusiasm and learning”
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“An excellent meeting. My understanding and management of issues around exercise has improved”
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“Great presentations and workshops. Speakers were happy to answer questions, interact with participants”
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Pricing structure

  • £195+VAT - one day full price for consultants and registrars
  • £135+VAT - one day full price for nurses and dietitians

On making your booking, you will be contacted by our Customer Service Team to select your workshops, choosing two options from 1a-1e and two options from 2a-2e. The workshops have a limited number places and are available on a first come, first served basis.

Commercial companies are invited to sponsor this day please email Sarah Kemm for further details.

Venue details

Venue name: Engineers’ House, Bristol
Address:  The Promenade, Clifton Down, Clifton, Avon, BS8 3NB
Tel: 0117 906 4800

Engineers’ House is a Grade II listed conference venue in Clifton Down, a prestigious suburb of Bristol. This high quality, high tech, prestigious venue offers ample free parking, 175 spaces across 2 car parks, and beautiful outside spaces.

Set just outside of Bristol`s Clean Air Charge Zone, Engineers' House is in the perfect location. It's easy to reach from Temple Meads Train Station, Bristol City Circular Bus Service, and has excellent links to the M5 and M4.


DirectionsClick here to plan your journey using Google Maps

Accommodation suggestions

You can book your bedroom directly with the hotel using the above contact details (SBK Events do not facilitate accommodation bookings). The venue is centrally located and there are a number of alternative places to stay. Availability for alternative accommodation can be identified by searching online, for example www.trivago.co.uk or www.uk.hotels.com and inputting the address and date of your visit.

What happens after you make your booking?

Once you have booked your place, SBK Events will correspond with you using the email address you provided at the time of booking and you will be sent a formal confirmation. If you have not received this within 48 hours of making your booking please check your junk folder and then email bookings@sbk-events.co.uk or call 01732 897788.

Approximately one week prior to the conference you will be sent an email which will include all the final details for attendance on the day, including a final agenda and venue information. 

Please inform us by writing to bookings@sbk-events.co.uk if you have any special dietary or other requirements.

Terms and Conditions

Registration fees
You will be sent an instant payment option or invoice on registration. Your payment is required in advance. If your fee has not been received prior to the event, and you are not able to provide a PO or proof of payment, you will be asked to make a credit or debit card payment on the day.
 
Modify registration
To let us know if your details are not correct when you have already registered, please email bookings@sbk-events.co.uk.
 
Cancellations and substitutions
A full refund of fees will be made only for cancellations received within the first 48 hours of the booking being made. Notice of cancellation must be received in writing by emailing the bookings team at SBK Events. Should you need to cancel your registration after this date, the registration fee remains payable in its entirety although a substitution will be accepted and conference documentation will be provided. Substitution attendees for delegates unable to attend after registering are acceptable at any time.
 
Conference changes
It may be necessary for reasons beyond the control of the conference organisers to alter the content, speakers or the timing of the programme. We will endeavour to keep you abreast of such changes but any unavoidable change to the format will not constitute a reason to refund the fee. Should the event be postponed, we will endeavour to reschedule the event. If, for reasons beyond the control of the conference organiser, the event is cancelled, a full refund will be made. We do not accept any liability for any incurred costs resulting from a postponement or cancellation.
 
Certificate of attendance
A certificate for Continuing Professional Development will be given to every attendee, as a record of continuing professional training and development.
 
Privacy notices
To view the details on how your data is being collected and used, please view our Privacy policy.

Upcoming events

These events are delivered by EXTOD, organised by SBK Events with full details available to view on the Diabetes National Networking Forums website.


EXTOD Sports Coach & PE Teacher Online Training – half day
Thursday 26th September 2024, Engineers’ House, Bristol
This half day online course will arm physical education teachers, or coaches with the tools and techniques required to help children or young people in their care to manage glucose around exercise.

EXTOD Healthcare Professionals South Conference
Friday 6th September 2024, Engineers’ House, Bristol
This new, one day forum is created to equip Diabetologists, Diabetes Specialist Nurses, Dietitians and Paediatricians with the knowledge, inspiration, and practical understanding to support T1D patients who exercise.

EXTOD Adults with Type 1 Diabetes Conference
Saturday 7th September, Engineers’ House, Bristol
Providing interactive tools, clinical cases, shared learning and problem/solution-based tasks, this training day will support adults with diabetes who find exercise challenging.


