Type 1 diabetes mellitus is a life longmetabolic disorder, which manifests when the pancreas stops producing insulin1-2.
As a result, patients living with type 1 diabetes mellitus are dependanton insulin for survival 1-2. However, regular physicalactivity for type 1 diabetes comprises with various health and cardiovascularbenefits including: increased insulin sensitivity, maintaining persistentglycaemic control by energizing muscle glucose uptake and promotes good qualityof life with diabetes 3-5. Blood glucoseMonitoring & Exercise Recommendations Before starting any training regimen It’s vitalto be aware of balancing the type of physical activity levels, correct insulindosing and tailored nutritional intake, in order to maintain normal bloodglucose levels: pre, during and post exercise to prevent hypoglycaemia 6-9. TheAmerican College of Sports Medicine guidelines propose people living with type1 diabetes participating in physical activity should aim to keep glucose levelsprior, during and following exercise predominantly over 5.5 mmol/L and essentiallyless than 13.
8-16.7 mmol/L in order to prevent hypoglycaemia episodes 10.This can be achieved by monitoring glucose 30 minutes prior to exercise, every30 minutes during exercise and following exercise; this can help enhancemetabolic control when exercising 7. If these glucose levels aren’t achievedprior to exercise it’s important to postponement exercise to establish ifketones are present 5. If glucose levels are below 5mmol/L consumequick-acting carbohydrates approximately 15-20 grams and recheck glucose levelsto determine if exercise can be started 5. Training Session Consent& Preparation Running a marathon consists of running thedistance of 26 miles 11 and preparing for marathon training sessions is achallenging task especially for type 1 patients, which compromises of vasteffort and constant practice 11. It’s not recognised if the client is aregular exerciser or has any other medical conditions that may restrict herfrom exercise (e.
g. hypertension, blocked arteries etc.). Thus, before startingany form of exercise, it’s vital she obtains consent from her doctor to determineif she’s fully physical to fulfil both short and long duration, low and highintensity training sessions and especially running the marathon before consideringto nutritional and medication advises discussed below 12. ImportantConsiderations During initial Training Sessions Before participating in initial aerobic training(e.g. running) and anaerobic training (e.
g. resistance training) sessions itsimportant to structure exercise programmes of appropriate duration and intensity,as different forms of exercise and intensity can result in changing glucoseresponses, which essentially could predispose to hypoglycaemia 13. Thus, its important to set realistic goals bystarting with low intensity and low duration and progress steadily, this waythe body would become accustomed to the exercise intensity and would help improveinsulin sensitivity, which would therefore help reduce the risk ofhypoglycaemia 14. It’s also important to inform someone before exercising incase of hypoglycaemia episodes manifest 14. To achieve constant progress fromtraining sessions the client could consider using technology devices and mobileapps to measure and keep track of intensity movement, calories consumed, heartrate and distances travelled. 69. This can help structure training programmeseffectively and support to achieve realistic results 69-70 Insulin Adjusting & Exercise Most challenging consequences of exercisingwith type 1 diabetes is adjusting correction insulin dose with nutrition andexercise to prevent hypoglycaemia 15. Several aspects could affect glucosereactions to exercise such as: glucose levels prior to exercise, timing, typeand intensity of exercise, timing of insulin injections and last meal consumedprior to exercise 15.
Taking vast amount of insulin prior to exercise cancause hypoglycaemia, as it diminishes the amount of glucose that adds to theblood from the liver and taking smaller amount of insulin would predispose to hyperglycaemia16. Thus, it’s vital to reduce the dose of insulin with meals prior toexercise, which will again depend on the duration, time and intensity of theexercise session 16. The client is currently taking ‘Novorapid’insulin with meals. If the client decides to exercise after a meal Diabetes UKguidelines for insulin adjusting prior to exercise intensity 17 suggest: ifexercising within 30 minutes of short duration of mild exercise, its advised toreduce 25% of rapid-acting insulin. If exercising for at least 60 minutes ofmoderate to high intensity exercise, a reduction of 50-75% of rapid-actinginsulin reduction is recommended and exercising for over 90 minutes reductionof rapid-acting insulin from 25 to 75% is advised. If exercising beforebreakfast consider a taking less sugary fluids during exercise and take normalinsulin dose with breakfast post-exercise.
