Low Sugar with exercise

Food
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Hi! I’m a newly diagnosed T1D…diagnosed 4 months ago at age 49. I have SO much to learn! So far, I’ve lowered my A1C from 10 to 5.9! My carb ratio is 1:15 and I take the 7 units long acting one although at today’s appointment my doctor lowered it to 6 units.

My diagnosis took several months. Following my 49th birthday last May, I had meningitis and then started having vision problems, diagnosed with Hashimotos in August and then with what was assumed by primary care doctor to be Type 2. A visit to 2 endocrinologists confirmed Type 1. Decreasing sugar level has corrected the vision issues and I think I’m still in the “honeymoon” phase as my sugars are very manageable so far.

So, one of my initial symptoms of my diagnosis was weight loss which I was attributing to the thyroid medicine. I was quickly diagnosed when the thirst kicked in so I only lost about 10 lbs…wishing it had been more but with the +ketones I would’ve been super sick! I have 4 kids and would love to lose weight (or not gain it!) as a T1D.

I play a LOT of tennis and struggle with low sugar when I play. I’m not sure if I’m not eating the right foods to sustain the exercise but I’m having to supplement with gatorade and/or protein bars which is only adding calories. Every night, I have to take a snack because I’m below my required 120 so I’m adding calories there as well. And, I can chase a low sugar for hours after a hard tennis match. I wear a CGM which really helps me see the trends although it’s often not super accurate.

So I guess I’m curious about what people are doing to get sugars high enough prior to exercise and what to do during exercise to maintain them.

Usually I will drink a fruit and veggie smoothie pre workout if it’s the morning and I’m don’t take any insulin if I’m working out within an hour of exercise. I try to add something with more protein and fat - to slow the sugar - like an egg. If I’m playing tennis in the evening I am eating something like hummus and pita bread and adding protein like chicken along with it. But, it’s not getting my sugar to 120-150 which is what i need to maintain appropriate levels during exercise and I seem to burn through it rather quickly so I have to start supplementing with sports drinks.

I know a lot is trial and error but I’m ingesting a lot of extra calories trying to get sugars right. I hope this makes sense to someone! lol .

Thanks for any advice and for sharing your experiences and expertise. I guess I’m lucky to be diagnosed later in life but I’m also set in my habits need to tighten up my nutrition. Any suggested resources would be excellent as well. I’m still getting the “are you SURE you’re not Type 2?” questions because of my adult onset. Ugh. I don’t really know how to explain the differences so education there would be helpful. Thanks!

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Hello! I am in a similar situation - diagnosed 3 months ago, T1, at age 47, although I am taking a little more insulin than you. I am a runner (competitive once upon a time) and through lots of testing and a couple of exercise-induced lows have figured out that I need to eat 15g of quick acting carbs (I use gu, glucose tabs, candy, or gummies) after about 25 minutes to prevent a low and then again every 40 minutes or so and I will stay pretty even. If the whole run is less than 30 minutes I won’t take anything. I don’t normally snack before running as I am typically running 130-150 right now. I agree it sucks to keep ingesting carbs while exercising, especially for someone trying to lose weight!

My first exercise low was kind of scary, I had blurry tunnel vision and knew I had to fix it but was moving in super slow-mo. I remember having to squint and it took a couple tries just to read the number on my meter! I had glucose handy so everything was fine a few minutes later. I also got a medical alert thing I wear on my watch so people might have an idea what happened if I ever pass out running in the forest :slight_smile:

I am still on MDI but am planning to go on an Omnipod soon. A pump should help since then I can set a temporary basal (or turn it off) while right now I have Lantus floating around in my system. Right now I think the only way to compensate is by ingesting glucose, until we get glucagon delivery from the bionic pancreas.

