Hi, everyone, and welcome to today's hands-on tips to improve diabetes care webinar. Today our panel will share their expertise on overcoming glycemic barriers through exercise and lifestyle. We're glad you're here. I'm Dr. Maria Bonvini, and I will be moderating today's webinar. To share a little bit about myself, I'm a staff physician at Joslin Diabetes Center in Boston. I'm a research investigator as well and an instructor in medicine at Harvard Medical School. My research is focusing on the beneficial effects of exercise on different organ systems, including skeletal muscle, adipose tissue, and brain. We will spend the next hour together by following the agenda, which is in the next slide. If we could advance the screen to the slide, good. We will be using interactive features during today's session. We will send you important links and information throughout today's session in the chat box, so please check the chat box. We will be using Zoom Q&A at the end of 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. And we will be using an interactive tool called Kahoot today during our webinar to ask you knowledge-based questions and collect your answers in real time. So just to introduce Kahoot and how to connect with Kahoot to Kahoot, if you have a mobile phone or tablet nearby, that is often the best and easiest method to use. You can also use whatever device you're using right now to watch the webinar. You'll just need to open another window or tab on your browser. And to connect, open the browser, type Kahoot.it, then enter today's game theme, which can be found in the Zoom chat and on screen. And I'm going to give everyone a few, about 15 seconds or so to connect to Kahoot. So please go ahead and follow the instructions that you see on the screen. And join us on May 14th for the next installment in the hands-on webinar series, Empowering Adults with Diabetes Strategies to Support CGM Use in Diabetes Self-Management. You can click the link in your chat box to register. And with this next slide, I'm going to introduce the panelists for today's session and today's webinar. We have Dr. Roland Young-William Middlebeck, who is a staff physician and assistant investigator at the Joslin Diabetes Center. His research focuses on the role of physical activity and exercise in obesity and diabetes, with a particular focus on white adipose tissue. As co-investigator of the DPPOS and Lookahead clinical trials, he studies the role of physical activity in relation to glucose metabolism and live cell interventions in relation to timing of physical activity. Dr. Middlebeck has a specific clinical interest in the role of exercise in the prevention of prediabetes and the treatment of type 1 and type 2 diabetes. He also participates in the Young Adult Clinic at Joslin. Our second panelist today is Catherine Gentile Alvarez. She received her Bachelor of Science in Exercise Physiology from Ave Maria University in Florida and a master's degree in clinical exercise physiology from West Chester University in Pennsylvania. She's certified by the American College of Sports Medicine, as well as the International Sports Science Association. Catherine was diagnosed with type 1 diabetes at the age of 12. Along the way, she has studied the effects of various forms of exercise on glucose levels and enjoys developing basic and advanced exercise prescriptions for patients, as well as providing diabetes education to improve time and range. At this time, I will let our panelists introduce themselves and state their disclosures. Thank you for the introduction. I'm Jan-Mila Middlebeck, and I have no disclosures. And I am Catherine Gentile Alvarez, and I also have no disclosures. Okay. Okay, we'll get started. Thank you, everyone, for joining today during today's webinar titled Overcoming Glycemic Barriers Through Exercise and Lifestyle. So it's my great pleasure to talk to you about this topic, and we'll give a little bit of a background on the topic first. But before we do that, we'll start with a quiz. The first question is, what is the definition of exercise used? And you can indicate in Kahoot if this is physical activity, such as house cleaning, unplanned activity that increases energy use, planned activities such as child care, or planned structural activity with the goal of improving physical fitness. Okay, most people selected answer that D, which is correct. Okay. Well, we'll start with the learning objectives for today's webinar. The first one is to define the effects of different exercise modalities on blood glucose regulation in people with diabetes, with both type 1 and type 2 diabetes. And also to recall strategies to really empower the healthcare team to counsel people with diabetes in planning their exercise and activity routines, such as to remove barriers to becoming more active. So before we dive into some of the mechanisms underlying the regulation of glucose in the context of exercise, it's important to define the different terminologies, including physical activity and exercise. So physical activity, when we think of that, that's all movement that increases energy use. And an important component is work, is physical work, as well as recreational activity or household work and yard activities, as well as child care and exercise is a part of that. But then when we specifically talk about exercise, we talk about more planned, structured physical activity with the goal of improving physical fitness. And it's important to note that both are useful in diabetes management, and I'll make a comment that in counseling patients, sometimes terminology can be somewhat sensitive in terms of describing exercise. So another tool might be to talk about activity or becoming active. So why is this important? What are the benefits of exercise? I will start with outlining some of the studied and demonstrated benefits of aerobic or cardiovascular exercise. And this is summarized in the position statement listed here from the ADA and the AC, the College of Sports Medicine joint statement, where we know that