Hi, everyone, and welcome to today's hands-on tips to improve diabetes care webinar. Today, our panel will share their expertise on optimizing pediatric and adolescent diabetes through exercise, and we are glad you're here. I am Amy Katona, and I will be moderating today's webinar. To share a little bit about myself, I am a senior clinical research coordinator in pediatric endocrinology at Michigan Medicine. I have spent the past 23 years at Michigan Medicine specializing in exercise physiology, diabetes, and cardiology, working as both a clinical exercise physiologist and a clinical researcher. We'll spend the next hour together by following the agenda on the screen. We will be using the interactive features during today's session. In the chat box, we will send you important links and information throughout today's session. We also want you to engage. We will have two poll questions pop up during the presentations. Please keep an eye out for them. We'll also use Zoom Q&A at the end of the presentation for panel questions. If you think of a question as our presenters speak, use the Q&A box on your control panel to type your question. We'll use... And again, join us in the new year on January 14th, 2025 for the next installment in the hands-on webinar series. Click the link in your chat box to register. Now I'd like to introduce the panelists for today's webinar. Dr. Desi Zaharieva is an instructor, certified exercise physiologist, and certified diabetes care and education specialist, currently working in pediatric endocrinology at Stanford University School of Medicine. Her research focuses on stress-induced diabetes at Stanford University School of Medicine. Her research focuses on strategies to manage blood glucose concentrations around exercise in youth and adults with type 1 diabetes. Also, Dr. Nader Kassim is a board-certified pediatric endocrinologist and diabetologist at Helen DeVos Children's Hospital, part of Corwell Health in Grand Rapids, Michigan. His main clinical interests include type 1 diabetes, exercise, and diabetes technology. He lives with type 1 diabetes and has competed in multiple endurance races, including ultramarathons, trail races, and cycling rides. At this time, I'll let our panelists introduce themselves and state their disclosures. Hello, everyone. Dessie Zaharieva, and these are my disclosures. Hi, my name is Nader Kassim, and these are my disclosures as well. Thank you, everyone, for joining. All right, so I will kick things off. Thank you all for being here. We're looking forward to the Q&A. It's always my favorite part of these discussions to be able to chat with you all. Our learning objectives today is looking at the primary factors influencing glucose levels around exercise and looking at barriers to exercise in youth with type 1 diabetes. So I always like to get started by looking at the exercise guidelines in pediatrics. So the physical activity guidelines for children and youth up to age 17 years old, generally, we think about the four S's, sweat, step, sit, and sleep. Kids should be aiming to achieve at least 60 minutes of moderate to vigorous physical activity per day, including both muscle and bone strengthening activities at least three times per week. For steps, there is evidence to suggest aiming for at least 10,000 steps per day. Of course, that changes a little bit as kids get older. So even starting at younger ages could be anywhere from 15,000 steps and decrease slightly as people get older. With sit and sedentary behavior, there should be no more than two hours per day of recreational screen time, and we should be limiting sitting time. Sleep, the research suggests that there should be aiming for uninterrupted sleep per night anywhere between eight and 11 hours depending on the age of the child. And of course, consistent sleep and wake hours. This becomes a little bit difficult because these guidelines were set in place for kids without diabetes. They are the same guidelines that apply to kids with diabetes, but the reality is those consistent sleep and wake times can be quite challenging, particularly for those low blood sugars that may occur overnight, and all of the alerts and alarms that tend to happen, especially in the nighttime. So these are all the guidelines for optimal health, and this should be a starting place for all kids. So we're gonna kick it off with a quick poll question for everyone. True or false? It should be a pretty easy one, but let's give it a shot. Most youth with type 1 diabetes are meeting exercise recommendations of at least 60 minutes of moderate to vigorous physical activity per day. So one choice, true or false? I think this one, one challenge to answering this is that it's hard to generalize across the whole population, but if we were to generalize, if we were to generalize, do we think that most people are meeting or not meeting those guidelines? Take a second to answer. Well, you all nailed it. It sounds like you could lead this presentation for me. We got 100% of everyone on the call answering false. And like we said, that is the correct answer. It is false. But like we also mentioned, this is difficult to broadly mention across the entire spectrum of people with type 1 diabetes because we know many kids are meeting those guidelines. But the reality is a really nice meta-analysis and review that was recently published looked at over 35 studies, over 4,000 youth, and looking at youth with type 1 diabetes compared to youth without type 1, finding that those with type 1 diabetes generally were less physically active, were more sedentary, and had lower fitness overall. So some of my research has gotten into, well, what are the reasons behind kids with type 1 diabetes maybe not engaging in the recommended physical activity? There may be other barriers aside from just feeling like they don't want to exercise, although that may be a barrier in itself. The one that we see, the larger the word, the larger the barrier on this screen. So fear of low blood glucose or hypoglycemia tends to be one of the leading barriers to physical activity in kids with diabetes. We actually see this similarly in adults with diabetes, so I just wanted to mention a lot of our work is focusing on reducing those barriers. An initial focus