2016 Q1 LET'S GET PHYSICAL BEST PRACTICES IN FITNESS & EXERCISE EDUCATION

LET'S GET PHYSICAL:

BEST PRACTICES IN FITNESS & EXERCISE EDUCATION


Fitness & Exercise Education

Let's talk about exercise and fitness.

While everyone knows physical activity is a critical component of optimal diabetes control, it's important to use fresh, creative approaches when discussing this topic with patients so that you can keep them engaged and motivated.

We've brought together 4 diabetes educator (DE) thought leaders to share the best of their best practices in this area. Their focus, like yours, is on helping patients connect the dots when it comes to the key role that exercise plays in helping them achieve optimal diabetes control. Two of these experts have the added perspective of personal experience, since they are on sensor-augmented pump (SAP) therapy themselves.

Q: What are some of your best practices to encourage patients to exercise?

GETTING OFF TO A GOOD START

"We encourage exercise through a 'Keys to Control Diabetes Program' offered through the local wellness center. The program is a free 1-month membership with an individualized exercise program from an exercise physiologist. Once the month is completed, ongoing membership at the wellness center is encouraged. Some patients are not able to maintain their membership due to the cost, in which case we recommend walking/biking on local trails, a home regimen, and/or joining a fitness center with a lower cost." -Alicia Devore, RN, CPT

KNOWLEDGE IS POWER

"The Plans and Recommendations template in our practice's electronic medical record allows us to enter take-home exercise instructions for patients. I encourage adult patients to get at least 150 minutes of exercise weekly.

In Maine, the winter weather can be severe, and it is imperative that patients have access to indoor exercise that they enjoy. I frequently show patients short clips of YouTube exercise videos such as Leslie Sansone's 'Walk at Home' series or Paul Eugene's 'Chair Fitness Workouts.' They can see for themselves that these routines are fun and do-able by the average person." -Heather Leclerc, MS, RD, CDE

CARROTS INSTEAD OF STICKS

"I like to remind patients that diabetes doesn't own them—they own their diabetes. Therefore, I encourage them to integrate exercise into their lives, while explaining that everyone should take part in regular physical activity to better their overall health—whether they have diabetes or not. Patients need to buy in to the fact that exercise is something good they are doing for themselves, and not some type of punishment or burden to bear." -Geneva Kennedy, CPT

Q: What are some specific challenges patients on pump therapy face when it comes to exercise, and how do you overcome those challenges?

SENSE & SENSOR-BILITY

"The biggest challenge that insulin-using patients experience when exercising is hypoglycemia. One helpful feature of SAP therapy is the ability to use a temporary (temp) basal rate. When necessary, a patient can program a lower basal rate for a specified period of time. Intense exercise of long duration can have a prolonged BG-lowering effect, and a reduced temp basal rate can help prevent low BG hours later.

I am on SAP therapy myself, and have found this approach to be very helpful when I am getting core exercise such as weeding the garden. Knowing that core exercise makes my BG drop significantly, I have my low alert set on 70. When I reach a sensor glucose (SG) of 70, I am alerted. When I am using my elliptical machine, I watch my SG while exercising and afterwards. I have found that my elliptical exercise does not result in the same intense drop in BG as core exercises. How do I know this? From data provided by my sensor, of course!" -Heather Leclerc, MS, RD, CDE

EMPOWERING PATIENTS WITH TEMP BASALS

"There is so much flexibility in how you can use a temp basal, and I try to empower patients to just TRY IT! There is no magic formula for duration and percent. I may suggest an initial setting (example: 2 hours post-exercise at 50%), while emphasizing to patients that this is just a starting point and probably not optimal—but that they can experiment from this point forward. I find temp basal usage empowers patients to feel more in control of their diabetes regimen." -Laurel Messer, RN, MPH, CDE

Q: What are some considerations for patients on pump therapy when it comes to active vacations or exercise in specific weather conditions?

PACK 2 OF EVERYTHING!

"I have developed a Vacation Information Card to clearly guide patients when they prepare and pack for vacations. I always tell them to assume they will not be able to obtain supplies at their destination, so it is in their best interest to pack 2 of everything." -Laurel Messer, RN, MPH, CDE

HOPE FOR THE BEST, PREPARE FOR... INEVITABILITIES

"Patients who live in Maine frequently go to the Caribbean or Florida during the winter. We get many questions about how to deal with the sand, salt water, and hot weather while on IPT.

