Hello, everybody, and welcome to today's hands-on tips to improve diabetes care webinar. Today our panel will share with you their expertise on in motion through ages, tracing the legacy and application of exercise in diabetes care. And we're glad you are here. Hi, I'm Michael See, and I'll be moderating today's webinar. Just to share something about myself, I'm a clinical exercise physiologist, diabetes care and education specialist, and board-certified health coach in the Boston area. And I'm chair of the ADA Physical Activity Special Interest Group. We'll be spending the next hour together by following the agenda on the screen. We'll be using interactive features during today's session. We'll send you important links and information throughout today's session in the chat box. We'll also have quiz questions throughout the presentation hosted on Zoom. When you see a quiz question pop up on your screen, take a moment to respond by clicking on the answer you think is correct. We'll be using Zoom Q&A to end the presentation for panel questions. If you think of a question as our presenters are speaking, use the Q&A box on your control panel to type in your question. Join us on September 10th, 2024 for our next installation on hands-on webinar series, addressing social and behavioral factors in diabetes care in rural populations. I hope you have a good one because Liz Beverly is a former colleague of mine and she's an exceptional speaker. Now I'd like to introduce our panels for today's webinar, and they are equally exceptional. So grateful for the opportunity to introduce you to our panel today. Dr. Michael Riddell is a professor in the School of Kinesiology and Health Sciences faculty at York University. His research interests center on the effect of exercise and stress on diabetes and metabolism. His lab works on development of new strategies and therapies for people living with diabetes to exercise more effectively and with better glycemic control. He has both preclinical and clinical studies of diabetes exercise, hypoglycemia, and hyperglycemia. In one project, he is determining new therapies, ZT01 Zutara therapeutics that targets the pancreatic alpha cells and can help blood glucose from falling too low after individuals with diabetes take their insulin up or exercise. In another study set off at Centricity Research, he is testing new glucose sensors and other technologies that help people with type 1 and type 2 diabetes exercise with better glucose management. In addition, as if Michael is not enough, we are grateful that Dr. Jane Yardley is an associate professor of kinesiology at University of Montreal and a member of the Montreal Clinical Research Institute. Her early work focused on blood glucose response and resistance training and the impact of prandial status on their response. Her recent research has focused on sex and gender-related differences in exercise behavior and blood glucose responses to exercise in people with type 1 diabetes, with a particular emphasis on menses and menopause. She is co-author of the 2016 ADA Consensus Statement on Exercise and Physical Activity in Diabetes and a recipient of Heart and Stroke Foundation of Canada, Alberta, New Investigator Award. And I just scratched the surface on the excellence of our panelists today. At this time, I'll let our panelists introduce themselves and state their disclosures. All right, I just requested the pointer, but it's just a pleasure, Michael, to be here and in particular with my good friend and colleague, Jane Yardley. How are you, Jane? Nice to see you. Nice to see you too, Mike. My disclosures are on the next slide, but Jane, you can talk about your disclosures briefly here if you like. Well, they're right there on the screen. So I think everyone can read them. It shouldn't take too long. They're not quite as numerous as yours. So I'll hand the microphone back to you at this stage, Mike. Well, I guess it's age before brains and beauty all get us started. This session really is focusing on tracing the legacy of an application of exercise prescription in diabetes care. Thanks to the ADA for sponsoring Jane and I to come and to speak to you today. We're going to start with a quick kahoot. So you have hopefully the game pin ID, if you haven't logged in yet, is 331-3989. It's in the chat. And here's a question for you. I think most of you will get this right. The optimal amount and intensity and frequency of physical activity is already known for people living with all forms of diabetes. Who thinks that's true and who thinks that's false? Jane, this is not a trick question, is it? All right, we've got a few people logged in and most people have agreed that this indeed is false. I don't think we fully know the ideal optimal intensity and frequency volume of physical activity in all forms of diabetes, in particular, given that exercise does so many things. Here's a scoreboard here. You're all beating me. All right, let's get started on what I'd like to present to you in the next 20 minutes or so. I hope that by the end of this session, you can recognize how the physical activity prescription has evolved over the last several decades, even hundreds of years for people living with diabetes. I'll highlight some of the new strategies based on technologies in this space that help people with diabetes better achieve their physical activity goals with less dysglycemia or activity-related low and high blood sugars. Then Jane's going to pick it up with some very practical recommendations on what really should be done if you're a person living with diabetes as far as a weekly prescription and deal with some subpopulations that I think are worth focusing on in this talk as well. In some early literature, you can find prescriptions of physical activity for people living with high blood sugar. One early philosopher has been cited to be Celsius. He really recommended muscle strengthening activities for his patients who were frequently urinating throughout the day and evening, obviously weak from perhaps what could have been a diabetes diagnosis, although the term wasn't around back then in 30 BC. They knew that something was wrong with these people who had polyuria, polydipsia, and muscle atrophy. Hundreds of years later, we know that the Greek physician, Areteus of Cappadocia, recommended that regular exercise should be done for people who had this melting down of the limbs and flesh into the urine, which was, of course, another mention to diabetes. In the 60s, I think there was really a renaissance for prescribing exercise in more of a nuanced fashion for all patients, including patients living with diabetes. I draw your attention to Kenneth Cooper from the Cooper Institute, who did a lot of work on assessing people's fitness and assessing people, their capacity to do physical activity and then prescribing activity in the form of a point system. If you were a sedentary individual, maybe living with