aerobic exercise can improve cardiovascular function, improves lung function, as well as immune function. And in our context, looking at diabetes, it improves insulin sensitivity or reduces insulin resistance in the tissues of the body. And looking at metrics related to diabetes management, it reduces hemoglobin A1C, blood pressure, triglycerides, and also has been shown in large studies to decrease cardiovascular and overall mortality. So overall, demonstrating numerous benefits, more than I listed here on this slide. But also another type of exercise is important to consider, which is resistance or strength training. And this modality has also numerous benefits that overlap, but also specific ones that are related to resistance or strength training, such as muscle mass increase, reduction in body fat percentage, improving physical function and strength, as well as bone density, improving posture, and shared metrics related to improvement in hemoglobin A1C, triglycerides, and blood pressure, as well as an overall improvement in insulin sensitivity. So important to counsel your patients with regards to benefits of both these modalities. So this is a complex slide, which unfortunately I couldn't animate in here, but what this represents is really some of the molecular mechanisms of skeletal muscle glucose uptake. So what you see in the top of the screen is a representation of a blood vessel going across, and this provides nutrients to the skeletal muscle cell represented here. And the complex cartoon, mostly on the left side, indicates delicate mechanisms of exercise inducing a cascade of protein activation. But what I want you to take away from this slide is that vesicles that are stored in the muscle that contain glucose transporters, GLUT4 transporters, translocate under exercise stimulation to the membrane, and that helps to take up glucose, sugar, from the blood vessels into the muscle so that the muscles can perform its function. Now, how can we then measure glucose uptake in the setting of exercise? So if you first focus on the on the left side with in some of moderate intensity exercise, low to moderate intensity exercise of 40%, over time, we can see that skeletal muscle glucose uptake increases. And with higher intensity, there's a higher rate of skeletal muscle glucose uptake. Now, on the left side, what we can see in people who are either insulin sensitive in the regular lines or in the dotted lines, people who are more insulin resistant shown here, that before versus after exercise for the same amount of insulin circulating in the body, there is more skeletal muscle glucose uptake in people who are insulin resistant, as well as people who are more insulin sensitive. So overall, underscoring the benefits of exercise and increasing skeletal muscle glucose, skeletal muscle glucose uptake, even in the setting when there is insulin resistance. So highlighting the insulin independent way that this occurs. So before we go into the next part of the presentation, focusing more on exercise, I do want to take a moment to highlight this figure, which is in the current 2024 standards of care, section five, that really highlights the sort of multifactorial way that exercise and physical activity can help overall blood glucose management and wellness in people with diabetes. This figure is focused on some of the data demonstrating people with type two diabetes, but it integrates importance of sweating, which is represented by moderate to vigorous activity, maintaining muscle strengthening activities, but also on the scores, sleep quality and sleep duration, the effect of different chronotypes that people may have importance of stepping. So increased stepping counts and breaking up prolonged sitting as part of a 24 hour physical behavior that helps maintain blood glucose. And these are the metrics that have been shown to be improved with these efforts. So I wanted to highlight next this slide that I sometimes share with patients from work from Mike Riddell and Peter's that have shown a different glucose responses into different forms of exercise. So what you can see is different types of exercise, for example, endurance exercise, which has a sort of a more steady work rate, more explosive exercise, high intensity interval training or resistance training. And these are all have different variations in work rate and duration, but also then have different effects on glucose trends. So with more steady, moderate intensity endurance exercise, you may see a steady decline in blood glucose. While this is not necessarily the case for more explosive or more resistance exercise and high intensity interval training can have a variable effect. We'll come back to this later. So other factors that are important to note and we'll zoom in here on people with type one diabetes that affect the glucose response to exercise include the exercise type and duration as well as intensity, the time of day, C-peptide status, and certainly also insulin on board, insulin treatment modality, the amount of carbohydrates consumed, the rate of change in glucose before start of exercise, as well as its level and somebody's sex and gender, competition stress that may add additional counter regulatory hormone concentrations, all affecting blood glucose. So what this underscores is the really the need to individualize the strategies with patients and to treat it as a case to case based on individual basis. So why is it challenging to engage people in patients in physical activity? Really one of the key barriers is and continues to be fear of hypoglycemia. This has been very well documented in younger adults and children. People with type one diabetes certainly on insulin treatment either with pumps or with multiple daily injections are one of the key barriers. And also post-exercise hyper or hypoglycemia can also be a major barrier. The hypoglycemia most commonly develops right during the exercise and immediate post-exercise, but also can stay can occur much later, up to 24 to 31 hours after exercise has finished. So