Hello, everybody, and welcome to today's webinar. This session is the fourth installment in the hands-on Tips to Improve Diabetes Care webinar series for 2023-2024. Today our panel will share their expertise and insights on exercise and type 1 diabetes, and we're glad you're all here. I'm Dr. Jacob Kolenberg, I'll be moderating today's webinar, and to share a bit about myself, I'm an endocrinologist at the University of Minnesota. My clinical and research interest is in the care of adults with type 1 diabetes. In addition to my clinical work, I'm a scholar in the National NIH K-12 Physician-Scientist Diabetes Docs Program, and my current research focus is on the prediction and prevention of diabetic ketoacidosis in adults with type 1 diabetes. We'll spend the next hour together by following the agenda that you can see here on the screen. We'll be using interactive features during today's session, and so we'll send you important links and information throughout the webinar today in the chat box. So please locate the chat box on your control panel now, and be sure to click on it when you see a notification pop up or when you're asked to use it. We'll 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. There's no need to wait until the end. We'll address all questions that have been submitted once we get to the Q&A session. Finally, we'll be using an interactive tool called Kahoot today during our webinar. Kahoot is an interactive game-like platform that allows us to ask you both knowledge-based and open-ended questions and collect answers in real time. So let's talk about connecting to Kahoot. If you have a mobile phone or tablet nearby, that's often the easiest and best method to use. If you don't have anything else nearby, you can just use whatever device you're using at this time. You'll just need to open another window or tab on your browser. Once you have your way to connect to Kahoot, open your internet browser and type Kahoot K-A-H-O-O-T period I-T. When the Kahoot join screen comes up, you're in the right place. You can now wait until we show you the joining information in just a moment. And I'm going to give everybody about 15 seconds to connect to Kahoot before we move on. I want to share a quick announcement about the next installment in the hands-on webinar series. Everyone's welcome to join us on February 13, 2024 for a live one-hour panel discussion webinar titled the Big Shift Weight Management in Type 2 Diabetes. In this webinar, the discussion will be on cutting-edge research and advancements in the field of weight management in Type 2 Diabetes. Click the link in your chat box to register today. To register for the Innovations and Latest Treatments in Type 1 Diabetes webinar, click the link in your chat box on Zoom. Now I'd like to introduce the panelists for today's webinar. Jaime Ferrer was diagnosed with Type 1 Diabetes at age 3. He's a college baseball player at Florida State University. Jaime is not shy when talking about his diabetes. He learned early on from other people living with diabetes that being open and sharing his story was powerful and helpful to others living with Type 1. And knowing that other athletes with Type 1 had achieved excellence in their sports motivated Jaime to pursue his dreams at a young age. Dr. Ann Peters is a professor of clinical medicine at the Keck School of Medicine of the University of Southern California. She runs diabetes centers in Beverly Hills and in underserved East Los Angeles. In addition to her clinical work, she has been a principal investigator on multiple grants, has written over 200 articles and four books, and has given over 1,000 lectures locally, nationally, and internationally. Her major interests involve translating research findings from lifestyle interventions to technology to people with diabetes throughout the socioeconomic spectrum. She's a recipient of the ADA Outstanding Physician-Clinician Award, the Bernardo Jose Award from the National Minority Quality Forum, and an Endocrine Society Laureate Award for Public Service. At this time, I'll let our panelists introduce themselves and state their disclosures. How's it going, everyone? My name is Jaime Ferrer. I work with the Dexcom University Program, as well as I am a Tandem Ambassador. And I'm Ann Peters. Welcome everyone. And I hope this is a lot of fun for everyone joining. And you can see my disclosures here, and you can read them at your leisure. Thank you. A lot of baseball and obviously Florida State was the school that I always wanted to go to in Florida because I knew the rich tradition that it had and being able to have the opportunity to play here and represent is just a blessing to me and I think about that every time that I go out on the field. I'm Jaime Ferrer, I'm an outfielder and I play baseball at Florida State University. I was diagnosed with type 1 diabetes when I was three so I really don't remember life how it was without type 1 diabetes so for me it's normal I mean it's just I have to do some stuff that other athletes don't have to do but it's the cards that I was dealt with and all the staff here at Florida State has done a great job of supporting me as well as my family to make sure I can accomplish all my dreams. It's amazing what he's had to do essentially from the time he was born to manage this and his parents have managed it and the neat thing about it is if you're on the outside watching it you would never know. He handles it so well and the poise and the responsibility it takes to deal with that every single day and then to play athletics at this level it's just remarkable. He was diagnosed at age three he doesn't remember life before it but he says that it's almost an advantage for him because he has to be so disciplined about what he puts in his body and baseball is such a disciplined routine based sport that it's really done very well for him to be on top of his game and be his very best him. Mike Martin Jr. said Jaime has come in and they don't make many like him. Shoots this one to right field, put a charge into it, Ferrer opposite field. How's it going, everyone? As I say, you know, my name is Jaime Ferreira. I'm going to talk a little bit about, you know, Type 1 diabetes, sports and exercise from research to practice. So let's let's get going. So both my learning objectives today will be explain how an athlete with diabetes can compete and thrive, as well as state some of the challenges and successes as an athlete with Type 1 diabetes. So, yeah, explaining how an athlete with Type 1 diabetes can compete. One of the factors that plays such a crucial role in my life would be the support. As you guys heard, I was diagnosed with Type 1 diabetes at the age of three. And honestly, I don't remember how life was without it yet. The only thing that I can truly, you know, look back at is the way that my family always supported me and the way that my family always had my back. One of my favorite memories is honestly growing up and I used to wear an insulin pump and my family put them on. And and it kind of just made me feel like, you know what, I'm normal. I'm just like them. And something that, you know, my parents have always said, it's Type 1 diabetes. At that at that young of an age, it's not a personal thing. It's a