for us is simplifying those exercise guidelines. So we know that there's a number of published guidelines that exist to date on exercise. We'll talk a little bit more about an existing paper that was actually just launched and live today that we'll dive into a little bit deeper. But really the goal is how can we simplify both glucose values and what the goals and targets should be? What should we discuss around exercise, intensity type, duration? What do we need to know about carbohydrate feeding, assessing the needs of how many carbs, if they are needed, and what types of carbs? And then insulin, IOB, so insulin on board, and insulin dose adjustments, which we'll get into further along today. I wanted to jump in by talking about a study that was highlighted here in the T1-DEXY. It's the largest pediatric study to date to be published in real-world data. And what this Type 1 Diabetes Exercise Initiative study was looking at, there are many different papers from this group, but one of the papers I'm highlighting here is understanding in the largest real-world data set of pediatric patients, over 250 kids analyzed in this paper, looking at the overall outcomes in glycemic index and the overall outcomes in glycemic control in that 24 hours following physical activity. So sometimes people wonder, why are we looking at 24 hours post-exercise? If I can orient you, that's what the X-axis on the bottom is showing, buckets of time from zero up to 24 hours to the right-hand side of duration post-exercise. The reason we often look at 24 hours in the recovery period is that insulin sensitivity can often be impacted for the 24 hours after activity. And on the Y-axis on both sides, we've got mean glucose, both in milligrams per deciliter on the left and millimoles per liter on the right for my fellow Canadians. And what we wanted to show from this graph right here is that when we look at the different colors, those box plots that you can see, box and whisker plots, multiple daily injections are the group in red, open-loop insulin pumps where you're doing a lot of manual adjustments in green and closed-loop or automated insulin delivery in blue. And interestingly, the data did show that those with lower hemoglobin A1Cs tended to have lower mean glucose, but irrespective of that change, when you look at insulin modality and how people manage their diabetes, there was no significant difference in the 24 hours post-exercise in those groups. And I think that this is interesting because we often talk about the advancements and improvements of automated insulin delivery, but we also know, and we need to discuss today, that there are many challenges with using automated insulin delivery systems around exercise. So when we look at multiple daily injections, there are a number of studies that have shown when you're taking your usual basal insulin dose for multiple daily injections, so your long-acting insulin dose, that dose is already titrated based on your diabetes care team. They tell you how much insulin to take, and following that regimen is important. Now, for unusually active days, and we have two studies on the right-hand side that have shown this, with long-acting insulin, reducing that basal dose by anywhere from 10 to 20%, usually if that dose is taken in the evening, the evening before exercise would impact the next day's glycemia. So if you know, for example, the next day, as in tomorrow, your child is going to be doing something very active, when we say unusually active, I often say many hours of walking or a sporting event where it's going to be multiple games in a day, those types of events where it may be necessary to consider reducing that long-acting insulin dose by 10 to 20%. Anytime insulin dose adjustments are made, it's important to talk to your diabetes care team before making those adjustments, because of course it will depend on the type of long-acting insulin. Some of these studies, like the one on the top, showed that with ultra long-acting insulins, we need to make those adjustments, for some cases, three days before the actual exercise event. And so again, this can be really difficult to implement in the real world. Now, when we talk about the mealtime insulin dosing for exercise, there's differences around the type of insulin dosing that we're taking. So whether it's multiple daily injections, open loop pump therapy, or automated insulin delivery or closed loop. The recommendations are reducing that mealtime bolus insulin anywhere from 25 to 75%. Now what we often see is that meal before exercise, if it happens in the one to two hours before activity, reducing that short-acting insulin or fast-acting insulin may be necessary to reduce the amount of circulating insulin at the start of exercise. But what we also know is that if you reduce that insulin with the meal before exercise too aggressively with a closed-loop system or automated insulin delivery system, glucose levels tend to rise with that aggressive reduction, and many of the pumps will automatically dose insulin to bring you below target. So this is why the recommendations for reducing bolus insulin with automated insulin delivery is often softened compared to the other two methods. And we're very excited to share. Today we'll be talking about some recommendations and strategies for managing exercise with automated insulin delivery systems. This position statement officially went live today, so it's a joint position statement. You can find it on Diabetologia and on Hormone Research and Pediatrics journals. So when we talk about planned physical activity, we see in some of these large real-world data sets that there is a number of reasons why we need to plan for exercise. And a lot of that has to do with the fact that with a high amount of circulating insulin on board, there is an increased risk of hypoglycemia with activity. So I highlighted specifically insulin on board. We'll spend a little bit of time talking about that today, but the reality is this entire list on the left-hand side are factors that need to be considered when going into physical activity. All of these factors can make glucose responses highly variable during exercise. So when we're looking at different systems, with this position statement, we focused on