in some of the older pump systems, the incidence of exercise induced hypoglycemia can reach up to 44% when there is no specific strategy applied to adjusting for exercise. And this is prior to the more automated insulin delivery systems. And with more vigorous training, we can also see hyperglycemia that can last a few hours after exercise, if not managed correctly. I'll show you this in the next slides. So we'll walk through some of the strategies to manage glucose in patients who are on insulin treatment, either with a pump or multiple daily injections and or those who use a continuous glucose monitor, which is really helpful in detecting hypoglycemia and hyperglycemia. Okay, so some of the strategies to address late onset hypoglycemia, this is after exercise has terminated, is to perform physical activity or exercise earlier in the day, which can help prevent some of the delayed hypoglycemia that is seen when patients are active later in the evening or at night. Consuming low glycemic index carbs throughout the day can help, and consuming a bedtime snack prior to going to sleep is another strategy. Also in some of the more fixed insulin pump systems, reducing basal insulin by about 20% for a number of hours overnight can also be of help. Now, what to do about hyperglycemia post-exercise. So there could be ways to keep the exercise mode on, avoidance of extra snacking with no bolus before intense exercise if glucose is predicted to increase significantly, which some of the sprint or high-intensity interval practices may show. Perform a cool-down after high-intensity exercise. And studies have shown, work from Mark Riddell, that a correction bolus for 50 to 150% at the end of a high-intensity exercise is recommended and safe to do based on an individual's incident correction factor. Now, what to do prior to start of exercise. So it's important to keep a couple aspects in mind, and here I'll show you a schematic representation of some of the strategies that can be employed to reduce the amount of insulin that patients have on board while starting to exercise. So in the pump systems, in the open-loop systems, people can reduce their basal insulin delivery by at least 50 to 80%, at least 60 to 90 minutes before exercise. This is shown here with 90 minutes pre-exercise. And virtually all the AID, autoimmune insulin delivery systems have either an exercise mode or temporary targets that targets a higher blood sugar target for about one to two hours prior to exercise. Now, this is in an ideal world where people know that they're gonna be exercising, but this is not always the case. So if this is unplanned activity, people in practice can and will suspend their pump just before exercise is performed, but they can still be at risk for hypoglycemia. Now, bolus adjustments for exercise are also important, particularly if there's a bolus right before exercise, because that will increase the amount of insulin on board. So boluses can be reduced by 25 to 50%, about 30 minutes prior to exercise. And the reduction can be 50 to 75 for 60 minutes of exercise or longer when performed during the peak of rapid insulin action, so one to two hours after a meal. Now, we talked a little bit about insulin, but another really important aspect is carbohydrate intake. So muscles need glucose to perform well, and eating before training and competition is certainly recommended, but perhaps with a low to medium glycemic index carb-based meal about one to three hours before exercise. It may be required, particularly if aerobic exercise is initiated, to take a small snack closer to exercise training to allow for the start of the exercise in a comfortable glucose target zone. Now, during training and competition, carbs may need to be consumed. There's variability, but 20 to 60 grams of carbs per hour have been suggested depending on the blood glucose trends, the duration and intensity of the exercise, all underscoring the variability that can be observed with the individual needs for carbohydrate intake to avoid hypoglycemia. Glucose replacement could range even up to 10 to 20 grams of carbs every 10 to 20 minutes to maintain performance as well, and fast-absorbing carbs are recommended that can easily be tolerated and also taste good. Now, continuous glucose monitors, or CGMs, have become really critical in maintaining overall glucose management in people with diabetes, but certainly in the context of exercise, they provide an additional sort of safety layer and additional information with regards to glucose management. So this senses glucose in the interstitial fluid while blood glucose monitoring used by finger stick measure the capillary blood flow. So there can be a lag time between these two that is influenced by alteration of blood flow, body temperature, and body acidity, so that's all good to keep into account when comparing CGM versus finger stick blood glucose, and type of exercise, interfering medications, direction of change, and rate of change, and based on glucose level, all are key factors that could indicate differences between the two metrics. And in the more modern CGMs, the lag time can be around 10 minutes or so, so that's important to note. This is a guidance with regards to what to do with specific blood glucose values obtained during or at the start of exercise, and the different trend arrows indicating an increase, a stability, or decrease. And what this gets at is that an ideal starting range, particularly for aerobic activity, might be between about 130 to 180 milligrams per deciliter, which is a good starting point to avoid immediate low blood sugar. Now, if blood glucose concentrations are lower, taking a snack is recommended, and under 90 milligrams per deciliter, there is a high hypoglycemia risk, so certainly bringing the glucose higher is a good strategy. At the same time, at a high glucose level, particularly in people with type 1 diabetes, checking for ketones and avoiding exercise is a recommended strategy. Now, the automated insulin delivery systems where both an insulin