diabetes, you were recommended to gain at least 10 weekly points of some form of aerobic activity, which Jane will help clarify some examples in just a few minutes. That could be maybe running a mile in under eight minutes twice in a week or some other examples here, like walking three miles in less than 43 minutes, et cetera. These point systems were used, but really not taken up after the 1970s, I think, because people didn't like adding up all these points during the week for their activity metrics. After those studies, ACSM started to prescribe what I would say a more targeted exercise prescription of having a frequency and intensity and duration of physical activity, and this spilled over into recommendations for people with diabetes. Many of you in the audience would recognize we still do kind of encourage activity at least three times per week, maybe as much as five times per week. As far as the frequency is concerned, we like to recommend a fairly vigorous activity. Back in the 70s, it was quite vigorous, 60 to 90% of VO2 max, and then softened a little bit in the 90s. And then the duration of activity was at least 20 minutes in duration, and we now will talk about the evolution of exercise snacks and more modern prescriptions. But at the time, this was really the first to provide a frequency, intensity, and duration. In the 1990s, late 1990s and early 2000s, that's when the ADA started to ramp up their recommendations for physical activity in diabetes. And I just grabbed some screenshots here from the first consensus or position statement that was published by the ADA, and it had sections preparing for physical activity in patients who aren't accustomed to it. What were the nuances of physical activity prescription for patients living with type 1 diabetes who were on insulin therapy and frequently getting hypoglycemia, and then some good recommendations for patients with type 2 diabetes based on their disease severity and maybe risk profile for exercise. This position statement was actually a follow-up for this first book published on the topic, which was a 40-chapter, almost 700-page textbook on how to manage exercise and diabetes. It's called The Handbook of Exercise and Diabetes. I was lucky enough to be involved in one chapter on the exercise prescription for pediatric diabetes. That was a pretty detailed text that is out of print right now, unfortunately, but had lots of great information. In the later 2000s, we had lots of great standards of care that were coming out every year, and exercise was always mentioned in the form now of what's called cumulative physical activity. Any movement beyond that of rest to promote the contraction of skeletal muscles, and that's where we started to see exercise prescriptions that we recognize now as being more standard, 150 minutes of cumulative physical activity per week in the form of moderate to vigorous aerobic activity. Trying to spread that out across the week, maybe spread over three to five days and no more than two consecutive days off. We're starting to see more recommendations for resistance physical activity for the added health benefits of doing some resistance training on top of that twice per week based on the available literature at the time. We also can draw your attention to some great position statements that are a bit more recent. One led by Sherry Kohlberg that was published in Diabetes Care in 2016, and Jane was a co-author on that paper. And then one that I helped to spearhead related more to clinical management of type 1 diabetes published in 2017, but that was also a large working group of consensus builders to try to figure out what the best prescription was for physical activity and how to best manage both hypo and hyperglycemia. There's a follow-up for that earlier position statement published by ACSM shown on the upper right-hand quadrant here, an excellent resource for anybody who's prescribing physical activity for type 2 diabetes. And then there is some work that's coming out soon that is more nuanced for CGM users who are living with type 1 diabetes and wanting to use CGM and maybe automated insulin delivery systems for optimization of their glycemic control around activity. And that paper, again, Jane and I are part of, and we expect to see that out sometime in September. That's the one on the bottom right there. I think maybe we're most familiar with this kind of schematic where we're recommending patients with diabetes, all patients with diabetes should accumulate at least 150 minutes per week. This recommendation really evolved from the look-ahead studies where there was a minimum of 150 minutes per week to help limit the progression of pre-diabetes to type 2 diabetes. But in those earlier studies, more was better, more activity was better. So this was kind of the minimum and I guess a balance between what we could expect people to do and then what would have some sort of glycemic impact. And we would always recommend that they could accumulate all sorts of exercise or physical activity breaks throughout their day, throughout their week with all sorts of different activities like some of these could be occupational-related physical activity or maybe household chores, or they could be structured physical activity workouts, or perhaps even sport games. So there's some examples shown here. Moving on, I want to talk about this very important study that was just published that makes me rethink the exercise prescription that we give patients with type 2 diabetes. This was a meta-analysis that looked at several thousand patients living with type 2 diabetes and some very good quality RCTs with exercise interventions and then modeled the number of METs, which are physical activity metrics based on energy expenditure, for a given weekly prescription. So on this axis, what you see are MET equivalents per week and the likelihood of having a reduction in A1c as a metric of how beneficial the exercise volume and intensity is for improving glycemia in type 2. And to zoom in on this in the next slide, because it's a bit hard to see on this, I'll just show you kind of the take-home message. It looks like the ultimate prescription might be a bit more than 150 minutes per week. In fact, it's something like around 1,000 MET minutes per week to get that improvement in A1c. And if you want to convert MET minutes per week to active minutes per day, this table by another editorial on this article highlights that. So for example, for moderate intensity aerobic exercise that includes some strength training, that's 314 minutes per week of moderate intensity activity, well above the 150 prescription. If you do very vigorous activity, you can get away with that same 1,000 MET hours or MET minutes per week in something like 160 minutes per week. So again, teaching us that more activity is probably better and more vigorous activity may be better if the goal is to improve A1c. Of course, we know there's going to