I think the Diabetic Athlete’s Handbook by Shari Colberg is great reading: http://www.amazon.com/Diabetic-Athletes-Handbook-Sheri-Colberg/dp/0736074937

Here’s another one by Dinesh: http://www.amazon.com/Exercise-Sport-Diabetes-Practical/dp/047002206X
There is an excerpt here: http://www.diabetesincontrol.com/exercise-and-sport-in-diabetes-2nd-ed-part-7-adjusting-insulin-dosing-for-physical-activity/

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I am 44 and was diagnosed 4 months ago. My blood sugar averages around 100 or lower. Still considered to be in honeymoon phase. I only take 5 units of levemir once a day. I workout almost everyday and eat a low carb diet. Most of the time I run my sugar ranges from 75 to 95. I try to snack or drink gatorade before I start my runs. It sucks we have to do this but would love a clear cut answer on what to take before working out.

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I would second the recommendation of Sheri Colberg (Ochs). I have several of her books and she is probably the preeminent physiologist expert on T1. She also has a whole bunch of free articles on her site about exercise.

A key challenge for anyone on and MDI insulin regime doing exercise is that unless you have a pump it is very difficult to “dial” back your insulin levels. You just can’t suspend your basal unless you have a pump. And if you try to adapt by exercise after eating and restricting mealtime insulin, then the results can be quite unpredictable. One approach that can work is to exercise with a consistent regime and develop an adaptive pattern of treatment to match that regime. If you are doing cardio then you might find a glucose tab every 15 minutes work. Competitive exercise like tennis can be more difficult. I actually find the anaerobic exercise and competition raise my blood sugar and I need to actually bolus for the activity. The other thing you can work in is to use protein as a buffer. Protein is digested slowly and you may find a protein shake before working out provides an ongoing source of blood sugar during exercise.

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Hello KellyW.

Congratulations on getting your HbA1C down so quickly!

I’m Type 2 myself, but I take insulin and do water aerobics/swim regularly. It’s a new thing for me so I’m facing many of the same issues that you are. I can tell you that glucose tablets or glucose gel packs (which taste nasty IMHO) work more quickly and have far less calories than gatorade or protein bars - especially if you’re choosing the wrong protein bars. Some are practically candy bars in disguise! I personally like the Oatmega protein bars for after a particularly long session. They’re about 190 calories (so lower in calories than some bars) and fairly low in sugar, unlike some brands of bars, with 7g of fat (2g saturated) 14g of protein, 21g of carbs (7g of fiber and 5g of sugar). I find that it’s a good mix that gets my blood sugar up and then keeps me fairly even without having to ride a rollercoaster. If I have to eat one I usually just cut back a little bit on what I was going to eat for lunch since lunch is just a couple of hours away.

My workouts are in the morning, when I’m at my most insulin resistant. It’s taken time, and it’s still not perfect due to how different each instructor may lead the class and how hard they may push the cardio each day, but I’m getting better at not going as low as I had been (regularly getting out of the pool with BGs <50. Whups!) I’ve started eating a higher carbohydrate breakfast with a mix of protein and healthy fat, taking less of my insulin and letting my post-breakfast blood sugar go a bit higher - as high as 180. My Endo and I talked about this and it’s certainly better than the alternative. I keep a roll of glucose tabs by the pool in case I feel shaky mid-workout, though honestly I find that I’m not overly hypo-aware when I’m concentrating on just keeping up with the class.

When you say a “required 120” at night, do you mean that you won’t go to sleep if your BG is below 120? I used to be like that. I think that’s pretty standard in the beginning until you get better control and get more familiar with your diabetes. It won’t necessarily always be like that, though. Once you’ve got your insulin doses fairly squared away and are sure you aren’t having 3am lows you may be able to go a bit lower, I’m not sure. This may be something that T1s and T2s differ in, I’m not sure. I now regularly go to sleep with my BG as low as 85 or 90.

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If my daughter’s BG is 120 at bedtime (or any other time for that matter) I give her a correction bolus. Not sure why, especially with a CGM, you’d want to raise your BG to a number higher than “normal” (100) unless it was right before exercising…

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Thanks for the suggestion just bought the Shari book.

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John Walsh also has a good discussion on exercise in Using Insulin.

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We actually had Dr Colberg here for a live interview, here’s a link (she doesn’t begin to speak until 30 seconds in)

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Nice find thank you.