each commercially available system, we discussed what to do with planned, unplanned, and specific types and intensities of exercise. For focusing on planned activity, we won't go into the specifics, but if you read the paper, you can see these highlighted figures in more detail as well, setting those higher glucose targets well in advance of exercise, and like we talked about, reducing that mealtime bolus insulin in the one to two hours before exercise. So to summarize with planned activity, setting those higher glucose targets if hypoglycemia often occurs with exercise. It's important to check the glucose levels before and during exercise, consider those mealtime bolus reductions before activity, and sometimes if glucose levels are dropping below 126 mg per deciliter during activity, it's important to consider carb feeding. And of course you may need to also modify and think about that insulin sensitivity post exercise, which we'll talk about later. When it comes to spontaneous physical activity, when we think about most pediatric patients that I see, planning is not something that they're thinking about. So thinking about planning one or two hours before exercise, they often say, I'm not going to do that. And the reality is we need to meet patients where they're at. Of course if some are ready to plan ahead, that's very important, but some people don't often plan for physical activity, which is why we often will focus on carbohydrate feeding strategies in the moment. Now the position statement is using millimoles per liter, but in our supplement we focus on a lot of these as milligrams per deciliter. So you can take a look again at the position statement to translate that. Again, if glucose levels are dropping below 7 millimoles per liter or 126 mg per deciliter, we often encourage trying to have small amounts of carbohydrate feeding, fast acting glucose during exercise to reduce the risk of hypoglycemia. Earlier papers have often talked about how it's important to treat hypoglycemia once it's happened. We do focus on this as well, but there is an emphasis in the position statement to also consider preemptive carb feeding to reduce the risk of hypoglycemia. Now when we look at different systems, in this case with unplanned activity, in this case we're looking at the Omnipod 5 closed loop system. With unplanned activity, we focus on it's still important to set that activity feature or higher glucose target at the start of exercise if hypoglycemia is often a concern. We also talk about how many carbs to consider, which is also highlighted in this figure as well. So carb feeding strategies are going to be usually higher in those instances where there's more insulin on board and less preemptive planning for activity. So to summarize with spontaneous exercise, we often talk about, well, there are going to be often rapid changes in glucose when we're not planning ahead for exercise. And typically that means continuous glucose monitoring lag time can be increased compared to blood glucose during activity. Like we talked about with insulin on board, when you don't plan ahead and set a higher glucose target, that often means that there is higher circulating insulin at the onset of activity, which might make it more challenging during aerobic exercise in particular. So we still talk about the importance of setting a higher glucose target and consuming small amounts of carbohydrates. And now we're going to jump into the last section of the position statement, looking at special circumstances of exercise. I have many patients that come to me and say, well, Jessie, what if I do this with physical activity? And I might say, oh, well, that's not something we often recommend to be doing day to day. So these ultramarathon cases and part of the discussion after this will be a lot of these endurance-based sports or even people doing long-duration swimming events or being without a pump or disconnected from insulin pump delivery for a long period of time. Well, instead of saying we shouldn't do that, let's focus on how we can encourage kids to be physically active and what they should do to optimize their glycemia during those types of special circumstances. So I won't have time to cover all of these today, but we will in the position statement go through each of these different sections. Prolonged activity, long-duration events, competition stress and how to manage that, water-based activities, contact sports, different ambient temperatures, as well as high-altitude situations. Now, although there's limited evidence and clinical trials, especially randomized trials on these types of events, the importance of a position statement is getting, as we did, 25, 26 of the leading authors on this position statement together to discuss what do we do in clinic, what are the types of recommendations we would make even with level D evidence where we don't have clinical trials to showcase what we should be doing. So some considerations on the top you can read about with long-duration physical activity events or PA events and some possible strategies with these long-duration, often over three-hour events, sometimes in the case of six hours or longer. We encourage regular carbohydrate feeding for performance and fuel, but in order to reduce the risk of insulin deficiency during these very long exercise events, especially if you set a higher glucose target for six hours, we want to reduce the risk of insulin deficiency after a very prolonged period of time when you've set a higher glucose target. We often consider maybe turning off that higher glucose target after the second half of exercise. You may not need that higher glucose target any longer. Also paying close attention to glucose monitoring values as you are doing these events. Now, when it comes to competition stress, one of the reasons I went into research is hearing a lot about these adrenaline responses. I also have type 1 diabetes. One of my personal struggles was managing competition stress and the increased adrenaline response with this type of activity. So again, with competition stress, we often recommend, again, possible strategies on the bottom, monitoring the insulin on board. We have to remember that with adrenaline responses, if the liver is dumping a lot