Coping with excercise on a pump (and the tale of the Horrible Hypo...)

[Gary_W]

Hi folks,

My 'plumbing in day' cannot come soon enough. I'm sick of this at the moment.

I'm keeping fairly stable through the days as long as I don't do any physical activity at all. I work from home, drive places, talk to people, go home, work some more, watch TV / use the PC / play guitar and go to bed. An excercise junkie I am not. As soon as I do anything, I drop like a stone even if I throttle back the bolus insulin. Activities are not planned ahead well enough to alter the Lantus, so I'm hoping the reduced basals and 'suspend' will help.

An example for you. BG of 7.2 (130) before dinner (not great). I had just plated up, so I injected and gave an extra unit to cater for being above target range. Health food tonight; sausages, baked beans, sauted potatoes. A fresh orange afterwards. And a small piece of cheesecake :o All carbs counted. Please note I normally eat a little better than this, so don't shoot me... Now, had I not gone out, I'd have been fine and (baring miscalcualtions) be in range at 2-3 hours after the meal.

It was nice outside. That doesn't happen in England much. We have 3 great parks fairly locally. I decided I'd take my two daughters for a gentle walk around our closest park. We got there about an hour after I'd eaten. As bed-time was approaching, I decided to drive to the park so we'd get maximum time there; we had an hour absolute tops. I took a couple of cartons of OJ and had glucose tablets with me. Man alive did I need them.

All I did was gentle walking. That was it. Within 15 minutes, I started shaking. Tested and I was 2.9 (52). First carton of OJ goes down (23g of carbs). I had to keep walking a little to keep the little ones quiet (try explaining to a 22 month old that you're hypoglycemic). I felt worse. Tested again 10 mins after the first test. 1.7 (31!!!). At this point I downed the other OJ and took 5 glucose tabs (a total of 38g of carbs). I called my wife on the mobile who drove to the park in a hurry. I made it back to the car and was starting to feel better (I'd reached the lofty heights of 2.6 (47). It took me another 20 mins and a further 100mls of OJ to get to a 4.4 (80). I am so glad I managed to keep it together enough to look after the kids, but I'm obviously a little shaken by the incident; it's ridiculous that such a minor amount of excercise should drop me so badly.

The whole hypo lasted 45 minutes and consumed 70g of carbs! Total distance walked was maybe a mile.

For dinner, I'd injected 10u. I ate over 100g of carbs (a lot of them fairly fast ones too). My ratio in the evening is 1:11 at present (though it does vary) and the extra unit was because I started a little high. I cannot for the life of me see why I needed an extra 70g of carbs. I've just tested, and 5 hours after the incident I'm 7.6 (137) so I did need at least 60g of those carbs...

Anyway, when I am pumped up, how do I avoid this? If I'm going out for a walk after a meal, would a combo bolus do it to slow the old Apidra down or should I just plain not inject so much (which I could obviously do now). And this basal reduction thing; how soon before exercise do you do it, and by how much? Any other thoughts gratefully received. I currently feel like someone rather brutal has been shaking my head. 1.7 is the second lowest I've ever tested. I had a hypo that felt worse than this one last year, but didn't test on that one so no idea what my lucky number was.

I took them to a different park on last Saturday morning and needed 400ml of OJ to finish the walk... I figured on that day it was basal due to less stress at the weekends etc, but today kind of proved that wrong...

I am putting an awful lot of hope in my pump. I know it isn't a magic bullet, but I like to believe I have a reasonable understanding of diabetes these days and when the rules get thrown out of the window it really cheeses me off... I just hope it can reduce incidents like this both in number and severity. I am not asking to run marathons, all I want to do is go outside with my children. I don't think that's much to ask :(

Gary

[morrisma]

Gary,
Close call and a darn good thing you had all the supplies you did. The only thing I can think is that you were headed down pre-dinner at a fairly high rate. Any idea what you were sometime prior to the before dinner test?
Glad you recovered.
Mike

[BlueSky]

.... For dinner, I'd injected 10u. ....
Thats your problem. You injected a lot of insulin and you exercised afterwards. Exercise does two things. It accelerates absorption, which makes BG drop quickly. And it increases insulin sensitivity, which is why you needed so much more carbo to cover the insulin. The same thing will happen with the pump, but you will be able to reduce you basal rate. Next time, have a glass of dry white wine instead of the orange juice ;) .