family thing. You know, the whole family has to make changes and has to adapt and they have to get educated themselves to to be able to put their child in the best position. My symptoms were undiagnosed or unnoticed. I was lucky enough that, you know, my one of my doctors, her sister had Type 1 diabetes. So whenever my mom called her and kind of told her all the symptoms that I was seeing and I was losing weight, I was going to the bathroom a lot. And and she said, I hope it's not what I think is, but it might be Type 1 diabetes. So I went to the hospital and I got my blood sugar checked. And yeah, it was Type 1 diabetes. And I've been living with it every every every single day from then. And what my family's mission from the moment that I got diagnosed was, how can can we support him and how can we, you know, make sure that he accomplishes all of his dreams with Type 1 diabetes? Because I have two older brothers and and they both play base. They both play sports. And I wanted to be just like them. I compete with them every day, every single day. And they didn't want me to feel left out just because I got diagnosed with Type 1 diabetes, something that helped me a lot. You know, performing on the field is the technology, just the fact that I can have an insulin pump and a CGM that I don't have to be on the sidelines, you know, checking my blood sugar and kind of having to sit games out or or practices out is something that has given me lots of confidence on the field and has helped me perform. It's super encouraging, you know, seeing all these athletes with Type 1 diabetes and seeing how they manage their stuff and, you know, meeting all these athletes and kind of taking tips from everyone is something that's been super important. My parents have been super dedicated, you know, helping me stay on the field and stay healthy and accomplishing all my dreams. I have a quite a big social media following. My mom has a my mom and I have a blog in Spanish and we share all my stories and pictures. And, you know, I've met a bunch of fans that games have Type 1 diabetes and it's super cool, you know, to see them and seeing the support of that. You know, I'm 21 years old and my parents still have my CGM data and I still text them about, you know, I'm eating this. How much insulin should I send? So having that support has been huge. Then I would say another key factor would be, you know, education and the diabetes community, just having that support, you know, from from everybody in the diabetes community reaching out to you and whether it's they went to one of my games and they say, hey, we saw you at the game and you're a huge inspiration. You know, my four year old, my five year old, my six year old. It's something that, you know, I don't take. I take I take a lot of pride and something that I think about every time that I get the opportunity, you know, to go out on the field and and on or off the field, honestly. So, yeah, just meeting athletes with Type 1 diabetes at that young of an age, it meant the world to me. It's being able to, you know, here in this picture, I'm meeting Sam Fold. He was an outfielder. He played with the Rays and the A's for a little bit. And he's a guy that I truly looked up to every day because he played baseball, the game that I loved. And he has Type 1 diabetes. So kind of seeing guys like him and and going to these different events and these different conferences and being able to, you know, see all these people with Type 1 diabetes kind of showed me if they can do it, then why can't I do it? It was a huge boost to my own confidence. I wasn't, you know, the kid with Type 1 diabetes. I was I was Jaime and I live with Type 1 diabetes. It's part of, you know, kind of what makes me the person that I am. So, yeah, just, you know, the empowerment that I can see through through all these athletes, Garrett Mitchell was a first round pick in the major league draft and he has Type 1 diabetes. And, you know, lots of teams maybe said no to him because he had Type 1 diabetes, but he worked hard and proved them wrong. So that's something that I truly think about. And it's something that, you know, I've implemented in my own life. It's an inspiration for me to, you know, conquer all these challenges. And whenever somebody says, you know, you might not be able to make it because you have Type 1 diabetes, it's, you know, I'm going to prove you wrong. And I'm going to show you why I can and why I can do whatever any any other person can do with type without Type 1 diabetes. I'll do it with Type 1 diabetes and I'll do it at a higher level. So it's, you know, never taking no for an answer. And if you're truly passionate about something, you know, go conquer that dream and and, you know, go go prove them wrong. The next factor would be, you know, the empowerment, just being able to, you know, go out on the field and and, you know, be able to show that with Type 1 diabetes, I'm performing at this high level. So every kid in the stands or anyone out there with Type 1 diabetes or if their child has Type 1 diabetes and they can use me as, you know, kind of a role model, you know, he's doing at this high level. So why can't you as well? You got to understand, you know, the goals that you have with Type 1 diabetes. And every day is not going to be the same. So being able to wake up every day and motivated to, you know, be the best version of yourself that you can be is something that's super important and something that, you know, my parents instilled in me from a young age, as well as, you know, every diabetes educator that I've had. They've done an amazing job of, you know, making sure that I'm comfortable with any technology that I'm using, making sure that I'm comfortable with, you know, performing sports. I remember. One of my first ever diabetes educators, she used to run marathons. So having her on my side, having somebody that, you know, my parents could call any day or at any time, they could be like, hey, I'm just going to go play tennis at eight in the morning. He's going to eat breakfast. What should we do with his basils? What should we do with how much insulin he sends? Kind of having that person on my side was something that was truly empowering. Being able to, you know, mention like, you know, how these people that that are giving their lives to help us seeing their impact is something that's super important and something that, you know, it's I'm truly super thankful for every single diabetes educator that, you know, that I've had throughout my life, getting tips from them as well. Like the same diabetes educator that I had before, she used to deal with an Olympic swimmer. So getting tips from her that she gets from this Olympic swimmer that she passes down to me is something that, you know, I truly looked forward to every single appointment that I had and see what I could learn and and how I could improve my diabetes management, you know, one day at a time, because you're never perfect and and not every day is going to be the same thing. You know, the the the help that I've had here at Florida State with all the staff and everyone being so understanding and and so caring of, you know, what I'm going through. And they understand that I can do everything at the highest