EXTOD Healthcare Professionals National Conference
Tuesday 26th and Wednesday 27th November 2024, Radisson Blu Hotel, Edinburgh
Featuring evidence-based presentations, case study led workshops and invaluable lived experience of diabetes and exercise.


Why sponsor?

Our role at SBK Events is to bring industry together with healthcare professionals so that you can educate and inform your audience. These trail-blazing diabetes delivery forums offer dedicated presentations, Q&A, networking and discussion time, each sponsor will be fully immersed into the event and able to effectively engage with your NHS audience.

Interested in having your own event, managed by us?

SBK Events also provides in-house forums. Working closely with you as the client we can research, produce, market and deliver the conference or online forum that best suits the audience and meets your goals.

Reach out today

If you would like more information on our sponsorship options an in-house forum or if you wish to discuss your needs and what solutions may be appropriate for your business, please contact:
Sarah Kemm
Contact: 01732 897788
Email: sarah.kemm@sbk-events.co.uk

Supported by JDRF and the Diabetes Research and Wellness Foundation

SBK Healthcare would like to thank JDRF and DRWF for their support.



DRWF was established in 1998 to raise awareness of all types of diabetes and associated complications. We provide information and support to enhance good self-management, whilst funding vital research to establish the causes, prevention and treatments of Type 1 and Type 2 Diabetes to facilitate diabetes management. We aim to ensure that they are "staying well until a cure is found..."


        


JDRF, the leading global type 1 diabetes charity, works every day to help people live better with the condition, prevent people ever developing it and one day, find cures.



Regular physical activity (PA) plays a key role in the management of Type 1 diabetes mellitus (T1D).

This has been known for years as on the Joslin Victory Medal it is one of the three horses that controls Type 1 diabetes, the other being Insulin and diet.


 
Figure 1: Joslin Victory medal for living with T1DM
    
Figure 2 summaries what is known about the benefits of exercise in people with T1D . The known benefits include

  •     improved insulin sensitivity
  •     improved well-being
  •     reduction in lipids
  •     reduction in microvascular complications
  •     reduced mortality

For further information see What are the health benefits of physical activity in type 1 diabetes mellitus? A literature review

Figure 2: Summary of health benefits of regular exercise in Type 1 diabetes.


Although there is as yet not conclusive evidence that regular exercise helps to preserve beta cell function there is some evidence to support this

 In mice susceptible to diabetes (NOD mouse) regular exercise prevents the development of diabetes. See Exercise Training but not Curcumin Supplementation Decreases Immune Cell Infiltration in the Pancreatic Islets of a Genetically Susceptible Model of Type 1 Diabetes

 The Type 1 diabetes honeymoon period is more than five times longer in men undertaking high levels of physical exercise, compared with age‐, sex‐ and BMI‐matched sedentary controls. See The Type 1 diabetes ‘honeymoon’ period is five times longer in men who exercise: a case–control study
In a pilot RCT of newly diagnosed patients with Type 1 diabetes there is some suggestion that exercise preserves beta cell function. See Exercise to preserve β‐cell function in recent‐onset Type 1 diabetes mellitus (EXTOD) – a randomized controlled pilot trial

Note that improvement in HbA1c is not listed as one of the benefits of exercise. A meta-analysis of studies carried out in 2013 by us did not demonstrate an improvement in HbA1c with regular exercise in adults and children with Type 1 diabetes. For more information about this see Does exercise improve glycaemic control in type 1 diabetes? A systematic review and meta-analysis

One reason for this could be that advice given to people with Type 1 diabetes around how to control glucose around exercise is not very good.

Recommended Levels of activity for people with Type 1 diabetes and barriers to exercise

Based on this evidence guidelines recommend that adults with Type 1 diabetes undertake at least 150 min per week of moderate to vigorous aerobic exercise, spread out over at least 3 days, with no more than two consecutive days between bouts of aerobic activity (see Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association and Physical activity levels of people with Type 1 diabetes.

Over 70% of people with Type 1 diabetes do not meet these recommendations and thus are not getting the full benefits they could do from exercise. (See Physical activity levels of people with Type 1 diabetes to learn more about recommended levels of activity for people with Type 1 diabetes and current activity levels of people with Type 1 diabetes.)

Reported barriers to exercise in those with Type 1 diabetes include fear of hypoglycaemia, competing work commitments, loss of control over diabetes, low fitness levels, cost, lack of social support, and lack of knowledge. Greater knowledge about insulin pharmacokinetics and using appropriate approaches to minimise exercise‐induced hypoglycaemia or hyperglycaemia are factors associated with fewer perceived barriers to exercise (see Barriers to exercise in people with Type 1 diabetes to learn more about barriers in Type 1 diabetes).This suggests that the provision of knowledge and skills is essential if we are to support people with Type 1 diabetes to become more active and enable them to exercise safely at the level they wish to.