pump and continuous glucose monitor in combination regulate insulin with minimal interaction proprietary from the person with diabetes have become more widely used. And these algorithms try to adjust insulin delivery based on multiple factors, such as the amount of active insulin circulating, patient's insulin sensitivity, CGM values, target blood glucose, and recent history. I should say that in practice, exercise still remains one of the key challenging factors, even for the most advanced closed loop automated insulin delivery systems. But if you look at the guidance from all the different pump manufacturers, it's generally recommended to set exercise mode or temporary target about one to two hours in advance of exercise for the duration of exercise or longer, all with the goal to have less insulin on board. So this is guidance from the different current systems. I should say that for ILIT from Beta Bionics, there is similar guidance. What I highlighted here is some of the variability in the range between 60 to 120 minutes, but this is generally recommended for all pump systems. And it's important to know to avoid a large, to indicate a large carb snack on the AOD system, because this will increase insulin delivery for this snack and then bring more insulin on board, risking, inducing risk of hypoglycemia. So zooming in on the specific types of exercise, I'll talk mostly about aerobic and endurance exercise in the next few slides, showing you some of the studies that have been presented over the last few years. This is a study using the MiniMed 780 system with spontaneous exercise by cycling for 45 minutes compared to either announcement of exercise 90 minutes prior to exercise with a 25% reduced bolus. And this is a 45 minute prior to exercise announcement with again, a 25% reduced bolus. And what I hope you can appreciate from this slide is that with this snack, prior to exercise, the glucose rises, but then at the start of exercise, there's a steady decline in the glucose concentration in all three arms of this study, but the study arm where there was announcement of exercise 90 minutes in advance avoided hypoglycemia compared to some of the subjects in the spontaneous exercise group. So underscoring the importance of early announcement. This study looked whether there may be differences in having a meal with exercise announcement and reduced insulin delivery, either 120 or 60 minutes prior to exercise. And there overall was not necessarily a difference between the two treatment modalities. So either one or two hours before a safe, you see again, the robust and steady reduction in the glucose concentrations during the 60 minutes of cycling in this case. So this study concluded that premium meal bolus production and increased glucose target was effective and safe during 60 minutes of aerobic exercise, whether or not this was done at 60 minutes or 120 minutes following a meal. I'll zoom in on some of the guidance on resistance exercise. And here general principles still apply. So it's important to announce exercise in the AID system. If patients are using this system to manage their glucose, CGM is again, really helpful in monitoring glucose concentrations over time. And some of the strategies I'll show you next, but is to perform resistance exercise first prior to aerobic exercise component during a workout session which could provide some buffer against hypoglycemia by maintaining or raising blood glucose. And overall resistance exercise shows a little bit of a milder glucose decline compared to aerobic and lowers the need for carbohydrate intake to counter hypoglycemia. Some of the key studies from Jane Yardley published a number of years ago in Diabetes Care. So this was a crossover study that looked at the glucose concentrations during three different types of exercise, either in no exercise control or aerobic exercise or resistance exercise. And you hopefully can see that again, aerobic exercise led to this sort of steady and persistent decline in glucose, almost bordering on hypoglycemia. And then this stabilized, but resistance exercise showed a sort of more milder trends and avoided some of the hypoglycemia that was shown in the aerobic exercise. Jane Yardley then did this crossover design where both aerobic and resistance exercise were paired in one exercise session that lasted 90 minutes. So RA is resistance exercise followed by aerobic, which shows stability in the glucose and the decline post aerobic exercise. But the first, the white circles show the steady decline leading almost to hypoglycemia in the aerobic exercise. And this was then reversed partially in the resistance exercise that followed. But the point is to potentially recommend patients to do the resistance exercise first as to avoid the hypoglycemia and need for further treatment. So with that, we'll have another question. A person with diabetes using an AOD pump system starts a workout, sense of glucose is 98 with a downward arrow. What is the best next step? So turn off exercise mode, turn on 10 basal, keep exercise mode on and eat a five to 50 grams of carbs snack or just eat a snack, 10 to 15 grams of carbs. Okay, that's great. Okay, so with that, I'll summarize this part of the talk of the webinar session. So different forms of exercise have different effects on glucose, really underscoring the point to individualize guidance to patient. And insulin adjustments either via injections or the insulin pump are critical to prevent low blood sugar, hypoglycemia, as well as hyperglycemia. Carbohydrate intake is important to maintain performance and also to avoid hypoglycemia. And use of CGM to guide exercise and avoid hypo and hyperglycemia is extremely helpful. And using in an insulin pump setting, using an exercise mode, a temporary target or reducing basal or bolus in advance of exercise can help prevent hypoglycemia during and after exercise. And again, trial and error are key components for more individualized strategies to help with glucose management during exercise. Turn it over to