level. And there's their support me and anything that I need to, you know, made felt like like I'm part of the team and I'm normal is something I truly appreciate it. I've never felt, you know, like like I'm not the same as anyone else. I've always made they've always made me feel like like any other high college student, just, you know, there's challenges that everyone has to deal with and they're all different. And yeah, just growing up with that, that huge support and, you know, my friends, my family and everyone that I've ever met truly have been they've been a great help for me and they've never made me feel, you know, out of place or like I don't belong just because I have type one diabetes. I, you know, I want to see and see myself as, you know, I'm Jaime. I'm not, you know, the type one diabetic. I'm just, you know, I'm going to have to deal with type one diabetes. So we're going to the next slide. Next slide would be my diabetes management formula showing up every day and planning ahead. It's I like to relate it a lot to, you know, it's kind of like baseball. Baseball, you have to show up every day and and you have to plan against what you're going to face from the other team. And you have to plan. You have to stick to that game plan. Type one diabetes, it's the same way. You never know how how type one diabetes is going to is going to be that day. You might wake up, you might wake up at one hundred and then the next day you have the same basals, you eat the same thing and you wake up at at sixty five. So it's never a bad or good number. It's a number that you have and it's how you react to it. It's how you how you game plan against it and how you attack it. So just being, you know, I was diagnosed at three. So I had to mature a lot quicker than than every other kid that I was growing up with. And I had to keep myself more accountable than anybody else. Something super important that one of my diabetes educators told me was there's never going to be a day in your life that you don't have type one diabetes. You can't take a break from it. You can't. You know, today I'm not going to I'm not going to check my blood sugar. I'm just going to do whatever I want and it's going to take care of itself. Unfortunately, that's not the truth. So, you know, being able to instead of, you know, I have to do this. I get to do this today. I get to wake up today and I get to go, you know, to the gym. And and it's it's kind of changing that mindset from my I have to do I get to it's something that you're going to become, you know, a lot more positive about your type one diabetes. And, you know, there's there's just not a bad number. It's what you have to deal with and how you react to it. It's the cards that I was dealt with in life. And and I'm doing the best that I can with it. I'm trying to empower, you know, as many people as I can with it. Asking for help is truly OK. That's something that, you know, I've learned throughout my entire life. And and having these great diabetes educators there for me and and knowing that I can call them and I can reach out to them with whatever question there's there's not a bad question. So they've they've been through everything. They've seen tons and tons of patients and they know how they can help you. So reaching out is such a key tool. And that's why I always, you know, make it known that in social media that if any any family, any young kid has a question about type one diabetes, I'm there for them. I'm there for, you know, whatever whatever question they will ever have, because I've lived 18 years with it. And my parents have have also been there through with me through every step of the way. So they've you know, they're there, you know, to answer any question and make me feel comfortable. Having that nighttime support for me is super important with all the technology. And I three years ago, I was a freshman in college and I was kind of scared of how I'm going to deal with this on my own. But, you know, having that support from your parents, even though they're not with you, is something that's super important. And we always call my parents like three or four times a day. And I always call them at night. And we always make sure that, you know, I'm going to bed with no insulin on board or as little as possible. And and I'm at a flat number so I can, you know, sleep my eight hours and wake up the next day with energy and feeling good. Having that open communication with your parents is also super important to me. It's something that I've always known that, you know, my parents, nobody wants what's best for you more than than your own parents. And they're going to love you. And they're going to be there for you throughout the whole way. So, yeah, just using that as well as the technology has been a great help for me and has helped me, you know, show up every day and attack diabetes with the right way, the right mentality. We got next slide would be, though, another diabetes management formula would be observation, analytical and embrace diabetes technology and be proactive. I think the most important part of this is being proactive. Instead of being reactive, be proactive. Know what you ate and how that affects you. And know, you know, I'm going into and I ate, for example, I ate a sub which has a lot of carbon out to send a lot of insulin. So knowing that, you know, I'm going into a game with six, seven units of insulin in my system is going to be different than if I go into the game with no insulin in my system. So just being proactive about that and and being positive. And it's trial and error. You know, you're never going to figure it out completely because two plus two isn't always four with diabetes. So it's kind of just, you know, you learn from the experience and and you learn from all all the highs and all the lows. Leveraging, you know, the CGM and the insulin pump, the reports that they give you is great. And you can talk about that with your diabetes educators as well. And it's it's cool because I'm a big numbers guy in baseball. You know, the stats are super important. So whenever I go to the my doctor's appointments, it's cool to see, you know, how the graphs look and what I ate, how it affects me and kind of talking about that and having that open line of communication with your diabetes educator is super important. It's it should never be, you know, you're criticizing because you had this number. It's all right. You were here and this is how we can help you. And this is how we can, you know, push you to be at the best levels that you can be. It's never there's never a right or wrong answer. It's trial and error. And once you find kind of something that you're comfortable with, with your diabetes educator, then then that's kind of we have to stick to. And, you know, you you never stop learning, learning. And obviously, this is what works for me. And it's totally different from what works for other people. It's funny because I had a teammate that had type one diabetes as well. And I would send, for example, six units of insulin. He would only send four and we'd be at the same level. So kind of knowing how your body reacts to it and what you what level of exercise you just did is something that's super important. And it's never you know, it's