[SueM]

Sausages baked beans and the spuds would take forever and a day to kick in for me. So perhaps that was your problem plus far to much insulin for the exercise.
Have you got the book pumping insulin?
Have a good read of that it gives a lot of good advice.

[Gary_W]

Thanks for these, folks :)

Mike - I'm almost certain that I wasn't; my basals are typically OK in the late afternoons (or this month they are anyway....) and it was about 5 hours since the previous meal and Apidra shot. For this reason, there was nothing to be putting me down and I certainly didn't feel myself drifting that way before dinner.

BlueSky - 10u is what I would normally take to cover that kind of meal; these saute potatoes are on the menu at home every couple of weeks and normally get in fairly quickly. I can accept that excercise increases the rate and could cause a hypo. What I find hard to accept is the extreme of hypo I had and the fact that the excercise (such as it was) was walking around a small lake / pond in the park. Had I rowed across the thing I'd feel a bit better. It's the frustration that such minimal effort caused it.

Sue - Those potates do normally absorb quite quickly, and baked beans normally go in like lightning with me and spike me (all other pulses are pretty slow, but the old Heinz 57 buck that trend quite nicely). The amount of extra carbs needed would have required 5u of insulin to cover had I sat at home as opposed to going for a walk. As I didn't spike that badly later, I just wonder where all those carbs from the evening meal went?

I have got 'pumping insulin' and I've been dipping into it for a month or so now. I always like to get the opinions of others on here as well, as I know from my own experiences that the books are fantastic starting places but user experience is always a huge bonus to go with the text; everyone here is very helpful and it's great to get the alternative viewpoints.

Gary

[Eddy]

BlueSky - 10u is what I would normally take to cover that kind of meal


Interestingly, your basal is much lower than your bolus. When you exercise with no bolus, that teeny bit of Lantus isn't amplified much. When you exercise with that 10U bolus, look out!

1.7 definitely is getting too low for comfort. Glad you were okay.

FWIW:

During my first post-DX exposure to cold, I'd begun a walk w/ BG of 113. I consumed a 12-oz. can of Sprite (worth 100 mg/dL if I don't exercise), then began walking. That should have held me stable for about 30-45 minutes in "normal" weather.

Only 15 minutes and 3-4 block later (had stopped to pet a neighborhood kitty), I felt not right. Stopped, tested... 28. Chug sugar... 24.

I was stuck between remaining in the cold -- the apparent culprit -- or walking to get out. "Do you think I could give you a crash course on how to inject this [glucagon] and you'd be able if I passed out, or should I do it myself now just in case?"

The punchline: I had no bolus in me. Seemingly-little things can make a _big_ difference.

(FWIW, I got out of that okay without shooting glucagon. A warm car ride back to the indoors worked a treat. Now that I'm using Levemir instead of Lantus, I'll tinker with basals this next winter.)

Oh, and taking a warm shower speeds up R to the point where it's nearly as fast as rapid.

[MarieD]

With the pump you'll be able to reduce your basal by a selected percentage when you are doing any sort of exercise. I've had my pump since January and am not the sort of person who does lots of exercise but now we've had some reasonable weather I've been out in the garden so have been trying out the reduced basal funtion. About 1 hour before gardening I set the reduced basal rate, then this reduced amount continues for three hours. After the three hours the alarm goes off to say that the reduced period has come to an end. If needed then you can reduce it again for another three hours and so on...
It will take some time to work out how much you will need to reduce your basal by for different types of exercise. I've been gradually changing mine -started with 80% basal but ended up hypo and now down to 50% when gardening.
What pump will you be using?

[Gary_W]

Hi Marie,

Thanks for the reply. The pump is an Animas 2020. I've got a loaner here with me but I'm not plumbed in for another couple of weeks. What are you using?

It has 4 different basal programs on there plus it also does the temporary % adjustment that you are mentioning. Not sure if it alarms at the end of this, as I haven't tried this particular feature yet. I am certainly looking forward to this reduction feature as it should help in a lot of cases. I think the hypo I had yesterday would have happened no matter what the basal; it was definately an Apidra overload.