Catherine. So thank you. Great, so we're going to look a little more into a lot of things that we looked at in the previous slides and then go over some case studies as well. So first we're starting with the quiz. Which of the following is found to be productive in helping patients find motivation? Fear tactics, going over the benefits of physical activity, avoiding any physical activity throughout the day, staying up late at night to enhance motivation for exercise. Perfect. So yes, like Dr. Middleby said, there's so many benefits to physical activity. So helping them learn what those are make a big, big difference. So our objectives here are to recognize the common barriers to exercise for people with diabetes, and then identify goals that are going to meet individuals and what their fitness level is, is their health status, what they enjoy day to day, other health conditions that they might have. First, I want to touch on the FIT recommendations. So this is frequency, intensity, time and type. This is the same for people with diabetes as it is for the general population, as long as they don't have other comorbidities or diabetes related complications. So these recommendations are three to seven times a week of exercise that is moderate to vigorous in intensity, spending 150 minutes a week doing prolonged arithmetic exercises using large muscle groups. Important things to be included are both, so we have the strength base, the cardio base, but also flexibility and balance is another important thing to include in there. So the top common barriers that we come across is diabetes related. So fear of both hypo and hyperglycemia, which are very valid fears around exercise. And it can be an argument that exercise can make diabetes management more complicated because of the adjustments that we need to make to keep our blood sugar within target glucose range. Making time for it is a big thing as well. So, you know, people have busy schedules, especially in the United States. We are hard workers. We work, work, work. And a lot of times you get home from your work day and you just want to relax at that point. So how do you find the motivation to emphasize to people how important it is to make time for physical activity? Or how do you incorporate it into their busy work day? Access is another issue for a lot of people. Not everyone can afford a gym membership or have transportation there. So meeting them where they're at, encouraging them to use things that they already have at their house. We don't need exercise equipment to get physical activity. And this motivation, find what is going to motivate people. Do they have a grandchild that they want to stick around for and be able to play with? How can you convince them that this movement is very important to them? And body image is going to be another barrier. So we hear a lot that people feel uncomfortable in the gym. They feel like everyone's looking at them and therefore they don't go. So, again, kind of helping them work through these barriers. And then weather. You always need to have a backup plan because if you're planning to go on a walk outside for your physical activity, and then it starts to downpour out of nowhere, which of course can happen, you can't control the weather. You're going to want to give them other ideas of things that they can do, especially because if we're prepping our blood sugar for this physical activity and then you can't do said physical activity, then your blood sugar is going to get messed up. So backup plans, especially for people with diabetes, is very, very important to work through. Goal setting is important. So we need to write down these goals and reference back to them for individuals. Write it out on a list, have them take it home, and you need to keep it for yourself, too, to remind them of their goals. Every individual is a little different. So it's, I would argue, inappropriate to give everyone the same target glucose for physical activity. So we need to look at where they're currently at and give them a target range based on that, where their comfort level is and what's going to be achievable for them. And then follow up with them. You really want to encourage them to track the time of day that they're doing the physical activity and what type of physical activity they're doing. That way, you can go back and you can look at their data and you can see, OK, well, what happened? Because I promise you, two individuals go to the gym, both have type 1 diabetes. They do the exact same thing, do the exact same, maybe they do the exact same adjustment to their pump on the same hybrid closed-loop system, and they're going to have completely different outcomes. So individualized strategies will lead to much more success and confidence in doing physical activity. And it is truly incredible how a person can go to the gym, let's say in the morning, and do the exact same workout the next day in the evening, and their results are totally different as well. So going over the data is the best way to come up with the best program and what's going to work the best for them. And we want to have a place where they feel comfortable doing physical activity. And what we found over COVID is for a lot of people, it actually is at home. But home is also a place where we can easily get very comfortable. So that motivation really, really needs to be there if their plan is to get these workouts in at home. On top of that, you also need to make sure that you're listening. That's so incredibly important. The concerns that they have validate them, but help them overcome any fears that they may have. There is a lot of resources that we can provide. A lot of them are free. We have to have resources that we can refer them to and send them to. We can't be experts in everything, but we know that physical activity is really important to our patients. So where are we going to refer them to? Exercise physiologists are a great consideration. Personal trainers, excellent, but they don't have the same specialized training in diabetes that