always the same for these ten different people. It's always, you know, kind of a separate thing and more of an individualized individualized. Strategy. Some of the challenges and successes as an athlete with type one diabetes, sharing my story on social media, something that I take a lot of pride in and, you know, being open to them and and the community strength that the type of diabetes community has. And, you know, you see all these stories and all these all these people that are thriving with type one diabetes. It's super cool to see and kind of feel like I'm part of that community and I have their support no matter what. You know, I had childhood heroes growing up, like Sam was one of them. And, you know, seeing myself now close to that level that he played at and seeing that, you know, I accomplished it with type one diabetes is super empowering for me. And it's it's what keeps me going every single day. You know, being able to give tips to families and from my own experience is something that's super cool because it's nobody knows your life better than than yourself. So whenever I have the opportunity to talk about that and kind of help them out, it's something that I truly enjoy, as well as, you know, all the encouragement from from health care professionals and how great they've been in my life. And, you know, I'm endlessly thankful for all the help and all the time that I've had with them and all the conversations and, you know, the impact that they've had and from other patients as well as myself. So that's something that, you know, I'm truly thankful for. And and, you know, I try to thank all my health care professionals whenever I can. The next. The next thing would be the the technology has been, you know, been been such a huge help for me, it's something that, you know, it would be impossible for me to play baseball at this level without the use of technology. So it's something that, you know, obviously not everyone's going to be open to using technology. But if you want to play for me at this level where I'm playing a D1 baseball, it would be virtually impossible for me to take breaks in between innings and check every single time. It's something that if I can take a quick peek at it, a quick glance at it. It's something that helps me a lot. Obviously, it's it's not perfect. And as you guys see here in the left hand side, I broke my insulin pump on my first ever collegiate baseball game. So having been being proactive and being able to deal with that on the fly is something that, you know, I gained from my experience and all the you know, all the times that I've dealt with issues and dealt with site failures and all that type of stuff. So just being able to make those adjustments and having that open line of communication with your with your health care professionals is something that's super important. You know, you face a lot of lots and lots of challenges as an athlete in general, and then you pile on top of that, that, you know, you have type one diabetes and you have to look out what you eat and what you put in your body and how it affects you is it's something that's super important. So being able to, you know, look at all the information that you have and all the experience is super important. Oftentimes, too, you know, these these youth coaches don't take players with type one diabetes on their teams or professional teams don't draft players with type one diabetes, not because they don't want to, but because they're miseducated, they don't have the education to, you know, to see all the athletes that are doing it. So they're they're scared to do so. So instead of, you know, sometimes being upset, it's about educating people. So that's why I take it into my own hands to educate as many people as I can and post, you know, educational stuff. And whether it's, you know, the symptoms or any anything else with education, I know I take a lot of pride in doing that and and kind of helping out in any way that I can. Yeah, that's kind of all I have. Kahoot Game Pan is down here. It's three, four, nine, eight, six, five. This is something that's super cool that I share on my social media a lot as well. I'm strong, resilient, determined. I'm greater than my highs and lows. I'm stronger than diabetes. I think the greater than highs and lows is something super important because you're not only going to see highs and lows in life, but you're going to see them in type one diabetes as well. It's about how you react to it and how you're proactive about it. And it's you know, it's not a bad or good number. It's a number that you have and it's how you react to it. You can't go into it with a negative mindset or or be upset at yourself or be upset at your your patients for for having these numbers. Obviously, we all wish we could be at 100 every single day. And we all wish that, you know, we we didn't have to to be waking up in the middle of the night to do corrections or eat some some gummies or whatever it is. So it's kind of what you have to deal with. And it's the mindset that you look at that, you know, something positive or it's you know, you have this information, it's how you use it. So it's you know, it's never a good or bad numbers. We kind of have to deal with and and how you how you react to it and how you deal with it is is what makes you the person that you are. We got an open end question, it's what are some resources and systems of support that can help athletes with type one diabetes? So this is a you're going to type the answer in and we're going to we're going to look through these and we're going to talk about these for a little bit. We've got five more seconds and we'll go through these answers and we'll see how. All right, perfect. So family and friends, obviously, that's a huge one. That's something that I've used my entire life. Physician and provider team is also a super important one, something that I've seen my entire life as well, families, huge. Diabetes camp, something that I used to go to a lot as a young kid and meeting all these other kids and athletes with type 1 diabetes was super important for me and seeing them, you know, was life changing for me. Technology, huge, huge help for me. CGM, also huge. ADA website and your pharmacist, super important. I remember my mom used to go on this website all the time and, you know, read other family stories and kind of see how it changed your life and it changed my life, honestly, because it helped her take better care of me. Diabetes team, super important. Choosing who's on your team and what circle you have is super important for your entire life and type 1 diabetes also helps a lot, having a good circle of people. I'm getting some great, great answers here. Compassionate doctors like Dr. Ann Peters who provides support and expertise. She's absolutely awesome. It's an honor to share, you know, this webinar with her and, you know, she's the best of the best. I'm excited to hear from her in a little bit and kind of see what I can learn and what I can put into my own life as well, obviously. You know, these are some great answers. Yeah, these are all right. This is awesome. All right, with that, I'll pass it on to Dr. Ann Peters. Thank you guys so much and go NOLS. I mean, thank you for being so