Situations and Solutions

Case Study: Avoidance of Hypoglycemia with Exercise. A 32-year-old male with Type 1 diabetes approached the diabetes educator with a complaint of increased exhaustion, excess sweating and feeling shaky on the days he worked out at his exercise facility. During the assessment and interview, the educator asked the following questions. Listed below each question is the rationale and information the educator hoped to gain.

QUESTION 1. Have you tested your blood glucose when you get these feelings, and if so, was it low?

Q1 reasoning: His symptoms very well could be reflective of hypoglycemia. This question is attempting to either establish or rule this out.

QUESTION 2. How long after your workout do these symptoms occur?

Q2 reasoning: He may not associate the symptoms as being related to exercise if they occur hours later. However, the educator knows that exercise can increase insulin sensitivity for up to 36 hours after the session.

QUESTION 3. What symptoms do you usually get when your blood glucose is low and what is your usual treatment?

Q3 reasoning: Again, this is to confirm that the symptoms he is experiencing are related to his usual symptoms with hypoglycemia. If they are different, it may be that he experiences different symptoms depending on how low his blood glucose is, and this would be good information for him to have. Also, the educator needs to make sure that his treatment of hypoglycemia is adequate.

QUESTION 4. What time of day do you go to the health club?

Q4 reasoning: It is important to know if his exercise session is at the same time every day.

QUESTION 5. What type of exercise do you do and for how long?

Q5 reasoning: The intensity and duration of exercise affect the utilization of glucose and may determine the necessary precautions that need to be taken.

QUESTION 6. When is your last meal or snack before exercising?

Q6 reasoning: The timing of the meal or snack in relation to the timing of the workout is important in determining what preventative action to take. It may be that he could just decrease his meal bolus if the meal is close to the time of exercise, for example. Also, if he takes a large bolus close to the time of exercise, the educator knows that high blood insulin levels block the release of glucose from glycogen stores and also the release of free fatty acids from fat stores.

QUESTION 7. Do you adjust your bolus or basal rate for exercise?

Q7 reasoning: Again, this is important for determining what preventative action to take. If he is already decreasing his basal rate, he may need to decrease it further, or start the decrease earlier, and/or maintain the decrease for a longer period.

QUESTION 8. What are your basal rates throughout the day?

Q8 reasoning: It might help to know if his basal rate at the time of exercise is actually increasing or decreasing. It is common for rates to be higher between dinner and bedtime, when many people do exercise. In that case, the temporary reduction may need to be greater than if the basal rate stays the same.

QUESTION 9. Where do you put your infusion sets?

Q9 reasoning: If an infusion set is located in a limb that will be exercised rather than in an area like the abdomen or hip, the insulin absorption and action will be increased with the exercise. This is important to keep in mind.

QUESTION 10. How often do you test your blood glucose?

Q10 reasoning: It may be that he was already hypoglycemic before starting the exercise or is not testing enough to be aware of blood glucose trends.

QUESTION 11. How do you determine your bolus doses?

Q11 reasoning: The educator needs to know if he is doing carbohydrate counting or fixed insulin doses, etc, in order to help him make adjustments.

QUESTION 12. Do you eat or drink anything during your workout?

Q12 reasoning: This information is important to take into account when deciding on preventive recommendations.

Assessment

Based on the responses to each of the above questions, the educator can come up with an assessment and plan. The right plan will have to be based upon trial and error, and close monitoring and record keeping by the patient.

Some of the possible recommendations the educator could make include:

Alternative 1: Decrease the pre-meal bolus, even in half, if exercise is within an hour or so of the previous meal.

Alternative 2: Leave the basal rate as is, but have him eat, for example, 30 grams of carbohydrate for every 30 minutes of intense exercise.

Alternative 3: Reduce the basal rate by 20-50% or more beginning 30 minutes to an hour before exercise begins and continue the decrease for 2 times the duration of the workout.

Alternative 4: Omit the pre-meal bolus if the meal is within an hour of the time of exercise.

Alternative 5: Make sure his infusion set is in his abdomen on the days he exercises.

Alternative 6: Ask him to monitor his blood glucose to obtain a baseline before exercise begins and then frequently during and after.

The educator should also provide him with general recommendations for safe exercise such as keeping hydrated, wearing good fitting shoes, etc. The bottom line is to individualize recommendations based on a comprehensive assessment!