Type levels to determine if exercise can be

Type 1 diabetes mellitus is a life long
metabolic disorder, which manifests when the pancreas stops producing insulin
1-2. As a result, patients living with type 1 diabetes mellitus are dependant
on insulin for survival 1-2. However, regular physical
activity for type 1 diabetes comprises with various health and cardiovascular
benefits including: increased insulin sensitivity, maintaining persistent
glycaemic control by energizing muscle glucose uptake and promotes good quality
of life with diabetes 3-5.  Blood glucose
Monitoring & Exercise Recommendations  Before starting any training regimen It’s vital
to be aware of balancing the type of physical activity levels, correct insulin
dosing and tailored nutritional intake, in order to maintain normal blood
glucose levels: pre, during and post exercise to prevent hypoglycaemia 6-9. The
American College of Sports Medicine guidelines propose people living with type
1 diabetes participating in physical activity should aim to keep glucose levels
prior, during and following exercise predominantly over 5.5 mmol/L and essentially
less 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, every
30 minutes during exercise and following exercise; this can help enhance
metabolic control when exercising 7. If these glucose levels aren’t achieved
prior to exercise it’s important to postponement exercise to establish if
ketones are present 5. If glucose levels are below 5mmol/L consume
quick-acting carbohydrates approximately 15-20 grams and recheck glucose levels
to determine if exercise can be started 5.  Training Session Consent
& Preparation  Running a marathon consists of running the
distance of 26 miles 11 and preparing for marathon training sessions is a
challenging task especially for type 1 patients, which compromises of vast
effort and constant practice 11. It’s not recognised if the client is a
regular exerciser or has any other medical conditions that may restrict her
from exercise (e.g. hypertension, blocked arteries etc.). Thus, before starting
any form of exercise, it’s vital she obtains consent from her doctor to determine
if she’s fully physical to fulfil both short and long duration, low and high
intensity training sessions and especially running the marathon before considering
to nutritional and medication advises discussed below 12. Important
Considerations During initial Training Sessions Before participating in initial aerobic training
(e.g. running) and anaerobic training (e.g. resistance training) sessions its
important to structure exercise programmes of appropriate duration and intensity,
as different forms of exercise and intensity can result in changing glucose
responses, which essentially could predispose to hypoglycaemia 13.  Thus, its important to set realistic goals by
starting with low intensity and low duration and progress steadily, this way
the body would become accustomed to the exercise intensity and would help improve
insulin sensitivity, which would therefore help reduce the risk of
hypoglycaemia 14. It’s also important to inform someone before exercising in
case of hypoglycaemia episodes manifest 14. To achieve constant progress from
training sessions the client could consider using technology devices and mobile
apps to measure and keep track of intensity movement, calories consumed, heart
rate and distances travelled. 69. This can help structure training programmes
effectively and support to achieve realistic results 69-70 Insulin Adjusting & Exercise
 Most challenging consequences of exercising
with type 1 diabetes is adjusting correction insulin dose with nutrition and
exercise to prevent hypoglycaemia 15. Several aspects could affect glucose
reactions to exercise such as: glucose levels prior to exercise, timing, type
and intensity of exercise, timing of insulin injections and last meal consumed
prior to exercise 15. Taking vast amount of insulin prior to exercise can
cause hypoglycaemia, as it diminishes the amount of glucose that adds to the
blood from the liver and taking smaller amount of insulin would predispose to hyperglycaemia
16. Thus, it’s vital to reduce the dose of insulin with meals prior to
exercise, which will again depend on the duration, time and intensity of the
exercise session 16.  The client is currently taking ‘Novorapid’
insulin with meals. If the client decides to exercise after a meal Diabetes UK
guidelines for insulin adjusting prior to exercise intensity 17 suggest: if
exercising within 30 minutes of short duration of mild exercise, its advised to
reduce 25% of rapid-acting insulin. If exercising for at least 60 minutes of
moderate to high intensity exercise, a reduction of 50-75% of rapid-acting
insulin reduction is recommended and exercising for over 90 minutes reduction
of rapid-acting insulin from 25 to 75% is advised. If exercising before
breakfast consider a taking less sugary fluids during exercise and take normal
insulin dose with breakfast post-exercise. If exercising after breakfast,