inspirational and wonderful. I'm very proud of you. I feel like I have a tiny piece in your life and diabetes. So all right, I have 15 minutes to tell you what I normally spend two hours talking about, which is exercise and diabetes and sort of the things I've learned along the way. So I'm just going to go through. These are my conflicts. You've seen them previously. And now I'm going to tell you where all this started. So I'd actually been helping people with type one diabetes, do whatever their athletic endeavors were before I met Gary Hall Jr. But it was Gary Hall Jr. and helping him to get through the Olympics twice that really made me an expert. So sometimes doing is what makes you an expert. And Gary Hall came to me. He was in his mid 20s. It was in between the Atlanta Olympics where he'd won four medals and the Sydney Olympics and he developed type one diabetes. And the doctors he saw at that time said he needed to quit trying to be an elite Olympic athlete, that he couldn't do it with type one. Now, this is before the days of having all sorts of technology. Gary never wore a sensor during all this phase of competing. And it was really before people had really owned this, that the world of athletics had opened. And so there were a lot more restrictions. And I didn't really realize why anybody would say no, but I know nothing about sports. And so I think the reason that it was concerning to other endocrinologists was because if you look at this, and this is actually the finish of the 50 meter freestyle race in Sydney, is you can see that winning and losing is by like a hundredth of a second. This isn't like, you know, your way down the road running. This is like, boom, you've got to get there. And all that this is, is we're trying to get adequate amounts of glucose to working muscle to give him fuel. But if you think about it, diabetes can limit that, right? If you are more insulin resistant, if you're sick, if you're not feeling right, and actually it's a much longer story, but I could tell you when diabetes did limit his performance, but it didn't uniformly. And we could do this. And I'm also going to tell you when I'm talking about this, I talk about me and Gary, because Gary was somebody that I helped take care of because of his potential to inspire others. And I knew that if I spent my time and energy helping him, that he would stand and really support other young athletes, he'd be a role model. So I traveled around with him and I didn't take care of him as part of a team. And normally I have a team. My diabetes nutritionist helped him, but by and large, it was me and Gary. And I just want to say that I'm not saying that I don't use diabetes educators. I do all the time, but with Gary, it was different. And so the first thing that I did was I flew up to Berkeley where he was training. And I sat by the pool because I was afraid that if he got hypoglycemic, he might drown and that the symptoms of hypoglycemia and the intense training exercises where he kind of felt nauseous and weak and dizzy anyway, would be very similar because he couldn't or didn't wear a CGM. It was worrisome to me. So I went up there and I sat and I learned about what it was to train. I learned about what it was to compete because I went to various meets with him. And I actually taught his coach what I could about diabetes management. Now my whole feeling about my athletes with type one diabetes is that they should be just like they don't have type one diabetes, do what the other people do. And so I looked at what other athletes were doing. Well, this is swimmer Michael Phelps. And you can see that on a training day, he eats 12,000 calories a day. It's an amazing amount of food. It's basically all they do is swim and eat, swim and eat. And you can see all of the carbs he's eating, grits and French toast and sandwiches and all this stuff. And this is such a carb heavy existence. And I knew that I couldn't quite get Gary to eat this many carbs. The whole thing seemed insane, but it would be so much insulin. And in fact, when he was training, he used a lot more insulin than when he wasn't training because of the high carbohydrate intake. But we had to account for this and we had to figure out the right nutrition. And again, I'm not going into detail, but what we found out was that the right nutrition was being fed to horses, to race horses who were recovering by an incredible vet named Doug Herthel, who was down in Buells in California. And we took this horse food and we made it into food bars and we started giving it to Gary and it really helped him because it was a low glycemic index. It was exactly the right things that he needed. And by the end of the season, the entire US swimming team was eating these food bars because they were actually very healthy and very helpful. So what somebody eats is so important and what obviously the training requirements are is so important. And together we worked out a sort of schedule. Now Gary is not that kind of athlete who does the same thing every day. And the hard thing about him was that it was hard to figure out a training schedule with regards to insulin, because some days he'd be swimming laps first and then other days second, and then he would always work out twice and dual workouts mean that he would do things like put like blocks at the bottom of the pool and go down and grab them up and do all these other things where he'd play basketball by the side of the pool. So I was always kind of chasing his activity because as you all know, the more we can plan in advance for what's going to happen, the better we are. But this is the kind of schedule that I would have for him. And he would be taking a lot of insulin during the day with all those carbs and then less at night. And we managed to figure out how to keep him well fueled and build up his muscle and his stamina. And in the end, we managed to get through the Olympic trials, get him to the Olympics. And here he is in the Sydney Olympics where he's getting a gold medal. But I say getting because he ties with his teammate and tying wasn't good enough for Gary. And I thought I was done, right, with traveling all about helping him, working with him. But I wasn't. And so he decided he had to go to the Athens Olympics because he had to win his own gold medal. And I personally wasn't sure we could do this, particularly because by now his diabetes was harder to manage. But you know what? He is the most determined human I have ever met. And he won his gold medal. I couldn't be prouder of another human being. He currently lives about five miles away from me. He's now a lovely young man to me still in his mid 40s. He's got two teenage kids. He runs a swimming school and he's doing great. His A1C has been below seven for most of the time. I kept his A1C a little bit higher when he was racing and training, but he's just done beautifully with his diabetes and beautifully with his life. So when I'm thinking about management, and many of these slides I stole from Mike Rydell, who's really the expert in this field and should be the one talking to you, he is genius as well as being a very dear friend. But he's the one who's taught me a great deal about this. And the whole notion of exercise is you have to plan it. And when