of glucose into the body, the muscles can only take up so much during these types of events and there may be an increase in adrenaline. That increase can actually cause blood sugars to rise. So again, automated insulin deliveries with a rise in glucose may increase insulin delivery. That's only going to lead to an increased risk of hypoglycemia later. It's also important to stay hydrated. We know that with regular hydration we see more accurate CGM tracings. We also want to maybe consider avoiding setting a higher glucose target 1 to 2 hours before competition, particularly if we see that consistent rise due to the adrenaline response. Now, if glucose levels rise above 270 mg per deciliter, we may consider partial manual insulin corrections. We typically recommend around 50% of a usual bolus correction and that can be during or post-exercise. But important to consider these because there's limited evidence on the structured studies on what we can do for guidance around this type of activity. So we absolutely need more studies to look at this. So for a summary of special circumstances with exercise, we talked about how there is a lack of evidence and studies for special circumstances in people using automated insulin delivery. However, that doesn't mean that we shouldn't be encouraging physical activity for all kids. It's important that we talk about some other considerations that have not been discussed. We touch on very briefly in the position statement, but due to shortness of space, what we could cover. There's other papers that are now starting to look at this, but the impact of menstrual cycle, active insulin, so circulating insulin or insulin on board, and adjunctive agents as more individuals are getting started on SGLT2 inhibitors or GLP-1 agonists. We know that there's going to be a shift in the type of research that we do. How does this actually impact glycemic outcomes, particularly around exercise, which is another area of interest for me. We need to consider that trial and error is a place that we often will see failures. We will see that kids are trying things, things don't work, and it can get very frustrating. But it's important to encourage continuing to trial and error in order to refine glucose management strategies. Now overall, healthcare providers, it's up to the healthcare providers to offer that support for all kids to be physically active. We also just wanted to share that there are a number of new resources available online. One of our current projects that we're working on with Dr. Corey Hood as a clinical psychologist at Stanford and our team are building out exercise resources on the DiabetesWise website. So now we have some exercise resources. We're constantly adding new content, and it would be really great if everyone could use that QR code or check diabeteswise.org for more resources. We often focus on areas that there's less researched areas of expertise, but we have a lot of feedback from people living with type 1 diabetes. That lived experience is very important to highlight. And so just to wrap up, we also have a DiabetesWiser online community. In fact, today we had another Ask an Expert session. We launch those monthly. We're aiming to have new experts join the team every month, and we focus on different topics around diabetes devices and exercise. So as I summarize and pass this on to my colleague, I just wanted to say that diabetes technology has come a long way, but exercise remains a challenge. The consensus guidelines should always be used as strategies as a starting place for exercise, but we know that at the very minimum, individualizing and tailoring our approaches is needed for everyone with type 1 diabetes, but those guidelines and position requirements should always be used as an initial starting place. Thank you, everyone. Looking forward to the Q&A, and I will pass this off. Thank you very much. Hello, everyone. Thank you, Desi, for that talk. I'm super excited to effectively take what you presented and put it in a real-world context. So everything I'm going to be talking to you about is effectively implementation of these newer guidelines. And my intention is to really practically apply them. And I wanted to give you real patients of mine that have actually seen success with a lot of this guidance. We're excited to hear this. The practical use is what's most important, because those guidelines are a place to start. But really, how does this work in the real world? So we're excited to hear more. Yeah, so our learning objectives today are to basically explain the role of exercise in the management of type 1 diabetes, so the big picture, and then effectively implement strategies towards addressing type 1 diabetes in children with exercise. So I just learned that my screen is not shared. So let me try again. All right, I think we should be okay. So a little bit about myself. I'm a person with diabetes. I like to stay active. My intention with activity is to effectively have fun. I'm not in it to win it. I'm not in it for any competitions or anything, but over time I've learned the value of exercise for my overall health. So in addition to, in addition for exercise being fun, it's, you know, it's my way to stay healthy. So I've done bike rides and runs. You know, I like to trail run as well. And every now and then hike, I've been up to the Himalayas with friends. But over time, a lot of it's transitioned to my kids and what they like to do. So, I mean, I never was a skier, but my kids like to ski. So we're taking on skiing. So a lot of what I'm telling you today kind of applies to how I roll just because I have diabetes as well. So I think one of the most valuable things and something that I've just learned through practice is explaining the big picture. So what's the role of exercise when we're treating diabetes? And when I was diagnosed, I never understood this until maybe one or two years after my diagnosis. And I think it's really valuable to communicate this to families. And I still see this. Like I get people who are transferred over and I ask them, you know, what is the reason for treating your diabetes? If it's not getting hospitalized due to DKA, why do you do it? And almost always, I don't get a really firm answer. And it all boils down