exercise physiologists get. Do you get that coverage of how do you help people with glucose management? And there's more and more exercise physiologists, diabetes care and education specialists out there. And hopefully they will continue or there's going to continue being even more of those. So great to have on your team and refer to to work with these people, especially because they can do one-on-one in person and go over the results firsthand with your patients. So as I've mentioned, anything can be your gym. We don't need to go to any of these big gyms, LA Fitness, Crunch, which a lot of health care plans do offer discounts with. There's different facilities where if you go to a gym, you get points towards your insurance. So that could be a motivation or something helpful if they did want to exercise in a gym. But a lot of household things that they could utilize instead, you can use water jugs. You can use your children, get pretty heavy over time. Books, you put a backpack on. There's so much you can do if you just get creative. And our body weight is adequate as well. So I'm perfectly good to utilize that. Probably notice that I'm standing. Just standing alone is something that is going to improve insulin sensitivity. Well, it can improve insulin sensitivity. sensitivity. So well, if you're watching this right now, you should stand up and encourage your your patients to do the same. Take those stairs. Instead of walking, I'm sure you've heard of these little tiny recommendations that are often made. Parking your car further away, hiding the remote so you have to go further in your house to go get it. Little things do add up are helpful. Now there is a lot of resources to refer people to. So for example, I work for integrated diabetes services. If you go on our website, we have lots of printable things that you can provide for your patients on all different topics of diabetes management. The ADA has a resource site. There's a lot of really, really great podcasts now that are out there. Some of them are led by top endocrinologists in the world, or diabetes care and education specialists. So great to check out. It is important to warrant people to be careful of what they are finding online and listening to. You know, you should never take medical advice from social media pages. That's something that's becoming more and more common. But finding the support in these things, and then you providing them with the podcasts and blogs and resources that you know are safe and useful things for your patients to reference. Because our consultations are short with them, and a lot of them are going to want to do a little bit of listening or reading and learning on their own time as they get more and more into fitness. So a key study I wanted to go over. I met a great guy, he's 5'7", well he was 260 pounds, a 39 year old man. When we met his goals were to lose weight, to increase his strength and also just general health. He wanted to reduce those risk factors associated specifically with diabetes. His current activity at the time was that he was walking his two dogs twice a day. He worked full time. And upon our first meeting, he was seated during all of those hours. For his personal management, he was utilizing DIY loop. So this is off label use of the Omnipod and Dexcom. Just a little note on that as we are looking at people with limited resources as well. DIY loop is an option that many people go to, because of the fact that the FDA can be kind of slow, but also, in many places, they might not have access to these same hybrid closed loop systems that we have here in the United States. So they might go this DIY route to be able to utilize newer technology. Or you can use older devices, which they might be able to get for cheaper and still get a nice automated insulin delivery system to help them in the background. So back to him, he didn't have any additional complications or noteworthy medications. And when we talked about the things that he liked to do, he mentioned walking, music, dancing, and bike riding. So in our sessions, two things that we were sure to include are Zumba based things, walks together, and music always on in the background, which he made a great playlist for, and I use it for all of my group exercise classes. And most of the people I meet with one on one for exercise. Our original plan was to meet bi weekly for 30 minutes for personal training sessions, gradually moving those up to one hour, which we were able to pretty quickly progress to. He really, his improvement was awesome to see. And then he also attended, which was optional, but he always comes attend one hour group exercise classes bi weekly. And just to know on those group exercise classes, what they are, and Dr. Middleby kind of touched on combining two forms of resistance training exercise and cardio based exercise, because they can make glucose management a little bit easier. So what I do in my group exercise classes is we always start with strength based exercises. And then we move into cardio based. Well, we don't start with that we do a warm up. And then at the end, we do a cool down and get the stretching in strategies we use with him. So with loop, it's called overrides, but similar to temp basal decreases or target blood sugar adjustments. Depending on what his day looked like, we might incorporate some carb supplementation. Another off loose off label use thing that he did do as many do many dose glucagon. He also depending on time of day, so more specific with the dinner, or group exercise classes, because they're around dinnertime is mealtime bolus reductions. And then just really noting the importance of depending on when that workout was being done is how we planned on what that adjustment to his regimen was going to be. And then the outcome of this is 35 pounds have been lost in a healthy way. He now absolutely loves physical activity. He's joined a power lifting gym, he goes to yoga classes very regularly, lots of physical activity based events. He has an under desk walking treadmill, and