you're planning it, you have to figure out about glucose levels, how much carbohydrate you're going to eat and when, how much other nutrients you're going to eat and when. And then the basal insulin, whether it's a pump where you can adjust it in advance or whether it's bolus reduction, whatever you're going to do with insulin up to about two hours before exercise needs to be done. And I think that's the hardest thing is having to anticipate exercise. Then there are factors such as the duration of exercise, the intensity of the exercise, and then post-exercise effects, which can lead to hypoglycemia, although acutely can lead to hyperglycemia. And each step of this path has to be thought through and planned. Now the type of exercise matters a lot. And this is from an article Mike and I wrote recently where we have the four different major types of exercise. And in general, and again, I'm not going to spend time with this, but when people want to do sort of endurance sports or even aerobic sports, I'll often have them do something like resistance training or even explosive training to try to get their glucose levels a bit higher so that that way they have a little bit of resistance on board. So the risk for hypoglycemia isn't as much. And then a lot of my patients do high intensity interval training, which I personally like and do for my own workouts because I like how it helps me more quickly do my athletic workouts in advance of my busy days. This is a study that Mike did as well, where he's looking at all the factors that could influence the glucose response to exercise. And if you sat down and thought about this every time you're trying to exercise, it is unbelievable. This is why I admire my patients so much. They're so amazing in terms of how they adjust all of this, but you have to think about the type of the duration and intensity of exercise, the time of day, whether or not someone's making insulin, the insulin on board, what form of insulin treatment they're using, what have they eaten in the past few hours, rate of change of glucose before exercise, pre-exercise glucose level, fitness level, whether or not someone's competing in that stress, sex and or gender menstrual phase, sleep duration and sleep quality. In addition to if you're feeling sick, if you're having this or that, there's all these factors that actually really impact what's happening during exercise. And so I think that this can be really daunting, but I'm telling you, my patients exercise all the time. I have amazing athletes in my practice and even just the regular person who goes out to walk their dog or wants to get extra steps in, all of that is exercise. All of that, when you have type one diabetes, takes some element of planning and yet it's all possible. Now this is a system of, this is a patient on a hyper-closed loop system. And I just want to point out that this is one of the things that annoys me the most about hyper-closed loop system is these auto-correct boluses. And you can see the top big circle is actually an episode of severe hypoglycemia because this patient was actually doing trail running up in Ojai. And she basically had gotten an auto-correct bolus, which is the lower circle when her glucose went up because she was eating something to bring her glucose up before she exercised, got the auto-correct bolus and then plummeted. And she actually fortunately had a husband who was on the search and rescue team because she had to alert them to the fact she was falling so fast and she was rescued. But I really think that this is a fault in these systems. And I know some of the newer systems actually allow you to turn off those auto-correct boluses, but they make it really tough if they happen before you're trying to exercise because glucose levels can go down too fast. Now this is a slide which hasn't quite been edited, but basically most of the time on these automated insulin delivery systems, you have to or should reduce the bolus insulin, the meal before the exercise, if the exercise is happening within 90 minutes of a meal. Then you really want to set the exercise target 90 to 120 minutes before exercise, at least an hour before. And that's a lot of time to think of in advance of doing something. It's difficult in these systems that have that auto-correct bolus to snack just prior to exercise. So if you can, in some way, either not snack on carbs or snack on carbs and then exercise to bring the sugar down, but you've really got to deal with that problem or you can put it out of auto mode if that's necessary. But remember that that snack can cause a problem and increase in insulin delivery. You can suspend the pump at the start of exercise and then eat carbs throughout, but that's not as good as using the exercise mode of some sort an hour or two in advance of exercise. And then just make sure if the exercise target is turned on, then you turn it off at the end of exercise if that's not automated. So this is the second patient I'm talking about, another patient I adore, but then again, I think I really do adore my patients because it's so amazing what people can do with type one diabetes, is this is Fiona Wild. And I started taking care of her when she was in high school and she's this water sport competitor. Like I didn't even know what this is, but then again, I don't know much about sports. And she was this kind of person who when she got type one, she just said, okay, fine, I'm going to adapt. And this is obviously a hard adjustment and everything else, but she just figured out how to make this work. So the first thing we started doing was using a sensor and remember, she's in the water a lot. So I had to figure out how that she wasn't going to like manage to make it so that the water affected any of this in terms of its function. And she then went on to do all of this stuff. These water sports athletes do more than just one thing and she's leaping about and she's doing all these things. And I worked with her really, really hard. And at one point during the summer, she went and she worked out with the team Novo Nordisk people. And she called me and she said, I figured it out. I figured out the key to how to compete with type one diabetes. And I felt a number of things. I felt glad for her, right, that she got the answer. But the second thing was, is I felt incredibly chagrined, like why did I miss the secret? There was some secret that I just hadn't taught her. Like what was my problem? I wasn't a good enough diabetes doctor. And you know, then of course I really admire what the cyclists all do. So I said, well, what is it? And she said, what I learned is there's no one way to do this. Every athlete's different. And I laughed and I said, you know, you're exactly right. And they've now done these studies where they look at different days and people doing athletic events and they have the same sort of test and they look in to see what happens in terms of glucose levels, test one, two, and three, and however they do it, there is actually no real correlation between what they do on one day versus what happens on another day. And we see this a great deal in terms of our, you know, teaching athletes how to manage your diabetes is there's so much variability in every day that the key is that