reduce novo-rapid by 25% with low calorie breakfast and take usual insulin dose
for lunch and dinner 18. In regards to the Lantus insulin taken at night, if
exercising couple days per week the dose of Lantus insulin can be split in half
to be taken twice a day, which can therefore allow the meal insulin dose to be reduced
prior to exercise 19. If exercising everyday, Lantus insulin can be reduced
by 20-25% at night, which would help prevent hypoglycaemia episodes the
following morning 19.  Alternative Insulin Deliveries If the client finds it challenging to adjust
insulin 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 each
snack or meal and it contains rapid-acting insulin in smaller dosages to cover
basal needs, which can programme bolus needs for snacks, meals and glucose
correction and deliver more insulin anytime if needed 39-40. Basal insulin
can be turned off or reduced during and after exercise and be used suitable to
wear during exercise 39-40. This can also prevent lumpy skin from multiple daily
injections and possibly cause less risk of post exercise hypoglycaemia 41.  Pre & Post Workout
Exercise Nutrition Considerations Carbohydrates are the main source of energy for
exercise that breaks down into glucose and stored in muscle tissue for fuel
during exercise 20. Thus, it’s important to fuel accordingly and timing meals
prior to exercise is a vital characteristic of pre exercise nutrition 20. Carbohydrates
intake for exercise from diet again depends on the type, time and intensity of
training 20.  Complex carbohydrates
such as: whole grains, bread, rice, pasta, potatoes are longer lasting energy,
which should be considered in a diet regimen if exercising longer durations and
should be consumed 2-3 hours prior to exercise to ease digestion and top up
muscle and glycogen stores 20-21. If planning to exercise for shorter
duration consume pre-workout nutrition 60 minutes prior to exercise and
consider more of rich in simple carbohydrate snack that is easily digested
e.g. brown rice, oatmeal, banana, yogurt etc.) 22.  Combing carbohydrates with protein and fat
macronutrients in diet can help maximize realistic results from intense
training sessions and minimalize hazards of muscle damage when consumed 1-3
hours prior to exercise; combination of carbohydrate and protein are essential to
consume straight after exercise for repairing damaged muscle tissue and replenish
glycogen stores to promote recovery and to prevent late evening hypoglycaemia 23-25.
 Nutrition During
Exercise Considerations When exercising long durations it’s
recommended to consume 30-60 grams of quick acting carbohydrate every hour or
break it down to consuming 10-15 grams every 20 minutes during exercise, which
would help prevent hypoglycaemia during exercise 17. Quick acting
carbohydrate snacks or supplements include: energy gels/bars, sports drinks, jellybeans,
and honey 17,26. If feeling light headed, week or fatigued during exercise
it’s important to consume these fast-acting carbohydrates straight away as
these are symptoms of hypoglycaemia and its essential to monitor glucose levels
during this stage 26.  Consequently, during exercise it is necessary
to keep hydrated during all forms of exercises and its helpful to note down if
any form of activity affected glucose levels during exercise for future
references 14-26. Thus, consider having a exercise diary to record which type
of activity, distance of activity, nutritional intake and blood glucose levels
were pre and post exercise that affected glucose levels if any; this can help prevent
hypoglycaemia in future training sessions 14, 26.  In-Depth Resources
For Exercise, Insulin, Nutrition & Marathon Preparations This assignment has covered the basic
information of exercise intensity, insulin adjustments and suitable nutrition
that the patient should consider in her training programme to prevent
hypoglycaemia. Full in depth information can be found in the following
resources in the reference list of: Exercises & Nutrition in Type 1 Diabetes
17, 26, 27, 28, 29, 37. Insulin Adjustments Prior to Exercise 17, 30-31;
Fluid Adjustments For Exercise 32. Marathon Preparation 33, Marathon Carb
Loading Nutrition 34, 36, 38 and insulin pump therapy  39, 42.       Section
2Pathophysiology of
Gestational Diabetes Mellitus Gestational diabetes is a form of diabetes
that manifests during pregnancy due to impaired glucose intolerance, resulting
in hyperglycaemia 43-45. During pregnancy stages the body changes in
carbohydrate metabolism, decreases insulin sensitivity and raises the hormone levels
produced by the placenta; these specific hormones prevent the action of insulin
approximately from the 18th week during pregnancy 43. Thus, the
reduction of insulin during pregnancy requires threefold increase in maternal
insulin secretion, in order to maintain normal glucose tolerance within 3
months of pregnancy 43.  Case Study Overview
& Key Learning Points In case study 1 and 2 both patients
displayed diverse personal experiences with the same diabetes diagnoses.