Other parts of the website should help you to arm your patients with knowledge to overcome these barriers.

Articles linked to this article

Physical activity levels of people with Type 1 diabetes

Barriers to exercise in people with Type 1 diabetes.

Assessment of the patient

People with Type 1 diabetes tend to have four main problems when exercising these are;

  •     problems controlling their blood glucose during and immediately following exercise
  •     unexplained severe hypoglycaemia particularly at night
  •     reduced performance due to excessive fatigue and reduced muscle strength.
  •     difficulties gain or losing weight

It is important that a detailed history and examination is undertaken to deal with these issues.


Key things in History and examination

Current approaches to managing T1DM

  •     Patients need to check their glucose regularly when exercising
  •     Patients who carbohydrate count and use carb/insulin ratios have more options to manage their exercise.
  •     High blood glucoses – make it difficult to build up muscle mass and glycogen stores post exercise so ideally HbA1c should be a good as possible.

Insulin regime

  •     It is difficult to manage patients who are performing regular exercise on premixed twice-daily regimes without incurring the risk of exercise-induced hypoglycaemia.
  •     Fast-acting insulin analogues (Insulin aspart (Novo Nordisk), lispro (Eli Lilly) or glulisine (Sanofi-Aventis)) have a shorter window of action than human, pork or beef insulin which can be helpful if exercising around meal times.
  •     The longer duration of action of the long-acting basal insulins whilst helpful in routine clinical care, can result in higher insulin concentrations during exercise and an increased risk for hypoglycaemia during endurance exercise and less flexibility in reducing dose post exercise
  •     In one clinical study NPH insulin (insulatard (Novo Nordisk), Humulin I (Eli Lilly)) and determir (Novo Nordisk) had lower risk of hypoglycaemia with exercise than glargine (sanofi-aventis)(see Plasma glucose and hypoglycaemia following exercise in people with Type 1 diabetes: a comparison of three basal insulins.)
  •     In another study glargine had similar rate of hypoglycaemia after exercise as Degludec (Novo Nordisk). (see Similar risk of exercise‐related hypoglycaemia for insulin degludec to that for insulin glargine in patients with type 1 diabetes: a randomized cross‐over trial).
  •     No studies to data have looked at Insulin glargine u300 (Toujeo – Sanofi-aventis) or Abasaglar (Biosimilar Glargine – lilly) and exercise in Type 1 diabetes.
  •     Changes to insulin rates and background rates during and post exercise can be different to those on MDI regimes (see Pumps and exercise).


Insulin injection techniques

  •     The aim to reduce day-to-day variation in insulin absorption and to avoid accelerated absorption of insulin when exercising.
  •     Injection sites should be checked to ensure there is no lipohypertropy.
  •     Injection techniques should be checked to ensure that air shots are being given. If the patient is on NPH insulin resuspension should be carried out correctly.
  •     Needle sizes should also be checked - 4 or 5mm needles are to be recommended.
  •     Patients should also be educated to avoid injecting into areas that will be used in planned exercise (eg. thighs before cycling) because the increased blood flow will increase insulin absorption.


Diabetes complications

  •     For most people with T1DM any activity can be undertaken and risk is minimal if people start at a low intensity of activity and gradually build up the intensity.
  •     Some diabetes complications restrict what people with T1DM, others suggest that further investigations should be done before exercise is started (see Exercise and microvascular complications and Exercise and macrovascular complications).
  •     Feet will need to be examined to look for: ulceration, deformity and evidence of neuropathy.
  •     Eye report/photos should be looked at so assess whether the patient has retinopathy if so what level.


Review of calorie intake


  •     Ensuring adequate fuel and fluid replacements is one of the most important components in ensuring safe and effective training in people with Type 1 diabetes.
  •     A common cause of hypoglycaemia and of fatigue during and following exercise is simply one of insufficient calorie intake.
  •     For these reason, all patients should have their dietary intake assessed if doing more than 1 hour a day of moderate intensity exercise. Ideal this should be done by a dietician.