It looks like my ratios have changed AGAIN. I've been fighting off a hypo since dinner again tonight and I've done very little physically. Could also be a bit of basal drift as well; guess it's time for more testing :( Excercise last night plus yet more body changes make for not a very happy experience...

Gary

[BlueSky]

.... BlueSky - 10u is what I would normally take to cover that kind of meal; .... What I find hard to accept is the extreme of hypo I had and the fact that the excercise (such as it was) was walking around a small lake / pond in the park. ... The amount of extra carbs needed would have required 5u of insulin to cover had I sat at home as opposed to going for a walk. As I didn't spike that badly later, I just wonder where all those carbs from the evening meal went? ....
Don't underestimate the effect of a large dose of insulin before exercise. Aligning the insulin action peak with the blood glucose spike is hard enough because of variability in absorption and insulin action. But it doesn't stop there. Injecting that much insulin stops the burning of fat dead in its tracks. It means that virtually all the calories that fuel exercise have to come from the carbs you have just eaten. That, together with the increased insulin sensitivity, is why BG drops much more quickly than one might expect. It is also why injecting/eating before going to the gym is counter-productive if you are trying to lose weight ;) .

If you consumed an extra 50 grams of carbs, that is only 200 calories. The activity doesn't have to be strenuous to use that up. I have to be really careful about avoiding lows when I do the shopping, which is normally after supper. The bottom line is that there are various uncontrollable variables here - insulin absorption, insulin action, insulin sensitivity, degree of lipolysis etc. And it looks like a number of them conspired against you at the same time.:eek:

[Gary_W]

Don't underestimate the effect of a large dose of insulin before exercise. Aligning the insulin action peak with the blood glucose spike is hard enough because of variability in absorption and insulin action. But it doesn't stop there. Injecting that much insulin stops the burning of fat dead in its tracks. It means that virtually all the calories that fuel exercise have to come from the carbs you have just eaten. That, together with the increased insulin sensitivity, is why BG drops much more quickly than one might expect. It is also why injecting/eating before going to the gym is counter-productive if you are trying to lose weight ;) .

If you consumed an extra 50 grams of carbs, that is only 200 calories. The activity doesn't have to be strenuous to use that up. I have to be really careful about avoiding lows when I do the shopping, which is normally after supper. The bottom line is that there are various uncontrollable variables here - insulin absorption, insulin action, insulin sensitivity, degree of lipolysis etc. And it looks like a number of them conspired against you at the same time.:eek:


Hi BlueSky,

Those extra calories were the last thing on my mind :) It just shocked me quite how much fuel seemed to vanish in a puff of smoke. I'm going to throttle back the bolus ratios a little, as tonight has surprised me a little without any excersise so yes, I think it was a whole bunch of events getting together to spoil my day... The old body is definately thinking it's great fun to keep me on my toes at the moment...

Gary

[thomasb]

I also read, and experienced that the more, eh out of shape you are, the easier exercise affect the bg. It did for me.

And a good thing i get from the pump is that when i drop, it goes much slower then on MDI. I have time to feel that i'm going low.

[MarieD]

I'm using the accu-check spirit. So far so good :)
Rather than just setting the temporary basal rate if you are excersing not very long after a meal it's probably best to slightly alter your carb:insluin ratio - then you're covered both ways :)

[Eddy]

I also read, and experienced that the more, eh out of shape you are, the easier exercise affect the bg. It did for me.


I can believe that...

More motivation to get back in shape. :)

[Gary_W]

I also read, and experienced that the more, eh out of shape you are, the easier exercise affect the bg. It did for me.

And a good thing i get from the pump is that when i drop, it goes much slower then on MDI. I have time to feel that i'm going low.

Undoubtedly true. These days, my weight / BMI are marginally over target; if I lose about another 5lbs I'll be spot on. However, I am certainly not very fit. What I will say is that weekend walks with the kids normally drop me hence I always take supplies. What got me here was the seriousness and sheer ferocity of the drop. It took no prisoners!

Gary