be other health benefits that we need to worry about. It's not all about glucose management in type 2 diabetes. There's also cardiovascular risk profile, and there might even be some risks of doing some very vigorous exercise. But I thought I'd bring this to your attention because I think it may help reshape guidelines in the coming years. Now we also may know as exercise physiologists or people who prescribe exercise that you can have very vigorous exercise in the form of interval training. And I just show this one article. It's not type 2 diabetes related per se, but it's one example of a novel exercise prescription that could be done if you wanted to try to do a HIIT interval training yourself or to prescribe it. This is the 10-20-30 exercise training protocol, which actually starts off at the 30-second end with a low-intensity warm-up. And then after that warm-up, do a 20-second moderate sprint pace. Let's say if you're doing it on a treadmill or running, you do a 20-second moderate pace sprint and then a 10-second all-out high-intensity sprint. You would take a small break after this for a couple minutes and then repeat this circuit five times. And the cartoons in the upper right show a patient profile of someone doing these 10-20-30 interval sprints. It's something that I like to do when I go for a run and whether it improves type 1 diabetes or not, I'm not entirely sure, but it is a good way to get a workout done faster and effectively as far as inducing a cardiorespiratory adaptation. Surprising there's not been a lot of research to look at interval training in diabetes, although work is currently underway from some researchers that I'm aware of outside of my own research sphere, but maybe Jane knows some of them. This one study was published though in 2020, where they did the 10-20-30 training protocol and looked at A1C levels in patients living with type 2 diabetes, which I congratulate them for doing this. They were already prescreened as having low cardiovascular disease risk profile, but they underwent this training paradigm. And after 10 weeks of this training paradigm, you could see a reduction in their A1C levels from a baseline of 7.5 to 7.0, which is a 0.5% reduction in A1C, quite significant. And that seemed to be a bit better than moderate aerobic training in that RCT. Another research letter that was published a little bit earlier showed that a similar type of high-intensity interval training could improve 24-hour glucose profiles in patients living with type 2 diabetes. In essence, in this one cartoon in the bottom right, the glucose profile tended to be better after every meal if HIT was done in the early morning. In that study out of McMaster, the HIT was done at around 8 or 9 o'clock in the morning, and the glucose profile was better on active days compared to non-HIT days shown in dark solid lines there. So I think there's some promise that HIT could improve glycemic profile, but there still needs to be some work done on the safety and optimal prescription of that modality, I think, for type 2 and maybe even for long-standing type 1. I'm going to finish talking about how technology maybe has helped shape the exercise prescription for many of us. It's a concept that I think is interesting that we can now have wearables that can tell us our glucose in real time but also wearables that can that can quantify our physical activity and in real time or near real time and maybe merging these two technologies together could make exercise more effective and safer for patients living with diabetes. And I think that we know from elite level athletes with type one diabetes that this data is really valuable to have in in real time. This is an athlete who is a competitive pro cyclist with type one diabetes on team Nova Nordic, Nordisk, and he can see on the headset of his on his cycling computer, he can see his glucose concentrations in in real time, which is very helpful for him for mitigating hypo and hyperglycemia risk, he can modify his nutritional strategies and maybe even alter his insulin dosing during a training ride or a race. And he can see this also in the context of his power output on his bike and and perhaps the elevation and some of the other factors that could impact his glucose like his his like the surrounding ambient temperature, for example. So I think it's kind of neat to see this technology is now being used a bit more widely for patients are all active patients with type one and type two diabetes to help quantify their activity and put it in the context of their glycemia. There's lots of new tech in the space. As many of you might know, there's all sorts of automated insulin delivery systems that are emerging in North America, but also others globally. There's also new formulations of insulin, either once weekly insulins for basal insulin, or more rapid insulin analogs for mealtime and corrective insulin. And there's also glucagon therapy, which could be used to treat hypoglycemia or maybe even prevent prevent hypoglycemia associated with physical activity. And I don't have time to talk about all these technologies. But I do think it's worth noting that as these technologies are invented, we do see more and more elite level athletes with type one diabetes reach their competitive dreams. I can see lots of athletes clustering in the last couple of decades, I think as we've enhanced the technology and the formulations for insulin, and closed loop insulin delivery systems, we can see lots of athletes achieving pretty competitive stages, including even the more recent Olympics where there was a breakdancer with diabetes competing. So I'll just finish off on some exercise and trying to manage dysglycemia for insulin users. That could be a patient with type two diabetes on insulin or patients with type one diabetes who are of course using insulin for their survival. And we like to try to quantify the types of blood sugar changes based on the modality of activity. But Jane will share with you in a minute that this is maybe not as obvious as we had once thought. Other factors may be more important, in fact, in the exercise mode on whether the blood sugar drops or rises, but we tend to categorize activities being endurance based, where blood sugar tends to drop, or perhaps explosive. If you have a sprint, or a swim match that is maybe a 50 or 100 meters sprint, you might see a rise in some individuals. Interval training, it's quite a variable response, sometimes a rise, sometimes a drop. And resistance training, as Jane will share with us, often we'll see an attenuated drop, or in some individuals at certain times of day, you might see a small rise. There are other reasons for hypoglycemia, and I think it's important you acknowledge that the hypoglycemia and hyperglycemia might actually not be activity related, it could be some other feature of their diabetes self-management. And I think we need to realize that we may not be fixing the