to the heart. So really when you look at all-cause mortality and when you look at actual morbidity from diabetes over your lifespan, it's tied to heart disease. It's what harms everyone else in this country. So communicating that is extremely important and reminding people of that is extremely important. So heart failure risk is high. The value of this slide is that heart failure, so not atherosclerotic disease, but heart failure is starting to become the main cardiovascular cause of mortality, at least within the US. And unfortunately, heart failure, your relative risk for heart failure is tremendously high with type 1. So this is from a review article that basically shows risk varying from three to almost six. And in type 1 diabetes in particular, your risk of heart disease is tied to effectively the duration of diabetes and your glycemic status, which is substantially different than type 2 diabetes. And in type 1, that's really the biggest impact you can make. So if there's any way to improve glycemic outcomes with type 1, you will have a tremendous impact with regards to risk reduction for heart disease across all fronts. And this is from a review article, but it's actually from a British data registry where they basically looked at all-cause mortality and broke it down based on type 1 diabetes status and disease duration. And you can effectively see, regardless of whether it's atherosclerotic disease or heart failure, the risk is high. And it's the main driver for all-cause mortality. Really the only form of heart disease that's really not impacted is in the realm of arrhythmia. So, and we all know that the impact of glycemic improvement or intervention helps. We learned that through the DCCT. So people were placed on intensive therapy for six and a half years. 30 years post, the risk reduction for heart disease is tremendously lower. So if we can improve glycemic outcomes in the context of type 1, we make an impact. So we know that exercise improves your overall glycemic control. That's not groundbreaking. Desi just presented data on this as well. So this is literature in children looking at, and it's a meta-analysis looking at different studies that impacted A1C. And long story short, A1C improves across all types of physical activity. If people combine both strength training and aerobic training at moderate to vigorous activity, that's typically where you see the best outcomes. And in addition to improving glycemic status, you're able to reduce total insulin use as well. So cardiorespiratory fitness impacts your long-term mortality. So this is a cohort study of over 100,000 patients at Cleveland Clinic, and they all went treadmill testing, and underwent treadmill testing. I think the median age was around 50. And they were effectively broke, they were stratified into their degree of fitness. And on the left, you'll see a survival plot that effectively shows that there's no end to the impact of your level of fitness in terms of risk reduction for mortality. So in other words, the more fit you become, the better your risk reduction is. And then on the right, it's in a different format, but you'll actually see the risk reduction in terms of relative mortality in people who have diabetes. So unfortunately, this study was done in type 1 and type 2, mainly type 2, but the point being is the impact is there. So really the point here is, and this is really what we need to communicate to patients and families, is that in type 1 diabetes, risk reduction for heart disease is tied to your blood sugar control. However, there are other modifiable risk factors that have tremendous impact as well, and a synergistic effect in terms of your risk reduction for heart disease. And communicating this is important because if you really think about the things that you celebrate with other individuals who may not have diabetes, like not smoking, weight loss reduction, the impact that you have with improving glycemic status is arguably higher. So we need to celebrate that just as much, if not more, and remind families of that. So we're gonna talk about two patients that I've seen actually both recently have effectively optimized their diabetes care in the context of activity through many of the strategies that Desi just described. I wanna start off with Brayden. So he's a 16-year-old. He's a state champion power lifter. His goals when we first met were to improve his overall strength and performance and reduce hypoglycemia. He was having a lot of low blood sugars, and he was effectively changing his lifestyle to reduce his hypoglycemia. By nature of bodybuilding, he was trying to navigate nutrition and his blood sugar control. And because of his inability to manage successfully, he was playing around with his bolus behavior to try to accommodate. So this is his CGM when we first met. At that time, he was on multiple daily injections. He was avoiding bolus dosing because he was fearful of having low blood sugars. He never really thought of his activity. So similar to what Desi talked about, planned versus unplanned, that concept was pretty novel to him. He was macronutrient tracking, which is a very awesome thing to do. However, not with the intention of navigating diabetes. And he was aware of automated insulin delivery, but he was hesitant because of concerns that he had, specific to pump sites and falling off. So similar to what most people do, we focused on goal setting. We developed a SMART goal. And him being a bodybuilder was extremely helpful in this because this is something that he routinely does and he is very goal oriented. So he wanted to get stronger. I remember when he first locked in, I asked him, like, you're coming in here, we're meeting, how can I make this useful to you? And he said, hey, I wanna get stronger and I wanna be able to pull off my diabetes while I do that. So I'm like, fair enough. So, we discussed what insulin does. So he never knew that insulin was an anabolic hormone. So I told him, we're able to pull off your insulin just as much as your macronutrient tracking, you'll be able to bulk up, get stronger. I offered him tools to effectively determine whether the things that he's doing is actually making an impact. So we have an in-body machine, which measures bioelectrical