someone needs to be able to be swift on their feet. They need to be able to adjust and do the things they need to do in order to make it work for them on that given day. So my job is to give people the tools to adjust for that day. And then of course, Fiona ends up being like a star and I'm so proud of her. And this is actually during COVID and she won a double gold medal at the ICFF World Championships and she's just spectacular. And I just want to point out that throughout all this, she has managed to keep this enthusiasm, but also to figure out what works for her. And so here you can see her and she's actually in this particular picture on a tandem pump and you can see the tubing, which is going down and the pump itself. She has some weird waterproof container that's inside the life vest that she has to wear when she's competing. And then you can see the tubing going down, but she just figures it out. And I think that that's the point. Your healthcare team, your diabetes educators, your team can help people figure this out. People just have to spend the time with their athletes. And for any exercise, it's not just these higher level athletes. It's for anybody with type one diabetes, a team helps other athletes help. We can all help each other understand how to do this. And I really do think almost anything is possible as long as people have the tools to do it. And the newer technology is making such a huge difference. Now, just in terms of simplifying the answers to this is what I think is I'm always helping people think about insulin on board, which is key and carbohydrates on board. And insulin on board is this big concept. I get asked again and again and again, why am I going low with exercise? And I always say, we've got to think about insulin on board. When do you stop your pump? When do you turn down the basal rate? What do we do for this? And so I always talk about the need for people to dose if they can, before the exercise, the meal before the exercise, give half a usual dose. Again, this on automated systems can result in these, the autobiosis, which people may not want. But then just before exercise, if the glucose is below 150, people may need to eat carbohydrate and everyone picks what they want. A lot of my patients will eat a banana or half a banana. And this is for aerobic exercise. So it doesn't hold the same for resistance training, but people generally need to eat or consume 15 to 30 grams of carbs for every 30 minutes based on their glucose levels, the CGM findings, where the glucoses are going, et cetera. And then after exercise, ideally people need to eat a snack that's 30 to 60 grams of carbs and dose for the snack, but not necessarily correct for the after exercise hyperglycemia that happens because that often happens and then people will go too low. And that correction is often not needed or less than a usual correction because that tends to be due to lactate after exercise. And if people just cool down and walk a bit, that glucose level will go down. And then finally, people often forget the need to reduce the basal overnight because there may be delayed hypoglycemia. And this is really important to stress, and obviously the current sensors and systems have alarms and they may change insulin delivery, so help avoid that. So with that, I'll say thank you. And I think we have to move on to a quiz question for you all. And the quiz question that I'm meant to ask is this one, which form of exercise nearly always increases glucose levels, endurance training, explosive resistance and high intensity interval training. So I'm putting your answers. And that's perfect. The most intense exercise is explosive if you do it correctly. And that's even like boxing or things. People love to box. I don't know why it's not my sport, but people do. And that always produces up sugar. So the majority got that answer right. So I think we're now into the question phase. All right, thank you so much to both Jaime and Dr. Peters. That was fantastic. I remember these five hands-on takeaways from today's panel. If you haven't already, please ask your questions for today's presentations by typing them in the Q&A box on Zoom. And now we're going to take a look at some of the questions that have come in as well. All right, so let's start with a question for Dr. Peters. Are you able to comment on how you manage insulin delivery devices, such as pumps, during sports, such as football or wrestling and so on, where there's a significant amount of contact between individuals? Well, that's an incredibly good question. And it really depends. So for a long time, I took care of Max Domi, who's a hockey player, which seems to me like a sport where there's contact, I guess. Somebody beats you up on the hockey field. I'm not that much of a hockey person. But anyway, he figured out a way to put it in a place that was much less likely to be hit. But if people have, it depends on how long they're actually going to be out there doing whatever their sport is. And it depends on if it's a competition or training, because you have a lot more latitude when training than when you're competing. So I really work to figure out how to do it. And there may be times when you can't wear a pump, and then you would use an injection or use inhaled insulin to get you through that phase. So a lot of the times, you have to go on and off things. But I work to figure out what would work best. But it's hard if it's really like no matter what, you're going to get your body squeezed, like with the wrestling, that's hard. And I can, the sensors are easy, but the pumps are really hard. And sometimes you just may not be able to use the pump. I mean, you might not, at least when somebody is actually competing, be able to do it, and then you'll just use injections. But then when they're not doing it as much, you'll end up with just using a pump. But I'm very, very flexible. There is no one way to do this. And there is no one way to deliver insulin, period. There's all sorts of ways. The one thing I actually really stress is CGM. I mean, that's, to me, the foundational piece of technology for people with type 1 diabetes. Thank you. I have a question for you. Are you comfortable talking about a time when you had a hypoglycemic event, either during a game, during practice, and so on? What caused the event? And what did you learn from that event and implement to prevent it from happening again? Yeah, so I've had a bunch of low blood sugars during games and practice. Obviously, in the last few years, with all the technology, it's been less, but obviously it still happens. It could be because of stress or you're a little bit anxious for a game, or you're going into a game with insulin in your system. Whether it's what you ate, maybe we're on the road and they gave us a sub pregame, and that's all you could eat, and that's not really a high-protein food, and it's high-carb, and yeah, you just kind of have to deal with it and learn, next time I eat this, maybe instead of five units, I'll send three, or something like that. Just kind of knowing what you did and kind of keeping a log and keeping an eye. When I eat this sub and five was too much, next time I'm gonna try four, or maybe next time I'm gonna try three and a half, or maybe