exercise response necessarily, we may have to optimize their insulin utilization strategies or their nutritional strategies, perhaps instead. You should know that time and range is now a key metric for glycemic control. And you should know that CGM use is rising. And because CGM use is rising, we can now recommend how to best use CGM for exercise for patients who are either taking an oral glucose lowering agent or perhaps insulin. In one study, in one large cohort study, we looked at prescribing exercise in patients with type 1 diabetes over a short course of just a month and to see if it improved any time and range metrics when they when they did the activity. And what was surprising to me is that it didn't really matter what activity we prescribed, whether it was aerobic exercise videos that lasted 30 minutes or interval training that lasted about 20 minutes or resistance training that lasts around 25 minutes. All three forms of exercise tended to improve the glucose time and range compared to not doing any exercise at all at least on a given 24 hour period. So I think this should provide us some confidence that we really have some flexibility on what to prescribe if our goal is to enhance time and range. And all forms of exercise could potentially enhance time and range. But we might be prescribing all forms of exercise for the other health benefits beyond time and range that Jane will highlight in a few minutes. What seems to be the Achilles heel is the variability around blood sugar changes to exercise if patients are on insulin, we see some individuals have a very attenuated drop, even if we standardize the type of exercise and standardize the time of day and the amount of insulin circulation, some people just drop more than others. And we don't know the mechanisms for that. If patients have no strategies in place, if they're a patient living with type one diabetes, and they do not change their insulin therapy, or they do not have an exercise, carbohydrate snack, we tend to get a 50% risk for hypoglycemia, maybe a 43% risk if you want to be more specific. So the risk is quite high. If they don't have a strategy in place, we we need to offer some some strategies so that we can limit this high risk for hypoglycemia, which which might depend a little bit on their baseline glycemia, what did they what did they start the exercise with? So they need to carry carbohydrates, we can model what tends to increase the risk for hypoglycemia. And one of our studies published recently from the T1 Dexi cohort, the baseline glucose did predict whether hypoglycemia developed and if you had a blood sugar that was a little bit elevated before exercise, your risk for developing hypoglycemia is much lower. We also know that the rate of change in glucose if you're using CGM can also predict the risk for hypoglycemia. So if you had a downward trending arrow on your CGM, you had about a 15% risk of developing hypo during just a 30 minute exercise session. Your time below range also predicted risk where if you had lots of hypoglycemia before activity, you're going to have a greater likelihood during the activity. And then this other concept called insulin on board, which some of you may never heard of, it's actually a quantification of how much bolus insulin is acting in circulation when you're doing exercise and higher insulin on board tends to increase risk as one might expect because insulin does drive down the blood sugar levels, just like the exercise also does. They work synergistically. So to combat these challenges of high insulin, and greater risk for aerobic exercise, we simply recommend taking less insulin before exercise and that could be done easily by reducing the bolus insulin dose at the meal before exercise. The cartoon here shows taking half the insulin at the meal before exercise. If the person is going to do a bike ride for an hour, which is predominantly aerobic, they just take less insulin, less prangial insulin or bolus insulin, and they should have less hypoglycemia risk, they wouldn't need to change the basal insulin. Now for patients who are exercising on an insulin pump, and it's exercise in between meals, they have the ability to turn down the basal insulin delivery, as shown here by the green solid lines, and it might be a 50% basal rate reduction. But you need to do that you need to ask them to do that 90 minutes before the start of exercise if you want to have maximum efficacy of this approach, because unfortunately, the insulin just doesn't turn off when we lower the basal rate on an insulin pump. It sticks around in circulation and still has some action profile. I wish I had more time to talk about that, but I don't. I'm just going to summarize what we know about automated insulin delivery systems, because about 30% of the US population of type one are on these AID systems are automatically delivering insulin at a variable rate throughout the day to help improve their glycemic management, but they still can have hypoglycemia. If they don't reduce the bolus insulin before activity by about 30%, some work out of Montreal shows nicely they can have hypoglycemia and there's a reduction in hypo risk if they reduce the bolus insulin by about a third. Set the exercise target many of these systems have a temporary higher target that can be set before activity. But again, do that around 90 minutes to two hours before the exercise starts and maybe even do it before you have that pre exercise meal because that'll limit insulin delivery at that meal before exercise. We don't recommend snacking on carbohydrates if you're on an AID system before exercise, but you're free to snack on carbohydrates. Once the exercise begins, if you snack on on carbohydrates before exercise, these systems will sometimes bolus insulin as they measure a rise in glucose before the activity starts, and that causes hypoglycemia during exercise. So that's kind of a key strategy that's quite a bit different now that we have patients on AID don't snack before exercise snack during exercise. And for patients who want to take their insulin pump off for whatever reason, maybe they're going high diving or doing mixed martial arts, that's okay. But if they suspend the pump, that tells the algorithm that the patient has had less insulin delivery while they've been physically active. And we think that's an important thing to ask them to do is to put the pump on suspend, don't just take it off and let the insulin dribble in to the side of the the bench or wherever they've taken the pump off, and then remove that temporary target once they reconnect to the pump is a good strategy. So to summarize everything I've talked about the last few minutes, we know the prescriptions evolving in diabetes, no one prescription may be ideal, but we're starting to see some benefits of high intensity interval training and obviously resistance training, which Jane will talk about next. And we like to see the use of