impedance within our clinic. And we periodically put him on there to help show that he's actually putting on muscle. And that gave him validation towards some of the changes that we were making. We spoke about automated insulin delivery. We addressed some preconceived notions. I told him, the goal is not to rock the boat. So we will take this device, put it on you as is, and then we'll keep your current dosing. And then you can help me make decisions about how you wanna roll on this device. We had a dietician meet with him to help validate his macronutrient tracking. And more importantly, focus on carb dosing so that he doesn't get reactive hypoglycemia with automated insulin delivery. And then he explicitly asked that I don't wanna provide bolus doses. So typically not a fan of that, because typically that results in a higher basal rate, potentially higher corrections. But with the intention of meeting his goals, we started out that way. So in order for him to pull that off, we discussed the impact of structured eating to minimize risk of hypoglycemia and minimize the amount of insulin on board. And then we also weakened his friction factor so that he doesn't get rebound hypoglycemia as well as a result of his eating behavior. So on the right, you'll actually see his updated, you know, his blood sugars on an automated insulin delivery device. And you can already see substantially different than when he was on MDI. So with all those changes, we brought him back. So if you guys are paying attention to the date, there's three month visits. So we kind of leveled them up further. At this point, I think, you know, I got buy-in from him and we were very open with each other and he's really receptive to most of what I was going to say not as much negotiation as before, but took on the goal to focus on mindful eating strategies. Again, he does not want a bolus. So if that's how you wanna roll then having structured meals, you know, at carb doses that won't result in excursions, result in any lows, it's gonna be the way to go. I started to give him a little confidence in making those changes on his own with the help of his parent. And we talked about situational awareness. So, you know, when he's at a meet, the way that he eats is gonna be different than when he's at home. And what he does with his insulin is gonna be different. He kind of needs to learn what the structure of his day is going to look like so that he can tailor that. So the CGM trend is actually from one of his meets. And you can see that he purposefully chose not to bolus. And we talked about specific food choices that he can eat as a way to basically gain energy because it's a very anaerobic activity. So, you know, a relatively decent carb load, but not significant enough where he'll get overcorrected. And he was able to successfully pull that off for the most part. He got some close lows, but he was able to address those. So he was able to effectively achieve his goals. He was able to improve his glycemic outcomes. And I think for the most part, he's relatively happy. I actually just saw him. And, you know, his goals have changed. So in follow-up, he is now asking about weight class and how to effectively curtail his diet safely so that he can go within a particular weight class to compete. And he's progressing, he's getting stronger and he's moving towards actually national level lifting now. So I actually arm wrestled him in clinic too, which was quite amazing and obviously lost. But again, you know, really this conversation, you know, the two slides that I just presented to you, we didn't really talk about heart disease, right? So when I did bring him back, that really was the reminder. I'm like, look, you know, you achieved your goals, but at the end of the day, the amount of risk reduction you had in terms of cardiovascular disease over your lifetime, it's tremendous. And I told him that, I told him, it's like, you know, you stopped smoking and, you know, and we laughed at that. So I'm gonna shift and pivot because we talked about SMART goals for Braden, but we're gonna actually move into another concept that's heavily tied to goal setting that we oftentimes forget. And that's actually intention setting. Intention setting has been shown to actually improve adherence or compliance with exercise. A lot of people use this as a way to remind themselves why they're doing activity or why they're doing a particular thing. But the word intention is effectively synonymous with motivation. And it really is the driver behind achieving a goal. So in other words, if you set a SMART goal for a patient, you know, you won't be able to achieve that unless you have the intention. So the difference between an intention and a goal is that an intention is independent of it. Goals are focused on the future, intentions are in real time, and then intention is always an internal thing. So, you know, while a goal can be for your team or your family, so let's do this poll question. Again, pretty easy, true or false, understanding insulin onboard and insulin action is important for mitigating. Sorry, I blocked it with my screen. Mitigating hypoglycemia in the context of exercise and type one diabetes in children. Correct. So good job, everyone. Hardest question ever, right? So the next patient we do talk about insulin on board. So his name's Levi, he's a 15 year old. So he moved to Michigan, came as a transfer of care. So he's a soccer player by default. He's actually showcasing for international soccer clubs. He likes to do track. He's kind of an oddball. So when I first met him, I literally asked him, what's your, what are you trying to achieve? Similar to Brayden. And he literally told me, I want to be present for my team. And I actually told him this. I'm like, wow, that's kind of corny. But I'm like, that's awesome at the same time. Because that is intention setting. Like literally the word present was in his sentence. But he never had an intention set for diabetes. So we actually went with that. And we, he really didn't have any structure. He did not have any concept of insulin action. He was given this device and didn't know how it worked. He's literally typing his carbs in and he's not getting the results that he wants. So this is what his AID report