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One of the things I slowly figured out (although its gonna sound pretty obvious here!) as a predictor of whether or not I was going to go low during exercise was how much insulin on board I had in my system. (See? I told you that would sound pretty obvious!)
My personal ‘algorithm’ seems to be that any rapid-acting insulin on board (as calculated by a bolus wizard/calculator) seems to become 3x more powerful when I exercise, and so if I have 2 units of insulin on board when I start exercising, that will now have the BG-lowering power of closer to 6 units. Reverse math using my insulin:carb ratio of 1:7 says that I will need about 42 carbs to keep from going low. That means I either need to postpone (sometimes an option, sometimes not) or eat now and carry a lot of snacks with me. I only use the rapid-acting insulin in the calculation, Lantus doesn’t seem to play much of a part but basal delivered by a pump does (which is why the reduced temp basal is so helpful when pumping, but I have not necessarily found it to be tragic not to have while on MDI).

Its a pain to adjust the food or exercise timing around active insulin, and sometimes it means I take maybe half of the insulin I would normally for a meal if I’m going to exercise in the next 2 hours, and I just know that I’m going to run higher than is ideal but the trade off is that I can exercise with less problems. Alternately, if I go mostly low-carb for a meal, that reduces the amount of insulin I take and that reduces the number of lows significantly also. Again,not always easy or possible depending on what life throws at you for the day, but can be a good trick to keep up your sleeve sometimes.

Ginger Viera’s [Your Diabetes Science Experiment] (http://www.amazon.com/Your-Diabetes-Science-Experiment-diabetes/dp/148106200X/ref=asap_bc?ie=UTF8) is a good book to work through some of this with, but I also whole-heartedly agree with recommendations about the books by John Walsh and Shari Colberg.

Your Diabetes May (will!) Vary on this one by a lot, and it took an awful lot of trial and error and thinking and figuring out what to look at to be able to fend off exercise lows, but I can do a pretty good job now guessing at how much (or if) to eat before heading out, and thats a nice change!

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Thank you! I’m looking forward to the pump as well. I think it will help a lot. I added the protein bar and did a lot better. I haven’t had the scary low that you mentioned but sadly, I don’t really feel my lows yet. Although, tonight on the tennis court, I DID finally feel it even though my CGM said I wasn’t low. I took some glucose tablets and felt a lot better so clearly the monitor was a tad on the high side.

Looking forward to checking out the references. Thanks!

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Wow…your sugar is running a lot lower than mine…I wonder if you are still on too much Levemir? I’m down to 6 units but I couldn’t workout on 75-95. I’m having to start closer to 150 and I end around 75 after drinking 2 gatorades, sugar pills and protein bar. Ugh. I think the pump is going to be key!

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Thanks for response. I did add protein tonight and that helped a lot and I took sugar more consistently during workout and it seemed to help.

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hmmmm… something to ask my doctor for sure. I was told not to go to bed with sugar below 120 but hopefully that will change as I get this figured out. I’ll add it to my list of questions! I’m dreading the crazy lows and hopeful I can avoid them! Thanks!!

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Hmmm. That’s interesting. I’ve been told to do a correction if I’m above 150 during the day. For me “normal is 80-150”. I think the correction factor is different for different people. I wonder your daughter’s age and how long she’s been T1D. It might make a difference? But, I’ll definitely ask the doctor their thoughts. Thanks!

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This was super helpful. But I’m VERY NEW so how do you know how much insulin is “on board”? What is the “Bolus/wizard calculator”? I’ll also order books and get caught up on my reading. Thanks!

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@KellyW as one of the few American College of Sports Medicine Registered Clinical Exercise Physiologist and the only one in the country with a specialized degree (masters) in diabetes education and management, I would concur with others who have suggested you read Dr. Sheri Colberg’s book, in addition Gary Scheiner as they are both living with T1DM and can offer a unique perspective on the exercise prescription as it relates to engaging in vigorous physical activity and T1DM.

However, most important I think you should also contact a clinical dietitian who is a clinical exercise physiologist as your challenge is not exercise your challenge is nutrition. Gary and Sheri haven’t received that academic preparation.

