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[IP] Re: exercise help!!! (it's a long one.... sorry!)

Hi Sue.... (my apologies for posting something so long to the list.)
	So sorry to hear about your frustrations with Amy's exercise response.
This is such a difficult one because of the true individuality of the
glycemic response to exercise, including post exercise metabolic changes.  I
am willing to try to be of help to you both... especially because I agree
whole heartedly with you - there is no way that Amy should have to give up
her activities/exercise because of diabetes.  I myself am an exercise
physiologist, a CDE, and a pumper (since 11/97).  I've celebrated 16 years
of diabetes in March, and I also ran track in highschool.... I *know* what
those workouts can be like.  *lol*  Anyway... I am happy to help if I can.

	I know that you are looking for specifics, and that may be a bit difficult.
But I think I have some ideas about what is going on (& please forgive the
physiology!).  Amy has actually done remarkably well with the "during
exercise" numbers.  Remarkably(!) well.  The elevated sugar 1 hour post
exercise is not "metabolically unusual".... immediately post fairly intense
aerobic exercise, the body's recovery response often is to immobilize and
metabolize muscle glycogen stores.  In fact, it is probably doing that
*during* exercise as well, but glucose is used for fuel during exercise -
via pathways that don't actually involve insulin.  I am assuming that you
corrected for the 400+ reading at whatever is her typical correction factor,
and then added the "usual" dinner bolus onto that?  I have found that after
exercise, even if I go higher... the correction factor is much lower that my
usual correction factor - in fact, I use only about a 1/2 correction
bolus... sometimes it seems that I need even less.  I also always use less
of an insulin to carb ratio with any meal that follows exercise, so as not
to bring on a low from a bolus - i.e. from my "usual" of 1/15 to 1/22 (Don't
ask how I came up with those numbers - oddly enough, it works for me!
*lol*)  Remember that the body's metabolism is elevated for a few hours
after exercise.  In addition, insulin sensitivity has increased & will
remain increased for those hours as well.  I have also experimented with an
elevated temp basal (.1 increase in basal lowers me 50mg/dl but YMMV) after
certain exercise regimens, although I am sometimes hesitant to do that,
especially overnight.

	Predicting what the response will be can be difficult, however.. there are
ways to begin to do this.  Generally, any "new" exercise regimen (Amy began
training for track a few weeks ago??) will cause the body to respond more
"anaerobically" (& produce more lactic acid) - and you may see rises in
blood sugars as a result.  Also, realize that there are sports (or even
particular training days) that are much more "anaerobic" than others - for
example, a "sprinting" workout, "interval" (higher intensity) workout, or
weight/strength training can elicit a greater anaerobic response & hence a
rise in blood sugars afterwards.  I wouldn't doubt that this is what
happened in Amy's case with the 400 one hr after completion of exercise.  My
assumption is that you guys over corrected for the high, not taking into
account the increase insulin sensitivity - & also covered your "usual" for
dinner, which again in this case was too much... you then had to fight not
only the possible rises in BS levels due to the exercise, but you also were
fighting her liver's response to the post prandial low.  Although perhaps
her high's overnight were related to exercise, I believe they were as high
as they were due to that post prandial low.

	If you don't mind, tell me a little more about the kinds of numbers &
responses you have observed at other times, on both exercise days and
non-exercise days.  At this point, I would start by decreasing the
correction factors in response to post exercise highs... and changing the
insulin to carb ratio (what ratio does she use now for dinner??) on the days
post ex.  Once you have a handle on where her post dinner / pre bedtime
numbers are, then you can make a more informed choice to adjust basals over
night either up or down as needed.  Take one step at a time though.... and
unfortunately, I would certainly continue to do those middle of the night
checks for a while.  I know it sounds frustrating and intense, but YOU CAN
DO IT(!) - you are actually not as far off as you think you are.  :)

	The good news is that, with continued training Amy's body will respond less
dramatically to the exercise.... just like with anything else, in the
beginning it is quite hard, but it DOES get easier over time.  Because of
this, you more than likely will continue to have to tweak the numbers that
you use downward.  I am convinced that over the next couple of weeks, as she
becomes "trained" for her track sports, the highs won't be so high, the
response won't be so dramatic.  If you don't mind, ask Amy to tell you more
about her training schedule at the moment... do they do strength training on
certain days of the week, long distance running on others??  What event does
she run?  Perhaps I can provide you with some ways to pattern out the
response based on her actual regimen.  Any details she could provide will
help.  And, is she on suspend or a decreased basal rate during training??

	Well... I feel like I've raised more questions than I've answered!  *lol*
My apologies if I have indeed done that.  I do indeed know how absolutely
frustrating it can be... for both of you.  I do quite a bit of exercise, and
I actually do different things with my pump - vary my insulin delivery, eat
carbs prior for some things.... it certainly depends on what kind of
activity I am doing.  I, like many others, have spent quite a bit of time
figuring this out.  I also work developing exercise programs for many with
diabetes - the response can differ from one person to another... but you'd
be surprised at the "similarities" as well.  Anyway... I am certainly happy
to help if I can.  Again, apologies for the length.

Kind regards,
Delaine M. Wright, MS, CDE
Clinical Exercise Physiologist

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