looks like. So you can see great interaction with his pump, typing in carbs, but still not in range. So these are a set of slides that I actually used for another talk. And I showed it to him. And I'm like, you know, do you ever feel this way where you look at insulin on board and then, you know, five hours later, you still have two and a half units of insulin on board. And he was, he couldn't relate to this. So, you know, I, we spent a significant amount of time talking about the impact of IOB, which we already covered, so we won't get into. And it became a new thing for him to follow. He went home, started following his IOB with an activity and started to make decisions. You know, basic concepts, taught him what, you know, taught him that insulin is what makes you go low. You know, so if you want to be present for your team, you, you know, insulin should not be present. That was the analogy that I gave him. You know, and then we stuck with his intention. I told him, be present for yourself. Let's take steps to simplify your diabetes. And then when it's time to interact with your diabetes, you interact. So that's, so that's what we did. So we talked about, we talked about making alarms useful. So he was on a G7. We turned off all of his pump alerts. So, you know, he was on a tandem T-slim X2 and he gets alerts on his pump and his CGM. So we turned off all the CGM alerts on his pump, and then we enabled the advanced alert features on the Dexcom G7. The predictive alerts on control IQ would still go off, but most importantly, we use the delayed first high alert where he was only notified if he was persistently high so that he could provide an additional correction bolus if needed. So I wanted to share this slide because I've been using it and he's actually my first patient that's used this app. And he's actually found intention with his blood sugar control using this app. And this is now available on the, in the app store as part of the beta, the beta test for it. But it's a way to gamify your diabetes control without necessarily competing with anyone. And it's had tremendous impact for him because it really put diabetes, it really put intention into his exercise and that intention became his diabetes. And he's been using it for a couple of weeks now. He actually gave me feedback on the app and he loves it. But with that, I'm gonna leave it there and really wanted to thank everyone for having me speak. So we'll have you just remember these five hands-on takeaways from today's panel. First, I'd like to thank our panel for their wonderful presentations today. And if you haven't already, please ask your questions for today's presenters by typing them in the Q&A box on the Zoom at the bottom of the screen. So let's take a look at some of the questions that have come in. And so I'm gonna direct this, I guess, to both Nader and Desi, is the additional benefits of exercise can get buried in clinical guidelines. How do you think other benefits of exercise such as non-scale and non-glycemic victories, quality of life, et cetera, can be best most effectively expressed in guidelines to optimize uptake and implementation by clinicians, especially in the case of pediatric population? I can jump in, but from the clinical perspective, we can leave it to the endocrinologist to give more feedback. I was gonna say for me, a lot of my work, because it is research, I'm not seeing patients clinically at the moment, but I was gonna say that my focus, even in research, is making exercise enjoyable and fun for kids can be one way to kind of steer away from focusing on only the glycemic impact or only the cardiovascular benefits as you start to encourage, and this isn't just for pediatric patients, it's really adults with type 1 diabetes as well. If they can find things that they enjoy doing and whether they have a person that can keep them accountable and encourage them and motivate them, those are the types of things that can in turn lead to a lot of those improvements that we talk about without necessarily making the focus about cardiovascular benefits. I think a lot of times people tell me that they get stuck with the activity they do and very bored of it, and I say, I feel the same way. It's important to validate that too and just say sometimes cross-training or mixing it up is a great way to encourage and promote physical activity so it's not just focused on the glycemic outcomes. Yeah, so I agree, and I think a lot of it boils down to motivation. So currently guidelines are explicit about what people are supposed to do, but I think a tremendous element in terms of implementation involves the coaching behind it. So in other words, explaining how to identify motivation boils down to intention setting. So the kids that I described are athletes just for the sake of this topic, the topic of this talk, but I mean, really, this is something that you can do in other children as well. So a five-year-old might be into Minecraft or... But the whole point is you need to figure out what their motivation is, and then really structure activity with that motivation, and it's a dynamic thing. So something might be interesting, especially as a kid's younger, something might be interesting one day and not interesting the next. So if you're able to set the intention, and for a kid, that's simply just saying, hey, we're gonna go outside, or hey, at this time, we're gonna do something fun, and then in that moment, you identify what their motivation is, that goes a long ways. So I think, but to answer the question specifically, I think the guidelines should incorporate a coaching element potentially to getting kids engaged, but I think part of the difficulty is a lot of what we talked about today, although some of it's evidence-based, it's really hard to yield a tremendous amount of evidence for coaching. So at best, they're just gonna be expert recommendations. All right, and we do have a few more questions in the chat. When, and I'm gonna direct this to Nader, is when and how do you transition from parental management supervision to child taking care or taking on self-care responsibilities with type 1 diabetes? So I'll answer it, I guess, both ways, because I don't know if they're asking specific to exercise or just in general. So