technologies both to quantify the activity that patients are doing, and to help better inform nutrition and insulin delivery for patients who are on insulin therapy and want to be physically active. These systems are not completely hands off, we still need some proactive measures to mitigate hypo and hyperglycemia risk. As we wait for newer systems that may be more automated in the next few years. We'll end with a quiz before we hand it off to Jane. So according to the ADA standards of care, the minimum goal for the volume of physical activity weekly right now as it's prescribed is how many minutes per week 100 150 250 minutes per week or 300. What are your what's your recollection of what I shared with you in the slides a few minutes ago, what's being prescribed right now? Great, most of you answered that 150 minutes per week of moderate intensity aerobic exercise is part of that standard of care prescription. Good job, you guys. Jane, I leave it to you to take them home with some of your wisdom and pearls for special populations and for resistance training. Okay, thanks, Mike. Mike knows that I could probably talk about this topic for hours. But we're sort of limited here to about 15 to 20 minutes, I'm going to do my best to get some key points across. We're going to start with a bit of a quiz. High intensity interval exercise is associated with is it a less pronounced increase in cardiovascular fitness than aerobic exercise, an increase in HbA1c, less time spent exercising for similar or bigger physiological benefits, lower insulin sensitivity or higher resting blood pressure. So you'll have a few seconds to weigh in on that one. And if you're not sure, don't worry, we're going to talk about it in a couple of minutes. Okay, so those of you who answered the less time spent exercising for similar or bigger physiological benefits, you are correct. Nice work. Alright, so I'm going to talk a little bit about some of the training effects of the different types of exercise that Mike was discussing in his presentation. I've been doing a bit of work lately looking at sex and gender related differences. And so I'm going to talk about some considerations for prescribing exercise, if you're dealing with female, male or people who identify as women or men. And I'm going to discuss a little bit the benefits of post inhaled and fasted exercise because we've had some information coming out lately about these that might make you consider prescribing exercise a little bit differently. So for some definitions, Mike already touched on a couple of these. But if we talk about sedentary behavior, that's basically what they say a waking behavior characterized by an energy expenditure of less than 1.5 METs. METs, of course, are metabolic equivalents. So it essentially means that you're not really getting up very often, there's a lot of sitting a lot of reclining or a lot of lying down. If we talk about physical activity, it's really any bodily movement that results in energy expenditure. So that could be you know, fidgeting, cleaning your kitchen, gardening, running after your toddler, anything like that is considered physical activity. And then if we talk specifically about exercise, that's a bit more planned, a bit more structured, a bit more repetitive. And often, if we're doing exercise, it's trying to improve or maintain physical fitness. And so I try not to use these terms interchangeably, because really, they do have different goals. You can spot the person who's done a lot of undergraduate teaching, I love word clouds. And so I've put in this word cloud, I want you to think about the clients that come into your office and tell me what are the most common barriers that they tell you about. And I believe you're allowed to give more than one answer here. So that come to the top of your head, please go ahead and type in as many as you want. We've got a few seconds to let you do that. I have a feeling a lot of you are going to come up with very similar answers. And let's see what we came up with. No time, time is actually, generally speaking, the key factor that people will name. We will also hear about things like it's expensive. I don't know what to do. I really just don't enjoy doing it. But then when we put in the context of type one diabetes, in particular, one of the really big barriers we see is fear of hypoglycemia. So all of these things have basically been mentioned here fitness is another one, if you have very low fitness to begin with, it's really difficult to start moving your body more, and it's very painful, and it can be unpleasant. So it is hard to convince people to start moving when they haven't been active before. So here I've got a list of some of the common barriers that we see. In addition to those, we do know that women tend to be less active than men, and that they have different barriers to exercise, they need a little bit more support, because they feel that they don't have enough of it. They tend to be a little bit less constant confident with exercise. And they often have more family related barriers, things like caregiving, and having to manage a household, as much as there in the 20th century, a lot of those tasks still fall disproportionately on women. We also see that these barriers change a little bit with age, as adults get older, fear of falling becomes a much bigger barrier to being physically active. And then in particular environmental concerns on top of that, so falling on the ice, for example, if you live in a northern climate, or, you know, tripping over anything that that might be outdoors, these are these are things that start becoming bigger barriers as people get older. As I mentioned before, with type one diabetes, we have hypoglycemia as a major barrier. And the 2008 study that that showed this as a strong barrier to physical activity has now been redone. And they found exactly the same thing. It hasn't changed in the context of new technologies. And understanding all of these barriers is really important in order to help some someone become physically active. Because the advice that you give has to keep in mind what it is that scares them what it is that's stopping them. So asking first, why aren't you active? Or what is the main reason why you are not active? Those that question is going to go a really long way. So here's another word cloud. Why would your clients want to be active? What's the most common goal that they are looking to achieve? And here again, you can have multiple answers. So feel free to type in as many as you want. These can be related to type one diabetes to type two diabetes to life in general. I will leave you another 10 seconds so that you can have your input on this one. And here we go. Glucose control, weight loss, weight loss, and be healthier. And that's actually what we see when we look at a lot of the diabetes and exercise studies as well. And there is a bit of a difference between what your men will say and