A detailed history of exercise program



History of performance in training and competition

  •     The approach to glucose management (for example the starting blood glucose) may need to be different in training and competitive events (seeBlood glucose and exercise for adults with T1D).
  •     Exploring performance in these two settings will enable the optimal approach to be designed for each of these settings


Articles linked to this article

Exercise and microvascular complications

Exercise and macrovascular complications

Fuel and fluid for exercise

Types of exercise and their effects on blood glucose

Blood glucose and exercise for adults with T1D

Carbohydrates for exercise for people on multiple daily injections


Carbohydrate for exercise for people on insulin pumps

In simple terms there are three ways that glucose can be managed during exercise. The easy way to remember these is through the mnemonic ‘ICE’.

I Insulin adjustment

C Carbohydrate for exercise

E Exercise - changing type or intensity


Insulin adjustment for exercise

The liver is main source for carbohydrate that is used when exercising. When insulin levels are high, the liver is prevented from releasing glucose (see glucose control during exercise). High insulin levels during exercise could therefore lead to a mismatch between the glucose produced by the liver and that used by the muscles. This will result in a fall in circulating blood glucose falling during exercise.

Ideally patients should exercise with as little insulin around as possible. Changes can be made to the quick-acting (bolus) or the background (basal) insulin to help with this. What changes are made to insulin will depend on the type, intensity and length of the exercise and on what time of day the exercise is carried out.


Carbohydrate for exercise

The two main fuels used during exercise are fats and carbohydrates (in the form of glucose). People with Type 1 Diabetes burn fat normally during exercise; it is only the production of carbohydrate that they have problems with.
The exercise carbohydrate value of an exercise is the amount of carbohydrate that is used during an exercise. The higher the exercise’s intensity, the more carbohydrate is burned per minute see figure 1 below.

The amount of carbohydrate needed will also depend on the age, sex, weight and fitness of the person performing the exercise.

When using carbohydrates for exercise, the aim is to take all the carbohydrate needed to perform the particular exercise so that the glucose remains stable across the exercise.

To find out more, go to Carbohydrates for exercise for people on multiple daily injections.

   
Exercise adjustment for exercise

Different exercise regimes have different effects on blood glucose concentration (see Types of exercise and their effects on blood glucose). This knowledge can be used to help control glucose during exercise. Changing the order in which exercise is done or adding a different type of exercise can help with glucose control during exercise.

To find out more about this go to exercise adjustments for exercise.


Summary

Each of these strategies has its pros and cons. The table below is a summary of the pros and cons. This may be helpful in deciding which strategy you choose to recommend first to your patients

Strategy

Pros

Cons

Insulin adjustment for exercise

Reduces hypoglycaemia during and following exercise, reduces carbohydrate requirement

Needs planning. Not helpful for spontaneous exercise.

Changing bolus insulin dose is not helpful if exercising 2 hours outside the bolus.

Carbohydrate for exercise

Useful for unplanned exercise

May not be possible with some exercises. Not helpful where weight control

important. May over-replace so blood glucose goes too high.

Exercise adjustment for exercise

Useful for unplanned exercise

May not be possible with some exercises. May not always have desired effect, lowering glucose or raising glucose more than needed.

Definition of exercise

Physical activity is defined as any bodily movement produced by skeletal muscles that results in energy expenditure. Physical activity in daily life can be categorized into occupational, sports, conditioning, household, or other activities. Exercise is a subset of physical activity that is planned, structured, and repetitive and has as a final or an intermediate objective the improvement or maintenance of physical fitness.

Exercise is performed for various reasons, to aid growth and improve strength, preventing aging, developing muscles and the cardiovascular system, honing athletic skills, weight loss or maintenance, improving health and also for enjoyment. For more details on the health benefits of exercise for people with Type 1 diabetes.

Guidelines recommend that adults with Type 1 diabetes undertake at least 150 min per week of moderate to vigorous aerobic exercise, spread out over at least 3 days, with no more than two consecutive days between bouts of aerobic activity. In addition, muscle-strengthening activities that involve all major muscle groups should be performed on two or more days per week. For more information on recommended levels of activity for people with Type 1 diabetes see Physical activity levels of people with Type 1 diabetes section of this website

Being able to define what type of exercise what type of exercise a patient does is key to understanding what will happen to their blood glucose when they perform that exercise. This will also help you to work out how much energy the patient will burn during that exercise and any changes you may need to suggest to their insulin regimen and eating patterns when performing that exercise.

The Pyramid of fitness

In simple terms, to improve at any type of exercise you need to work on four areas (see figure 1).

Figure 1 - the pyramid of fitness


How much someone needs to work on each of these will depend on what exercise they are doing.