If exercising after breakfast,reduce novo-rapid by 25% with low calorie breakfast and take usual insulin dosefor lunch and dinner 18. In regards to the Lantus insulin taken at night, ifexercising couple days per week the dose of Lantus insulin can be split in halfto be taken twice a day, which can therefore allow the meal insulin dose to be reducedprior to exercise 19. If exercising everyday, Lantus insulin can be reducedby 20-25% at night, which would help prevent hypoglycaemia episodes thefollowing morning 19. Alternative Insulin Deliveries If the client finds it challenging to adjustinsulin injections or injecting in general, she could consider insulin pump to injections.Insulin pump is touch of a button device that delivers correction dose at eachsnack or meal and it contains rapid-acting insulin in smaller dosages to coverbasal needs, which can programme bolus needs for snacks, meals and glucosecorrection and deliver more insulin anytime if needed 39-40.
Basal insulincan be turned off or reduced during and after exercise and be used suitable towear during exercise 39-40. This can also prevent lumpy skin from multiple dailyinjections and possibly cause less risk of post exercise hypoglycaemia 41. Pre & Post WorkoutExercise Nutrition Considerations Carbohydrates are the main source of energy forexercise that breaks down into glucose and stored in muscle tissue for fuelduring exercise 20. Thus, it’s important to fuel accordingly and timing mealsprior to exercise is a vital characteristic of pre exercise nutrition 20.
Carbohydratesintake for exercise from diet again depends on the type, time and intensity oftraining 20. Complex carbohydratessuch as: whole grains, bread, rice, pasta, potatoes are longer lasting energy,which should be considered in a diet regimen if exercising longer durations andshould be consumed 2-3 hours prior to exercise to ease digestion and top upmuscle and glycogen stores 20-21. If planning to exercise for shorterduration consume pre-workout nutrition 60 minutes prior to exercise andconsider more of rich in simple carbohydrate snack that is easily digestede.g. brown rice, oatmeal, banana, yogurt etc.) 22. Combing carbohydrates with protein and fatmacronutrients in diet can help maximize realistic results from intensetraining sessions and minimalize hazards of muscle damage when consumed 1-3hours prior to exercise; combination of carbohydrate and protein are essential toconsume straight after exercise for repairing damaged muscle tissue and replenishglycogen stores to promote recovery and to prevent late evening hypoglycaemia 23-25.
Nutrition DuringExercise Considerations When exercising long durations it’srecommended to consume 30-60 grams of quick acting carbohydrate every hour orbreak it down to consuming 10-15 grams every 20 minutes during exercise, whichwould help prevent hypoglycaemia during exercise 17. Quick actingcarbohydrate snacks or supplements include: energy gels/bars, sports drinks, jellybeans,and honey 17,26. If feeling light headed, week or fatigued during exerciseit’s important to consume these fast-acting carbohydrates straight away asthese are symptoms of hypoglycaemia and its essential to monitor glucose levelsduring this stage 26. Consequently, during exercise it is necessaryto keep hydrated during all forms of exercises and its helpful to note down ifany form of activity affected glucose levels during exercise for futurereferences 14-26. Thus, consider having a exercise diary to record which typeof activity, distance of activity, nutritional intake and blood glucose levelswere pre and post exercise that affected glucose levels if any; this can help preventhypoglycaemia in future training sessions 14, 26.
In-Depth ResourcesFor Exercise, Insulin, Nutrition & Marathon Preparations This assignment has covered the basicinformation of exercise intensity, insulin adjustments and suitable nutritionthat the patient should consider in her training programme to preventhypoglycaemia. Full in depth information can be found in the followingresources in the reference list of: Exercises & Nutrition in Type 1 Diabetes17, 26, 27, 28, 29, 37. Insulin Adjustments Prior to Exercise 17, 30-31;Fluid Adjustments For Exercise 32. Marathon Preparation 33, Marathon CarbLoading Nutrition 34, 36, 38 and insulin pump therapy 39, 42. Section2Pathophysiology ofGestational Diabetes Mellitus Gestational diabetes is a form of diabetesthat manifests during pregnancy due to impaired glucose intolerance, resultingin hyperglycaemia 43-45.
During pregnancy stages the body changes incarbohydrate metabolism, decreases insulin sensitivity and raises the hormone levelsproduced by the placenta; these specific hormones prevent the action of insulinapproximately from the 18th week during pregnancy 43. Thus, thereduction of insulin during pregnancy requires threefold increase in maternalinsulin secretion, in order to maintain normal glucose tolerance within 3months of pregnancy 43. Case Study Overview& Key Learning Points In case study 1 and 2 both patientsdisplayed diverse personal experiences with the same diabetes diagnoses.However, both patients were diagnosed with gestational diabetes due to the samepoor lifestyle and diet characteristics, which in turn caused glucose intolerance,which led both patients to insulin therapy. Mrs PTK had a family history oftype 2 diabetes and a sister who had past gestational diabetes during secondpregnancy. Whereas, this was Ms SB first pregnancy and she didn’t have familyhistory of diabetes but went through psychological distress during gestationaldiabetes stages. Overall, Mrs PTK had a more positive experience of health andsocial situations than Ms SB.