what your women will say. And there will be a bit of a difference between what somebody with type one diabetes might say compared to what somebody with type two diabetes might say. And that's where we see sort of repeated and continuous movement of large muscle groups. So that could be anything like cycling, walking, climbing stairs, skip rope, you know, cross country skiing, rowing, canoeing, there are so many different types of exercises that you can do. And there's a lot of different types of exercise that you can do. And I'm going to leave you with a couple of examples. So let's start with aerobic exercise. Aerobic exercise is a type of exercise where you're doing cross country skiing, rowing, canoeing, there are so many things that go on this list, as long as you keep something going repetitively, over a certain period of time, it's considered an aerobic activity. When you do this type of activity, you tend to improve your cardiorespiratory fitness. And this goes right down to the cellular level, the components of the cells that help you use your fuel sources get better at doing that you get more enzymes, you get more chondria, you even have more blood vessels to help shunt that blood out to the areas where you need to have that that blood go during exercise, cardiac output goes up, so your heart gets better at pumping things out to where it needs to go. We also tend to see lower insulin resistance, improved lipid levels and potential decreases in A1C. I'm kind of careful about how I say that. In type 2 diabetes, we do have randomized control trials that show decreases in A1C with an exercise intervention. In type 1 diabetes, the randomized control trials have had sort of differing results depending on which trial you look at. You can even see some where A1C goes up rather than down. So as much as there's a lot of observational data and cross-sectional data that show that people who are more active tend to have more time and range and tend to have lower A1C, when we take people who aren't active and make them active within the context of type 1 diabetes, we don't always see an improvement in A1C. Anaerobic exercise. So this would be anything that's going to use the anaerobic system. So it involves a lot less of the oxygen used for burning the fuels. That sounds a little complicated, but essentially it's anything that's going to be short, that's going to be intense. And it doesn't have to be done in one go all short and intense. So what I've described here is high intensity interval exercise. And Mike alluded to this earlier. The major benefits are basically, you get a fairly quick enhancement of that skeletal muscle oxidative capacity. So more of those mitochondria, better ability to bring oxygen in, a higher insulin sensitivity, and that cardiorespiratory fitness actually improves a little bit faster when you do these high intensity intervals. And high intensity has a variety of definitions. We could do anything from sprint, where you would do a super high intensity with a much longer recovery period, or you could just do something of about a 70% or 80% effort, which is uncomfortable, for a slightly longer period of time with a shorter recovery period. So there are a lot of ways to work with these intervals and work with the fitness level of the person that you have in front of you in order to make this type of program doable. We definitely see decreases in blood pressure with this type of training. Again, in the context of type two diabetes, we see a decrease in A1C. And most of the time we see these benefits in less time than would be required to see them with aerobic activities. Another type of anaerobic exercise is resistance exercise. And this one's kind of my personal favorite. It includes anything that has free weights, weight machines, body, or even elastic resistance bands. We do have studies showing that elastic resistance bands can help build strength, improve glycemia, and just get people more active. Overall with resistance exercise, improvements in body composition is an important component. We see lower fat mass, higher muscle mass, and greater bone density with this type of activity. We see greater strength and physical function, which is really important if we're dealing with aging adults. And we improve on lipid profiles and cardiovascular health. We also tend to see decreases in A1C. And here, there are not a lot of studies in type one diabetes, but the few that are out there tend to see a slight improvement. One of the more recent ones saw sort of a maintenance, but for now we'll say the jury's still out with type one diabetes. There's clear evidence again for type two diabetes. I usually bring this up because knowing where the fuel comes from basically gives you an idea of type of glucose response you're going to have, especially for people who are using insulin. So on the left, we see these aerobic activities where the main fuel is actually coming from fat, from adipose tissue. But the second thing that we're going to tap into is blood glucose. And if you think about it, there's not a lot of that going around. Most of us know this in milligrams per deciliter or in millimoles per liter, but 99% of the glucose that goes into the body actually gets stored. It goes into muscle glycogen, just 80% of our storage and liver glycogen, which is close to 20% of our storage. And so what's left in the blood in circulation is somewhere around 0.5% of the total glucose that's in our body. So if we start tapping into that for aerobic activity, blood glucose levels will come down. And then on the other side, the muscle glycogen, the liver glycogen, if we have a really pronounced high intensity effect, if adrenaline, so epinephrine, we have it here, is a key component, then sometimes with the right type of activity, the liver can actually release that glucose into the bloodstream and can cause an increase in blood glucose. Not very consistent response. It's hard to predict, but it is there and it can happen. And this is where we get to the prescription part, getting the prescription right, the right therapy, which is the exercise for the right person at the right time. Let's go back to that fuel selection idea. So blood glucose, if we know that that's going to be a source of fuel, we know that for people with type 2 diabetes, where we're dealing with a lot of meal-related hyperglycemia that prescribing aerobic activity after a meal or after all three meals of the day, for example, can actually help prevent some of that meal-related hyperglycemia and in the long-term should help decrease hemoglobin A1C. And on the opposite side where we see these anaerobic activities that let us tap into the stored glucose, for people with type 1 diabetes, where they're potentially afraid of hypoglycemia, being able to tap into that stored energy rather than the circulating glucose from being able to help increase the amount of circulating glucose can actually decrease