Some patients purchase waterproof cases for their pump. We also recommend that they take a cooler with them to the beach. They can put their pump into a container and in the cooler for brief amounts of time while they go in the water for a swim. It's important to remind patients that swimming tends to cause BG to drop significantly. I always remind patients to take juice and snacks to the beach, to stay well hydrated, and to pack more supplies than they think they will need.

Winter sports can pose different challenges. It is important that the infusion site is placed in a location on the body where there won't be a lot of jarring. Patients need to wear the clip that goes with the pump and ensure that it's securely attached when skiing or snowboarding. It's also important to keep insulin close to their warm body. I have heard of few if any problems with insulin freezing during winter sports while following these guidelines.

Skiing and snowboarding, both core exercises, can cause significant drops in BG. Patients need to be reminded that they always, always must carry glucose tablets or another form of fast-acting carbohydrate with them in case of hypoglycemia." -Heather Leclerc, MS, RD, CDE

Q: What are some considerations for intensive exercise regimens when on pump therapy?

LEARNING FROM OBSERVATION

"We have some patients who are elite athletes. I recall one young woman who participated in national track and field events who would have higher BG levels during competitions. Intense exercise or exciting athletic events actually can cause BG to rise temporarily.

We have some patients who find that they do not need to consume extra carbohydrates during an intense or exciting event—but they need to consume extra carbs afterwards, when the stress hormones subside and BG tends to drop.

Patients who are successful in managing their BG levels during exercise have watched their levels during and after exercise and have learned from those observations. We advise patients to take the time upfront to learn how their glucose levels react to various types of exercise. Sensor data is extremely important in monitoring how factors such as exercise affect glucose levels." -Heather Leclerc, MS, RD, CDE

FINDING THOSE SWEET SPOTS

"When patients plan to start new exercise regimens while on IPT, I advise them to check their BG before, during, and after exercise. If BG is < 100 mg/dL prior to exercising, I suggest they eat 15 grams of carbohydrates with a protein, without coverage, prior to exercising. If the patient has a BG >250 mg/dL prior to exercising and ketones are present, I advise them not to work out until the BG is <250mg/dL and no ketones are present.

Once the exercise effect on glucose control is known, education is provided on temp basal use. If the patient is experiencing hypoglycemia during exercise, usually 20% to 90% temporary basal is started 1 hour before and during exercise. The temp basal is then stopped after close monitoring of BG.

Hypoglycemia can occur 24 to 36 hours after intense exercise, so small frequent meals are encouraged. The patient is advised to continue to monitor their BG before, during, and after exercise, and changes are made accordingly to their exercise needs. Temp basal also can be used to manage hyperglycemia during exercise." -Alicia Devore, RN, CPT



ALICIA DEVORE, RN, CPT: Alicia has been an independent certified product trainer for Medtronic for 2 years. Most of her work is based in endocrinologist offices in Wheeling, West Virginia. She works with both pediatric and adult patients. Alicia was diagnosed 7 years ago with type 1 diabetes (T1D) and currently manages it with the MiniMed® 530G with Enlite® system.

GENEVA KENNEDY, CPT: Geneva is a certified product trainer on Medtronic Diabetes' insulin pump team, based in Kentucky. For the past 11 years, she has worked collaboratively with the medical team at a large endocrinology practice. Her work for Medtronic includes helping to identify patients with T1D and type 2 diabetes (T2D) who are candidates for pump therapy, and providing support for insurance processes, pre-pump training, pump therapy initiation, and ongoing training.

HEATHER LECLERC, MS, RD, CDE: Heather is a clinical supervisor of The Diabetes and Endocrine Specialists of Maine, an outpatient practice of Eastern Maine Medical Center, where she has worked for the past 28 years. Along with the office's 5 other certified diabetes educators (CDEs), she provides education for patients with diabetes of all ages and assists the 5 providers in the office with day-to-day medical management. Approximately 8 years ago, Heather developed latent autoimmune diabetes in adults (LADA) and is treating it with the MiniMed 530G with Enlite system.

LAUREL MESSER, RN, MPH, CDE: Laurel is a proud diabetes educator and clinical research nurse who has specialized for the past 10 years in T1D, insulin pump, continuous glucose monitoring (CGM), and artificial pancreas device system studies. She works with pediatric and adult patients at the Barbara Davis Center for Childhood Diabetes in Aurora, Colorado. Laurel helped author the Pump and CGM Pink Panther book and has contributed to others in the series.