also one of those under desk bike pedals. So moving constantly throughout the day, major improvements in his energy levels. He's always improving his one rep max and other strength tests. And I'm pretty excited about this. He closed his move stand and exercise ring on his Apple Watch 364 days. And he's on the same path, but at 100% so far this year, and he would have gotten all 365 days, but he forgot to wear his watch for one workout. But yeah, can't count it if the ring wasn't closed. But really, really excellent things. And um, it was achieved through us working together. Oh, here's our question, which of the following is not one of the fit principles? Woohoo! Nicely done. That is correct. Frequency, intensity, time, and type. So our key points, and just in summary, overcoming those barriers requires us talking, listening to our patients, and meeting them where they're at, understanding what is going to be doable for them, write down their goals, and make sure you're following up on these goals, and then making new goals once they reach the ones that were originally made, and then realistic solutions for people with limited resources, getting them to utilize things in their home or outside, whatever they can to get that physical movement in. Right, so summarizing both talks, we should remember these five key tips and takeaways. So number one, use of continuous glucose monitoring to guide exercise and avoid hypoglycemia and hyperglycemia is extremely helpful. The second point is that in insulin pumps, using the exercise mode and or reducing bolus in advance of exercise can help prevent hypoglycemia during and after exercise. The third point, trial and error are key components for more individualized strategies to help with glucose management during exercise. The fourth point is that write down and follow up on goals with patients, and the last is that realistic solutions can be achieved for patients with limited resources. And I see that there are a few questions in the Q&A, and also there was one in the chat. I can start with the first one from Michael C. He asked a couple of questions, and I'll try to summarize them. First, he's asking about the factors that can distinguish responders from non-responders in regards to insulin sensitivity and how you measure insulin sensitivity. And any of the two panelists can answer this question. Sure. Yeah, so I think as far as insulin resistance and insulin sensitivity, maybe thinking about patients with type 1 diabetes, you see in clinical practice, you can get a glance at this from their insulin requirements, so you can look at the total daily dose divided by their kilogram, by their weight to get sort of a kilogram, units per kilogram indication. There's variable metrics, 0.4 to 0.6, or maybe 0.4 to 0.8 is a little more in the insulin sensitive range. But if you see somebody who needs one, let's say one unit per kilo, that might indicate that somebody is more insulin resistant. Other facts could include excess body weight or, for example, having been on corticosteroids for a certain treatment. So that might help you guide to determine whether people are more sensitive or more resistant. There is some anecdotal data that people who are somewhat heavier or more insulin resistant are a little more protected against high excise-induced hypoglycemia, but we don't have good studies to dissect that. So certainly if you see low insulin requirements, people might be more sensitive. So it's really key to focus more on prevention of hypoglycemia. Yeah, with type 1 specifically, looking at that total daily dose of insulin, a lot of times I'll meet with people and they're running out of insulin on their insulin pump and they can't make it the full amount of days, the three days for most systems that they would be able to otherwise. And then they start physical activity and all of a sudden they're able to keep their pump on for three days. So it makes a huge, huge difference. My total daily dose, if I don't get physical activity, it's crazy to see the difference in what it is, how quickly that total daily dose goes up without movement. And you can even see it there. I used to teach a class for people with type 2 diabetes at a hospital and we would do this little test to show people. I'm taking credit. It was really my colleague who came up with the idea, but she would have them go on a walk and just look at the difference of blood glucose response. So with type 2, none of them were on insulin at that point. But yeah, super cool to see. And another question that is in the chat for Michael again, and this is probably for Catherine. So do you see a difference in the glycemic response with exercise between individuals who are trained versus untrained, like someone who doesn't exercise and starts a program versus someone who does a little bit and then engages in the program more? It's kind of like the grocery store phenomenon. People that are more untrained, if they go to the grocery store, blood sugar will typically go quite low because of all the extra walking around that they do. Whereas someone that is very, very physically active, they can go to the grocery store and not tank out. We all see it to some extent, though. That movement is definitely going to lower our blood sugar. Another question in the chat, does insurance cover exercise physiology visits and how do you utilize exercise physiologists in your team? So that's in the works. It's very challenging to get it covered at this point. But the whole exercise is medicine movement is really working on making that something that's much more doable. The trick right now is to get a referral from a doctor. If you get a referral from a doctor, then you should be able to get coverage for it. And on my team specifically, we utilize the exercise physiologist for exercise programming, getting people started along with adjustments to be made to help them stay within their target range for physical activity. And for type one, for people with type one diabetes, especially in pediatrics or on insulin