However, both patients were diagnosed with gestational diabetes due to the same
poor lifestyle and diet characteristics, which in turn caused glucose intolerance,
which led both patients to insulin therapy. Mrs PTK had a family history of
type 2 diabetes and a sister who had past gestational diabetes during second
pregnancy. Whereas, this was Ms SB first pregnancy and she didn’t have family
history of diabetes but went through psychological distress during gestational
diabetes stages. Overall, Mrs PTK had a more positive experience of health and
social situations than Ms SB. However, Ms SB had a healthier outcome due to no
complication diagnoses and postnatal glucose tolerance was found negative.  Insulin
Requirements During & Post Pregnancy During initial gestational diabetes stages,
it can be challenging for pregnant women to maintain optimal glucose levels due
to several physical and hormonal changes in the body 46. Pharmacological
insulin treatment may be needed during and post pregnancy, if diet and exercise
regimen 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 developing
hypoglycaemia; during this stage its vital to monitor glucose levels and adjust
insulin accordingly 48, 65-66. During second trimester, insulin requirements
would then start to increase due to changes of pregnancy hormone levels and the
placenta being fully developed 48, 67. During this stage the pre meal insulin
bolus will be increased to keep glucose control during post meals. In the third
trimester, patients may need to be given a larger insulin dose prior to pre meal
because insulin is absorbed more gradually during this stage, which can be
ineffective to lowering glucose during late pregnancy. Thus, higher insulin dose
would help balance glucose levels 48. Lastly, during birth, glucose
monitoring regularly is essential to confirm sugar levels are in control and
small 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 domain
whether hypoglycaemic drugs should be permitted during gestational diabetes.
Research suggests hypoglycaemic drugs such as metformin can be an effective
option for gestational diabetes patients due to improved insulin sensitivity, less
risk of hypoglycaemia episodes and prevents additional weight-gain 49-50.
Various studies have shown clear evidence that metformin was a safe treatment
during gestational diabetes in the following studies 50-56. One study in
particular showed metformin treatment was correlated with increased
preeclampsia and perinatal mortality 57. Despite vaster studies showing safer
use of hypoglycaemic drugs during pregnancy, further research is warranted to exhibit
clearer evidence if hypoglycaemic drugs are safe to take during gestational
diabetes.  Psychosocial
Aspects of Diabetes Treatment During gestational pregnancy women can find
it challenging to control their diabetes due to many psychosocial factors with
diabetes and the fear of the complications associated with uncontrolled diabetes
could lead patients vulnerable to various psychological behaviours (e.g. emotional distress and anxiety) leading
to poor pregnancy consequences 58-60. Even though every woman would go through
the same pregnancy stages, every patient would go through different experiences,
which in turn resulting in diverse psychological behaviours 61. Thus, the potential
treatment for diverse patients comes down to how health care professionals can
tailor personalised treatment plans to patients in order to achieve positive
outcomes 61. Personalising treatment plans can be achieved when assisting and
educating patients to available treatment plans, which would support diverse
patients to make treatment choices they believe would bring an effective
outcome during gestational diabetes 62-63. Alongside this, psychological
support from appropriate multidisciplinary teams should be implemented with the
patients chosen treatment (e.g.
lifestyle/medication interventions or both) that would achieve positive
psychology and supports patients to control their diabetes and positive
wellbeing during pregnancy 62-64. Future Practice Implications 

From this case study I’ve learnt that every
patient would have diverse experiences during pregnancy and not all patients
would 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 psychology
background, I comprehend that psychology plays a vital role during pregnancy
68. As pregnancy alone is a challenging journey and together with glucose
intolerance it could lead to depression various psychosocial aspects with
gestational diabetes, resulting in unhealthy psychological behaviours prominent
to unhealthy physiognomies 69-71. Thus, patients are in special need for
psychological treatment during this challenging journey. In my clinical
practice, I would work more closely with patients who are already diagnosed
with mental illness and patients facing psychological distress during gestational
diabetes pregnancy by initiating well-tailored psychological behavioural therapy
interventions to support my patients adhere to their pregnancy treatment
regimens and manage psychosocial gestational diabetes distress effectively. Furthermore
these tailored psychological interventions would aim to reduce depression and
anxiety, improve patient’s confidence and self-esteem during pregnancy to prevent
hyperglycaemia and diabetes complications, in order to achieve an effective childbirth

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