the amount that blood glucose drops during an activity. And so we see it as being quite beneficial for acute exercise responses in type 1 diabetes. Resistance exercise. I like this one, especially because I'm starting to deal with a lot more aging studies and because I'm getting older myself, let's face it. Faster loss of muscle mass and quality with aging for those with diabetes. This is a key component that I think really needs to be emphasized. For people who have both type 1 and type 2 diabetes, as they age, that natural progression, that natural loss of muscle mass and bone density, it's actually accelerated. We see a higher loss of that, especially the bone density and quality in people with higher hemoglobin A1C. So it's good to try and maintain those glucose levels in range. And we know that weight-bearing exercise or resistance exercise will help us maintain both that strength, that muscle mass, and that bone density. And if we're trying to think of it in terms of functional mobility, being able to do the activities that you need to do on a daily basis to take care of yourself, that is extremely important. Within type 1 diabetes, we also see that it has a less acute effect on blood glucose levels. So if they're doing this type of exercise after a meal, we don't see glucose dropping as much. I always recommend that if possible or affordable, that people should use a fitness professional to start this type of program. But I do recognize that that is a major barrier for a lot of people. That's why I always say, if possible, if affordable, some health insurance plans will actually cover this now because they have recognized the benefit of having professional guidance when starting an exercise program. Sex considerations. Believe it or not, male and female bodies do not respond to exercise the same way. If we look at all the changes that the female body goes through in a life cycle, the menstrual cycle, menopause, pregnancy, all of these things have a substantial effect on insulin sensitivity. We also see a little bit that sex could affect exercise blood glucose levels, so changes in blood glucose during exercise. So for example, if I take the menstrual cycle during the luteal phase, we tend to see that females will need more insulin to manage their blood glucose levels because there's a tendency towards hyperglycemia, a bit more insulin resistance. And if that's the case, as soon as exercise starts, they're starting exercise with more insulin on board. That can lead to a faster drop in exercise, in glucose, sorry, and a higher risk of hypoglycemia. Where am I on this one? All right. Smaller glycemic benefits after high intensity interval training is an interesting thing that's come out of the type two diabetes world, where we've seen a lot of studies on male participants that say, hey, this is great for glycemic management, but then we don't see those benefits as much in females. But what we do also see is that for people with type one diabetes, there may be less of a risk in general with different types of activity for females. And when we look at those studies, the question comes up, is it really a sex thing? Is it a female, male thing? Or is it a gender thing where the women are actually paying a bit more attention to adjusting their insulin than the men, which is a possibility. We don't have all those answers really solid for now. We have a little bit of qualitative data on that. And that's where my next slide comes in. I mentioned earlier that women perceive more barriers to physical activity and exercise. And overall, we do know that they're less active. Another interesting thing that came out of a qualitative study that we did recently was that women were more concerned with weight maintenance. That's probably not surprising for a lot of you. And if you're dealing with this in the context of type one diabetes, telling someone to eat as many calories as they're able to expend during activity to prevent hypoglycemia becomes very frustrating. We also see different activity preferences between the genders with the men trying to do more in terms of like sports, whereas the women tend to prefer sort of group fitness activities, anything that's a little bit more social. In type one diabetes, we see more women reporting dysglycemia as a barrier than men. But we also know from the literature that women do tend to experience more hypoglycemia than men overall. A really large study came out of the UK not too long ago. And the biggest predictor of having hypoglycemia was being a woman. Women also need a bit more support and creative suggestions for getting a bit more activity into their daily routine. I think the next thing I have is prandial status. And I see we're getting a little short on time. I'll try not to rush too much, but I got to get through this. With type two diabetes, we know that small bouts of post-prandial exercise can mitigate post-meal hypoglycemia. I mentioned that on an early slide, it's a really useful tool for preventing those highs. But we see a similar 24 hour mean when we're comparing it to fasted exercise. So post-prandial exercise might not really be any better than fasted exercise for the overall glucose levels. Type one diabetes, if you're exercising after a meal, we do see bigger declines in blood glucose. But as Mike mentioned, adjusting that meal bolus can allow for safe post-prandial exercise. It's useful to some people if they know that they're going to have hyperglycemia due to high intensity exercise. If that's their trend, then they may be better off actually exercising in that post-prandial period so that they have less of a tendency to go up. And then the last point that I make here is if you love morning exercise, none of this matters. Let people exercise when they want to exercise. It's our job to just put the tools in the box to let them manage that appropriately. And that brings me to fasted. And we all know not everyone's an early bird, but for those who are, with type two diabetes, we see that there's a greater acute decrease in exercise blood glucose with post-prandial exercise. So fasted doesn't help in that regard. The benefit is really the third one here where we see that if they do fasted exercise for the next 24 hours, there was one study showing that the post-meal excursions were lower just because they exercised that morning. In type one diabetes with fasted exercise, we actually tend to see an increase in blood glucose for a lot of people. There's less insulin on board. If it's in the morning first thing, there's more growth hormone and circulation. There's more cortisol. So for anyone who is really afraid of hypoglycemia and has that as their major barrier, fasted exercise might actually be a really good tool to put in their toolbox. The longer term evidence for fasted versus fed in both type one and type two diabetes is somewhat lacking, but in theory with longer term fasted training, we may see more