However, Ms SB had a healthier outcome due to nocomplication diagnoses and postnatal glucose tolerance was found negative. InsulinRequirements During & Post Pregnancy During initial gestational diabetes stages,it can be challenging for pregnant women to maintain optimal glucose levels dueto several physical and hormonal changes in the body 46. Pharmacologicalinsulin treatment may be needed during and post pregnancy, if diet and exerciseregimen fails to control glucose levels during pregnancy 47. During the first trimester of pregnancy,insulin dosage would need to be decreased due to risk of developinghypoglycaemia; during this stage its vital to monitor glucose levels and adjustinsulin accordingly 48, 65-66. During second trimester, insulin requirementswould then start to increase due to changes of pregnancy hormone levels and theplacenta being fully developed 48, 67. During this stage the pre meal insulinbolus will be increased to keep glucose control during post meals.
In the thirdtrimester, patients may need to be given a larger insulin dose prior to pre mealbecause insulin is absorbed more gradually during this stage, which can beineffective to lowering glucose during late pregnancy. Thus, higher insulin dosewould help balance glucose levels 48. Lastly, during birth, glucosemonitoring regularly is essential to confirm sugar levels are in control andsmall insulin bolus will be required during and immediately post-delivery.After post childbirth insulin bolus dose can be decreased 48.
Oral Hypoglycemic Drugs During Gestational Diabetes There’s a debate in the research domainwhether hypoglycaemic drugs should be permitted during gestational diabetes.Research suggests hypoglycaemic drugs such as metformin can be an effectiveoption for gestational diabetes patients due to improved insulin sensitivity, lessrisk of hypoglycaemia episodes and prevents additional weight-gain 49-50.Various studies have shown clear evidence that metformin was a safe treatmentduring gestational diabetes in the following studies 50-56. One study inparticular showed metformin treatment was correlated with increasedpreeclampsia and perinatal mortality 57.
Despite vaster studies showing saferuse of hypoglycaemic drugs during pregnancy, further research is warranted to exhibitclearer evidence if hypoglycaemic drugs are safe to take during gestationaldiabetes. PsychosocialAspects of Diabetes Treatment During gestational pregnancy women can findit challenging to control their diabetes due to many psychosocial factors withdiabetes and the fear of the complications associated with uncontrolled diabetescould lead patients vulnerable to various psychological behaviours (e.g. emotional distress and anxiety) leadingto poor pregnancy consequences 58-60. Even though every woman would go throughthe same pregnancy stages, every patient would go through different experiences,which in turn resulting in diverse psychological behaviours 61. Thus, the potentialtreatment for diverse patients comes down to how health care professionals cantailor personalised treatment plans to patients in order to achieve positiveoutcomes 61.
Personalising treatment plans can be achieved when assisting andeducating patients to available treatment plans, which would support diversepatients to make treatment choices they believe would bring an effectiveoutcome during gestational diabetes 62-63. Alongside this, psychologicalsupport from appropriate multidisciplinary teams should be implemented with thepatients chosen treatment (e.g.lifestyle/medication interventions or both) that would achieve positivepsychology and supports patients to control their diabetes and positivewellbeing during pregnancy 62-64.
Future Practice Implications From this case study I’ve learnt that everypatient would have diverse experiences during pregnancy and not all patientswould adapt to the same treatments plans effectively, which can be due to many personal,educational and psychological factors 68-71. As I come from a psychologybackground, I comprehend that psychology plays a vital role during pregnancy68. As pregnancy alone is a challenging journey and together with glucoseintolerance it could lead to depression various psychosocial aspects withgestational diabetes, resulting in unhealthy psychological behaviours prominentto unhealthy physiognomies 69-71.
Thus, patients are in special need forpsychological treatment during this challenging journey. In my clinicalpractice, I would work more closely with patients who are already diagnosedwith mental illness and patients facing psychological distress during gestationaldiabetes pregnancy by initiating well-tailored psychological behavioural therapyinterventions to support my patients adhere to their pregnancy treatmentregimens and manage psychosocial gestational diabetes distress effectively. Furthermorethese tailored psychological interventions would aim to reduce depression andanxiety, improve patient’s confidence and self-esteem during pregnancy to preventhyperglycaemia and diabetes complications, in order to achieve an effective childbirthoutcome.