pumps, are the recommendations the same as the adults? I mean, the recommendations out there are not the best. Like I mentioned in my presentation, you really need to individualize each strategy for people and what you're going to do. Now, for little ones, they're much more unpredictable and they're typically more sensitive to the insulin and they are going to be much more responsive to carbohydrate. So if you have a little one eat 15 grams of carbohydrate to treat their low blood sugar, even most adults on an automated insulin delivery system, telling them to eat 15 grams of carbohydrate is going to make their blood sugar go off the charts typically. So I'm kind of forgetting about some of these basics that we were taught. Not always going to be that rule of 15. And sometimes they need just a jelly bean to bump them up. No, I got that. And it's important to keep in mind that the recommendations to be physically active are different for children. People are right. Children are recommended to be active for at least 60 minutes every day. And at the same time, you know, as mentioned, fear of hypoglycemia is really, really one of the key barriers. So really sort of focusing on preventing hypoglycemia and addressing the risk of hypoglycemia upfront can make them successful in being active throughout their childhood and also adolescent. Their insulin sensitivity may change during puberty. So, again, it comes back to working as a team, working on an individualized basis to allow them to be active in a safe way. Okay. And what do you say to people that want to engage in a training program but have highly variable glycemic control, markedly elevated glucoses in the 200s or 400s, and they've been inconsistent with their multiple daily injection and glucose monitoring? That's good. So I'll start. There's a couple of things to unpack there, right? Sort of what are people looking for in a training program? You know, but before we do that, sort of, can we optimize the starting point for their glucose control a little bit better, glucose management a little bit better? Maybe just starting as a small step, working with a CGM might be helpful, engaging them more in their own management, but also talking not only about avoiding hypoglycemia, but certainly also performance is generally better when people have glucose levels that are a little bit lower, and also safety are important factors. So perhaps starting very slow with sort of incremental wins and incremental steps to engage patients in physical activity might be a starting point of the discussion that probably will take off over time. But I'm just curious to hear what you would say. Yeah, I totally echo everything that you said. And just kind of bringing up with the person, like what is leading to the forgetfulness of taking their medication? What reminders can be put into place to help them be a little more on top of it? Finding like what is going to motivate them to be more on top of it is really what you have to look back and start from there. Yeah. And one comment maybe that comes back to sort of how do you get people to become more active? Could you tie this into an activity that they love, right? So can they be active with, let's say, their children or their grandchildren by sort of starting engaging in a more walking pattern or tying it into sort of a hobby, all ways to make not only get started on the activity, but also make it more durable habit for sort of a lifelong increase in physical activity. And one last question. We have two more minutes to Catherine. So you mentioned in your case that the patient engaged in two sessions per week, if I remember correct, one hour per session, but he lost weight. And I wanted you to comment on the duration of exercise and what are the recommendations for maintaining cardiovascular health and glycemic control versus weight loss? What kind of exercise and duration and what is different depending on the goals that people set? Yeah, this is a great question. And it's tough to answer because there's no clear research that tells us that exercise truly leads to weight loss. So it's not a guarantee that people that increase their physical activity are going to lose weight. But we do know that physical activity helps us sleep better. It lowers our total daily dose of insulin, which is very specific to people with diabetes and can also contribute to weight management and improvements there. It reduces stress, which is another thing. A lot of people will do things like stress eat. So reducing those levels of stress and also anxiety, depression are going to be big things to get people both eating and more energized. It'll also increase the calories burned even when we're not exercising, which is, of course, helpful as well. So there's the other aspects that you have to kind of look into. We can't contribute it just to the exercise. The diet, unfortunately, is going to be by far the most important thing. But the exercise, we have studies that shows that it can help with that. All right. Thank you very much. I would like to thank our panelists for their amazing presentations. And just before we end today's session, I wanted to let you know what to expect from this point. Later today, you will receive a post-test by email. And please complete it so that you can claim your CE credit. Be on the lookout for today's webinar recording on the ADA's Institute of Learning page in a few weeks. And remind any fellow members that they can watch it for one CE credit eligible until April 2025. And I would like to thank you again. I would like to thank our panelists for sharing their experience and their expertise. And I would like to thank you, each of you, for joining us. And we hope to see you at another ADA webinar in the future. And this concludes our session today. Have a good afternoon. Thank you. Bye, everyone.

glycemic barriers

exercise

lifestyle

diabetes care

blood glucose management

continuous glucose monitoring

insulin dosages

carbohydrate intake

physical activity barriers

exercise physiologists