improvements in insulin sensitivity. And that's just based on what we've seen in people without diabetes. But as I said, if you don't wanna get up and exercise in the morning cause you're not an early bird, doesn't really matter what the benefits are. This is just showing with fasted exercise in type one diabetes, high intensity interval training. It goes up with fasted exercise here. It goes down with that exercise. That's a key point that I think I'm gonna make in every presentation from now on, because I've really been pushing the fasted exercise for those who are afraid of hypoglycemia. The last main point to make is that moving is just important. Anything that's not exercise, just physical activity, not being sedentary. High levels of sedentary time are associated with a really large increase in all cause mortality. If we can sedentary time, we can improve a lot of things. Liver enzymes, physical fitness and cardiovascular risk are well proven in type two diabetes. In type one diabetes, we have a really nice recent study showing that breaking up sitting time with short bouts of light walking. And I believe this was about three minutes of walking for every 20 minutes of sitting. It actually really helped improve 48 hour and even acute postprandial blood glucose levels. So sit less, that's kind of the key point of that slide. Moving matters. And honestly, it doesn't really matter what type of moving as long as you're doing it. So the hands-on tips, I say, ask about barriers, goals, likes and dislikes of your clients before making any suggestions. Work with their strengths. Encourage resistance exercise where they're amenable to this practice. If they hate doing it, they're not gonna do it. But if they're willing to, it will be very good for them. Where fear of hypoglycemia is a barrier to exercise, if it's anyone using insulin, I would recommend morning fasted exercise. And at the end, all movement is good movement. And then after that, I just have a couple of reference slides. And I think we are going to be opening this to questions right now with the limited time that we have left. Oh, sorry, I forgot there is a quiz. Which of the following statements about fasted state exercise is true? Is it associated with a high risk of hypoglycemia in people with type one diabetes? It may be a useful tool for people with diabetes using insulin who fear hypoglycemia. It has no impact on glucose levels in individuals with type two diabetes, or it is likely to have little impact on long-term glucose management. And there we go. It may be a useful tool for people with diabetes using insulin who fear hypoglycemia. Everyone got that one right, 100% gold star. Thanks, Jane. Thanks, Michael. I can tell you that nobody has left this presentation and we have time for maybe forward looking. So Michael, for you, I'd like to ask, what's on the future with diabetes rate related technology and exercise, accelerometry, bi-hormonal, movement sensors, algorithms? Yeah, there are a few things on the horizon that people are exploring to integrate a wearable into an insulin delivery system is one approach that a couple of labs have looked at them and starting to publish on. So if there is a metric that says the person's moving, then insulin delivery typically is shut down. But that's a problem because sometimes you make a change and that change in insulin delivery isn't soon enough. The wearables picking it up, you're already moving, the insulin doesn't change fast enough. So adding glucagon is another consideration, but that's another expensive hormone to add with maybe another infusion set. There are AI models that are looking at people who have more predictable schedules, like they exercise at a predictable schedule. The AI is doing calendar forecasting on when the insulin delivery may need to change. And there's also something called a neural network where they're looking at retrospectively over the last month, where were the activity related hypo events or hyper events, and then how could the algorithms modify that? But that's, I think, only gonna be good for people who have really predictable activity patterns. And we're not all like that. No easy solutions, but lots of work ongoing in this space for sure, Michael. Michael, your microphone's off. Just speak to the fact of type two diabetes and exercise in its many way it appears in glycemic control and other benefits. Was that directed to Jane? Yeah, Jane. We missed the start of the question, so. Jane, just talk to the benefits of physical activity in our type two diabetes population, often glycemic control. We don't have that apparent drop in blood sugar, and you've highlighted many of the factors, but just address that. Well, I think one of the biggest banks for your buck if you're gonna try and use physical activity to manage glucose is to put it in the right spot, the right time of day. And that approach to having it right after meals to prevent the big increases in glucose that are often seen is a really good one, which I think in the long-term should result in improvements in A1c that are measurable on people if they're consistent with that exercise. But we can even start having those metrics sooner by using continuous glucose monitoring where it's available. If a person has a continuous glucose monitor, I think giving them consistent feedback to say, okay, here's a day where you didn't do the three 10-minute walks. Here's a day where you did, and really showing them the difference between those two days. Because one of the things that really promotes ongoing exercise behavior is getting positive feedback. And that needs to come from something that's gonna be objective and CGM systems are objective. Certainly technology helps. Well, thank you both. Before we end today's session, I wanna let you know what to expect from this point on. Later today, you'll receive a post-test by email. Please complete it so you can claim your CE credits. Be on the lookout for today's webinar recording on the ADA's Institute of Learning page in a few weeks. Remind any fellow members that they can watch this webinar for one continuing ed credit eligible until August of 2025. And I wanna really say thank you again to our panel for sharing their expertise. It's not a surprise that we had an outstanding attendance here, and people stayed from the very beginning to the very end. So we are really grateful to our friends from Canada, actually, Jane and Michael. We appreciate your work that you do to support people and to raise awareness of the benefits of physical activity and exercise and prevention and management of diabetes. So I wanna thank you for joining us. We hope to see you at another ADA webinar in the future. And this concludes this session. Have a great afternoon. Thank you very much.

diabetes care

exercise

personalized prescriptions

aerobic training

anaerobic training

resistance training

hypoglycemia management

wearable technology

AI models