Defining a patient’s exercise

Defining exactly what a patients does should form part of the initial assessment of a patient (see Initial medical assessment of patient with Type 1 diabetes in relation to exercise part of this website.

To give good tailored advice to a patient you will need to know determine three things:

  1. What type of activity the patient is doing (click here to learn more about this)
  2. How intense the activity is (click here to learn more about this)
  3. How long the activity will last for (click here to learn more about this)

Once you have learned this you are ready to start to give advice on how your patient can manage glucose around exercise (see Encouraging patients to exercise and starting advice section of this website).

How much someone needs to work on each of these will depend on what exercise they are doing.


Defining a patient’s exercise

Defining exactly what a patients does should form part of the initial assessment of a patient (see Initial medical assessment of patient with Type 1 diabetes in relation to exercise part of this website.

To give good tailored advice to a patient you will need to know determine three things:

  1. What type of activity the patient is doing (click here to learn more about this)
  2. How intense the activity is (click here to learn more about this)
  3. How long the activity will last for (click here to learn more about this)

Once you have learned this you are ready to start to give advice on how your patient can manage glucose around exercise (see Encouraging patients to exercise and starting advice section of this website).

Defining a patient’s exercise

Defining exactly what a patients does should form part of the initial assessment of a patient (see Initial medical assessment of patient with Type 1 diabetes in relation to exercise part of this website.

To give good tailored advice to a patient you will need to know determine three things:

  1. What type of activity the patient is doing (click here to learn more about this)
  2. How intense the activity is (click here to learn more about this)
  3. How long the activity will last for (click here to learn more about this)

Once you have learned this you are ready to start to give advice on how your patient can manage glucose around exercise (see Encouraging patients to exercise and starting advice).

Recommended levels of activity

Shown below is the recommended levels of activity for adult, children and pregnant women with Type 1 diabetes.

Adults
  • At least 150 min/week of moderate intensity or 75 min/ week of vigorous intensity, aerobic, physical activity. This should be spread over three days with no more than two consecutive days without exercise.
  • In addition, muscle-strengthening activities that involve all major muscle groups should be performed on two or more days per week.
  • A reduction in sedentary time is also recommended. Prolonged sitting should be interrupted every 30 minutes
  • Flexibility training and balance training are recommended 2–3 times/week for older adults with diabetes. Yoga and Tai Chi may be included based on individual preferences to increase flexibility, muscular strength, and balance

Children

  • Children and adolescents with type 1 or type 2 diabetes or pre-diabetes should engage in 60 min/day or more of moderate or vigorous intensity aerobic activity with vigorous muscle-strengthening and bone-strengthening activities at least 3 days/week.
Pregnancy
  • At least 30 mins of moderate exercise daily if there are no medical or obstetric complications.


How active are people with Type 1 DM

Most studies of physical activity (PA) levels in adults with Type 1 diabetes have been based on self-reported data rather than objective data. They all suggest that people with Type 1 diabetes are not very active.

Self-reported studies

Objectively measured PA

The reasons for the reduced level of physical activity could be due to that additional barriers that people with Type 1 diabetes have to physical activity.


Patients with Type 1 diabetes have many barriers to exercise that are similar to the general populations such as

  • Lack of time
  • Work pressures
  • Bad weather
  • Cost
  • Lack of motivation

But there are certain barriers that are specific to them, see table below.

Table showing barriers to physical activity in patients with Type 1 diabetes.

New onset Type 1 diabetesEstablished Type 1 diabetes
  • Hypoglycaemia (both actual and fear of)
  • Lack of knowledge/confidence in managing diabetes
  • Advice from healthcare professionals to stop exercising
  • Planning (e.g. checking blood glucose)
  • Feeling overwhelmed by diagnosis.
  • Loss of control of diabetes
  • Lack of knowledge on the management of diabetes for exercise

To be able to increase activity these barriers will have to be overcome.

For more information on this subject see

  1. Brazeau A.S et al paper (Barriers to Physical Activity Among Patients With Type 1 Diabetes. Diabetes Care. 2008;31(11):2108-9).
  2. Dubé MC et al paper (Development and validation of a new scale. Diabetes Research and Clinical Practice. 2006;72(1):20-7).
  3. Lascar N et al paper (Attitudes and Barriers to Exercise in Adults with Type 1 Diabetes (T1DM) and How Best to Address Them: A Qualitative Study).
  4. Kennedy A et al paper (Attitudes and barriers to exercise in adults with a recent diagnosis of type 1 diabetes: a qualitative study of participants in the Exercise for Type 1 Diabetes (EXTOD) study).