just turn the exercise mode on your pump, which is what I do, and it just lowers my basals. I try to stay between 140 and 160 for whenever I'm playing, so just kind of having that and turning it on in time and having, you know, I always like to have either sour patch watermelon gummies or twin snakes with me, so something that I can eat quick that I know how it's gonna affect me. Just being proactive and having stuff in the dugout with you, and I share my CGM with my trainer, so he's in the dugout with us, so he has the readings every five minutes, so he can be there to help me whenever I need it. So just, you know, learning from what amount of insulin you send and what you ate is what I use to prevent, you know, being low every game. Thank you. Question for Dr. Peters. Can you talk about your approach to adjusting basal insulin after exercise? Well, it depends on if it's, it's a very complicated question. So if somebody's getting, it depends on the kind of basal insulin, right? So if it's a basal insulin injection with, you know, Traceeba, so it's long-acting, then it's going to be not much of an adjustment. If someone's on Lantus, and often I'll put somebody on twice a day Glargine because then I can adjust those two doses separately to deal with the overnight issue, but that's for injectable issue, and I've also had people on Levomir, which is Detemir because that often is easier even still to adjust, but that's going off the market. But if it's an injected basal, I often do better with something that I'm giving twice a day so I can adjust the pieces. And again, most of the time, I'm talking a lot about people who are running marathons and triathlons, and they're doing a lot of training, and they'll often go low at night. And I really want to reduce that if they're on MDI. But if they're on an automated insulin delivery system, you can either just have a pattern that's the exercise day pattern, or, you know, training day pattern, or they can just put it in exercise mode overnight. So it just depends on the system and on the person. But I often, you know, give them 80% of whatever their normal basal is if you want a number, but everybody differs, but that's sort of where I start. Thank you. Very interesting question here. And I think this would be great to hear both of your perspectives on this. What are some tips for activities such as baseball, where there's often a quick burst of activity followed by a lower activity level for a period of time? I mean, you should talk. Okay, I'll go first. What I like to do is I like to keep my blood sugar from like 140 to 160. Obviously, that's what I do. That's what works best for me. I know my teammates, because I play a position, I play outfield, so I'm playing all nine innings. But for example, one of my friends was a pitcher and he has type one diabetes as well, and he would completely take his insulin pump off. I've never done that before, but that worked for him. So like I said before, it's more of a personal thing, but for me, what's worked personally is keeping my blood sugar from like 140 to 160, having as little to no insulin on board and just having your CGM on you and being able to see your readings as much as you can and being proactive to it. So I'd rather be a little bit higher during games, just so I have a little bit of more margin of error than low, because it's not the same being from 80 and you drop to 60 real quick from being to 160 and you drop to 140. You're still in a comfortable range for you to play and your body feels the same. Yeah, that makes sense. I love any sport where it's not continuous. So I think it's to some degree you can make adjustments. And my big concern, I think that, I mean, you're right that's the level that I think your sugar should be at, but it works, it works, it works. And then one out of 10 times you'll go low or way higher. But the low, I just wanna make sure that anybody doing anything who can has the ability to take in some glucose to bring it back up. But I think if you're prepared, then it's fine. I like those sports better. Thank you. And I know we're coming to a close here and there's multiple great questions that I don't think we'll be able to get to, unfortunately. But I think we can end with this one. And I think this is a great question for both of you as well. Can you talk about your thoughts on having athletes with type one work with the sports psychologist, either Jaime, if you have personally or Dr. Peters, your experience with that? Well, I think mental health issues or it's not even an issue, but mental health is so important for anybody on the planet and in particular for people who are living with type one diabetes, just because it's hard to do. And so I'm a real advocate for having mental health professionals available and help. And I've had most of my athletes who are at a higher level do have some sort of a sports psychologist or someone that they deal with who really helps them because the psychology of this, Gary won in Athens because of his mind. I mean, he has a spectacular body. He was born into a family of Olympic swimmers, but honestly, it wasn't anything that we did for his glucose. I mean, yes, we did things for his glucose, but it was his brain that compelled him to win. I was so amazed and that's all psychology. Yeah, so we have a sports psychologist here at Florida State and I work with him. I think your brain's the strongest muscle in your body. And if your brain is telling you, you can't do something that you're never gonna accomplish it. So kind of being able to dominate your own mind and just positive self-talk. And instead of looking at something the negative way, look for the positive in it. Because there's always something good out of it, whether it's, I have to wake up for whatever, a six o'clock workout, a 6 a.m. workout, but instead of I have to, I get to. There's millions and millions of people that wish they could play baseball at Florida State. So just being thankful for that every day. Seeing the positive out of everything. And yeah, I was diagnosed with type 1 diabetes, but maybe that was my purpose in this life is to educate people and be a role model to people. So just taking that and going with it and living your best life with type 1 diabetes is something that's super important. And I truly take a lot of pride in. Thank you both. Amazing presentation and answers. And I think we'll conclude now with our final slide. All right, so later today everybody will receive a post-test by email. Completing this will allow you to claim your continuing education credit and also please be on the lookout for today's webinar recording on the ADA's Institute of Learning page in a few weeks. Remind any fellow members they can actually watch the webinar for one continuing education credit eligible until December 2024. And thanks again to our panelists for sharing your expertise with us today and thank you to everybody in the audience for joining as well. We hope to see you at another ADA webinar in the future. And this concludes the session. I hope everybody has a wonderful afternoon. Thank you.

exercise

type 1 diabetes

webinar

Dr. Jacob Kolenberg

Jaime Ferrer

Dr. Ann Peters

insulin delivery devices

basal insulin

sports psychologist

glucose levels