at least for how I treat patients, I let parents know that they should always be involved in their child's diabetes. Really, and the decision to provide independence should be done in a stepwise fashion and with supervision. And that's the beauty of technology now is it's much easier to peripherally supervise and effectively validate whether a child is dosing correctly, is staying in range. And even from an activity perspective, you can get a lot of that validation just by looking at a CGM trend. But it's always a team sport. I mean, even when you're an adult, you're gonna need help. You're gonna need to train someone on how to use glucagon. And if you're an athlete, you're gonna have a coach regardless of how old you are. So it's always a team sport. And when a child is younger, the parent's more relevant. Okay, so we do have a few more questions. We have one, and I'll direct it to Desi. How does varying levels of hyperglycemia impact performance in individuals with type 1 diabetes in the pediatric population? I wish I could guide someone to a paper, but as far as I'm aware, we were just talking about this actually yesterday with a group of exercise people that are doing a lot of exercise. Exercise people that are focused in the space. And there really isn't much literature when it comes to performance. Yes, there are studies on how to manage if hyperglycemia occurs with activity, but the focus is often on hypoglycemia and performance. The fact is hyperglycemia and performance, as far as I'm aware, and maybe I don't know all the studies, but from everything we've looked at, there's limited research. I haven't seen any actually that I can point to on the actual performance aspect of it. And apologies again if there is something I've missed, but we all discussed that it's challenging. You can only imagine with that adrenaline response, and this is what got me into research was my own personal struggles, that I often said that I would feel like my blood was like molasses. Everything just felt like it was moving slower and I was exhausted, and let alone I was doing a contact sport. And that's, again, a little bit just anecdotal of lived experience, personal experience. But because of that, you can imagine that, for me, I wanted to understand what's happening metabolically and what's happening to my body during this type of activity. It can impact my outcomes and my performance, I imagined. And just last year, when I got back to competing after some injuries, I had a similar type of experience. So even as someone's so focused in the space, that adrenaline response is really hard to mimic, especially in situations of research, to mimic competition stress and adrenaline responses and hyperglycemia. It's tricky to do. There's been some studies, Mike Riddell and colleagues have done this with HIIT or really high intensity training, but it wasn't as focused on performance, but more of what to do in that situation. Do you need correction doses after exercise? So yes, there's a need to do more in this space. And I think we have time for one more question and I'll direct this to Dr. Kassim. What is the best way to avoid an autocorrect when walking after a meal to blunt the post-meal spike using Tandem or Dexcom G6? So frustrating to get that correction bolus with exercising after dinner. If changing insulin sensitivity factor, do you do it per exercise session? Then how to remember to set that back afterwards? Yeah, so I think the guidelines have it spot on. And honestly, my recommendation would be on what Desi presented. So if it's in the context of a planned activity, especially with anticipated hypoglycemia, ideally you'd actually set a different profile that actually has a lower basal rate and a weakened sensitivity. So, you know, when I were in Tandem, I actually have a separate exercise profile for myself and my basal rate is effectively reduced by about 30 to 40%. To be honest, I don't remember. And then, you know, my sensitivities also decreased in that regard. And ideally you'd want to start that about two hours before. And then you'd also want to run an exercise mode to basically target a higher blood sugar. And in the circumstance of unplanned activity, so which I feel like if you're planning on a walk, probably is not unplanned, but, you know, you're gonna want a carb dose. And it's really the biggest, probably the easiest way is to find the sweet spot in terms of number of grams of carbs. Although there are certain food choices that don't result in a spike. So you have to remember that your auto-corrections are based off of your predicted blood sugar. So if you have a carb load that causes a rapid spike, your predicted blood sugar is likely going to be higher and you get a larger correction. So if you're able to eat something that is not as fast acting, that has a mix of protein, maybe fat, that might mitigate that phenomenon as well. I don't know, Desi, if you have any other thoughts. Yeah, I agree with all of that. I just wanted to jump in because we do have a section on this in the position statement that's now live today. So we also kind of touched on the fact that if you deliver a very, very small, the smallest possible bolus dose that actually stops auto-correction doses for the next preceding 60 minutes, so hour. So it's a consideration. Obviously something very small, as low as you can do, is something that will also stop those auto-corrections. So something to consider for unplanned activity. Yeah, exactly. It looks like someone in the chat said that as well. Okay, great. Well, before we end today's session, I wanted to explain 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 Continuing Education credit. And look 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 the webinar for one Continuing Ed credit, and that's eligible until December of 2025. I'd like to thank our panel again for sharing their expertise today. And I also wanted to thank each one of you for joining us. We hope to see you at another ADA webinar in the future. And this concludes the session. Have a great afternoon and see you next year.

diabetes care

youth exercise

glucose management

type 1 diabetes

hypoglycemia

exercise guidelines

insulin delivery

SMART goals

glycemic control

cardiovascular risks