Finally, I’d like to share the clinical exercise guidelines that inform American College of Sports Medicine Registered Clinical Exercise Physiologists. I hope they are helpful to you. Please know that these are just guidelines. And it is not safe for anyone to suggest what you consume or how to adjust your exercise without having given you an assessment and/or exercise test which is recommended for individuals living with metabolic conditions. In my industry you are categorized as “high risk.”

Much of what follows are things you are already doing, so I hope it is useful.

The 6th Edition of the ACSM Resource Manual for Guidelines for Exercise Testing and Prescription state:

“Recommendations for pre-exercise injections typically suggest injections injection into the abdominal fat tissue. Insulin dosage (pump or injection) may need to be reduced before exercise to avoid hypoglycemia. Insulin adjustments involve a trial-and-error process that requires understanding of insulin action and impact of exercise, food intake, and medication on glucose variability, combined with frequent routine self-blood glucose monitoring (SBGM). Regular PA (physical activity) combined with frequent SBGM is the cornerstone for safe and effective glucose control.”

The guidelines go on to further highlight:

"The acute effect of exercise on diabetes improves insulin sensitivity, facilitates glucose uptake, and aids in glucose homeostasis. Usually, an acute bout of exercise lowers blood glucose for 24 to72 hours post exercise, Thus, acute effects of exercise are transient and short-lived.

"SBGM is recommended before and after each exercise session in persons with diabetes, and blood glucose values ranging between 100 and 250 is recommended to participate safely in exercise…Conversely, if blood glucose is within the low-normal range before exercising, an acute bout tends to accelerate blood glucose lowering and increase risk of hypoglycemia. To avoid hypoglycemia, consumption of 20 to 30g of carbohydrates is recommended before exercising. Also, extra carbohydrates may need to be ingested during and after exercise predicated on intensity and duration of the exercise bout.

If post exercise hypoglycemia occurs, the exercise physiologist should encourage the person with diabetes to consume 20 to 30g of carbohydrate and monitor blood glucose after 5 minutes. This sequence of carbohydrate consumption and blood glucose monitoring should proceed until the patient’s blood glucose has reached a normal level. Acute exercise has a post exercise has a post exercise influence on diabetes for 24 to72 hours. Thus, vigilant SBGM before, after and several hours after the exercise bout is critical to prevent severe glucose excursions causing hypoglycemia.

I hope this provides a good place to start for you until you are able to meet face-to-face with a clinician with experience in prescribing exercise for a very active person living with T1DM and who is also a clinical nutritionist.

All the best!

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Kelly - it’s typical for a lot of doctors to have people keep a higher range when they are new and figuring these things out. A lot of doctors are MUCH more afraid of people going low than they are of going high. Admittedly, this is with good reason as going low can have horrible results, especially if someone doesn’t have a CGM and/or no hypo awareness. I’ve heard more than one story of people who want to maintain what is called “tight control” being in a bit of conflict with their doctors who are worried about hypoglycemic episodes - but many of us think its worth it as long as we have action plans in place. Doctors, of course, HAVE to worry about the “average” person who may not be as vigilant, and about getting sued.

I’m Type II, but on insulin. There’s the rare occasion when I go low in the middle of the night, but I have good hypo awareness even in my sleep (for now) and usually wake up when my BGs drop to around 50 or 60. But if I didn’t… ew. My understanding is that the chances of a TI going low during sleep are a bit higher due to their increased sensitivity to insulin and the way their bodies work in general.

Everyone’s body is so very different, and everyone’s diabetes journey is so different, too. I have little doubt that with a lot of testing and practice you’ll figure it out and get the level of control you’re most happy with, though!

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@jojeegirl, thank you! Very helpful. I think one of the most frustrating thing is that EVERY one seems to be an expert and they want to treat all diabetes the same. I can’t tell you how many want me to be “totally off of insulin” and I’m like “…uh, pretty sure that’s impossible!” I didn’t realize there was a specific certification that I need to find in nutritionists. I’ve been listening mostly to a combination of the nutritionists at my doctor’s office and other T1D regarding what works for them but it’s the other “experts” that I meet that want to give me their 2 cents worth every time I’m on the court!

I’m excited to figure out this next piece of the puzzle. I love tennis and what I’m doing is working but i know there’s a better way that will give me optimal energy without excess calories! Thanks for the info!