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Exercise and insulin-dependent diabetes mellitus questionnaire : modifications required in diet and insulin… Sankey, Willa Dawn 1997

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EXERCISE AND INSULIN-DEPENDENT DIABETES MELLITUS QUESTIONNAIRE: MODIFICATIONS REQUIRED IN DIET AND INSULIN ADMINISTRATION FOR THE ACTIVE PERSON WITH INSULIN-DEPENDENT DIABETES by WILLA DAWN SANKEY B.H.Ec. The University of Manitoba, 1987 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES School of Human Kinetics We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA JULY 1997 © Willa Dawn Sankey In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. 6cHooi. of^ The University of British Columbia Vancouver, Canada Date tto ^  V ^ > t DE-6 (2/88) A B S T R A C T Regular physical exercise is beneficial for the person with insulin-dependent diabetes mellitus (IDDM). Participation in regular physical exercise, however, adds extra challenges that must be overcome in order to maintain acceptable metabolic control with each exercise session. Research in the area of diabetes and exercise has focused on the potential for exercise to improve overall metabolic control. As a result of this research, a wide range of recommendations for modifying diet and insulin for exercise in this population have been developed. There is a paucity of research on what steps an already active person with IDDM makes in order to maintain metabolic control before, during, and after exercise. The purpose of this study was to use a self-administered, mailed questionnaire to obtain information on the adjustments in insulin and diet currently used for exercise in active people with IDDM. A total of 137 members of the International Diabetes Athletes Association with IDDM qualified to participate in this study. The insulin administered prior to planned exercise was significantly lower than the amount of insulin administered on a non-exercise day. For subjects who injected their insulin, there was a significant decrease in the short acting insulin (p < 0.001), intermediate acting insulin (p = 0.006), long acting insulin (p = 0.042), and total insulin (p < 0.001) used prior to planned exercise. The insulin adjustments represented a 28.4 % reduction in short acting insulin, a 38.4 % reduction in intermediate acting insulin, a 9.7 % reduction in long acting insulin, and a 17.7 % reduction in total insulin injected. For subjects who used an insulin pump, there was a significant decrease in the basal insulin infused (p = 0.024), the bolus insulin administered (p < 0.001), and the total insulin (p < 0.001) used prior to planned exercise. The insulin ii adjustments represented a 6.4 % reduction in basal insulin, a 12.0 % reduction in bolus insulin, and a 6.3 % reduction in total insulin used. The amount of carbohydrate (CHO) consumed on an exercising day was significantly greater (p < 0.001) than the amount of CHO consumed on a non-exercising day, by an average of 56.8 grams. In addition, there were weak positive correlations between the amount of CHO consumed and the duration of exercise for CHO consumption before exercise (r = 0.42; p < 0.001), during exercise (r = 0.19; p = 0.046), or a combination of before and during exercise (r = 0.35; p < 0.001). Linear regression estimated that for every 60 minutes of exercise there was a mean increase of 9.6 grams CHO consumed before exercise, 5.4 grams CHO consumed during exercise, while 15.0 grams CHO were consumed both before and during exercise. There was, however, no significant correlation between the CHO consumed after exercise (r = 0.017; p = 0.859) and the duration of the exercise session. Additional information related to IDDM and exercise determined that the signs and symptoms of hypoglycemia recognized during exercise were different than those recognized at rest, blood glucose was measured an average of 1.7 times during exercise, and a majority of subjects (73.9 %) reported that their metabolic control was better as a result of an active lifestyle. The results of this study suggest that a decrease in insulin administered prior to planned exercise was required to prevent hypoglycemia during and after exercise. In addition, an increase in CHO intake was required to provide an energy substrate during exercise and to maintain euglycemia. Insulin and dietary adjustments are required for exercise in active persons with IDDM in order to maintain metabolic control before, during, and after exercise. Further research is required to provide specific recommendations in the adjustments to dietary intake and insulin administration for exercise in already active people with IDDM. iii TABLE OF CONTENTS Abstract ii Table of Contents iv List of Acronyms vii List of Tables viii List of Figures ix Acknowledgments x Dedication xi Chapter 1 Introduction 1.0 Introduction 1 1.1 Definition of Terms 3 1.2 Statement of the Problem 5 1.2.1 Subproblems 5 1.3 Hypotheses 7 1.3.1 Research Questions 10 1.4 Delimitations 10 1.5 Limitations 11 1.6 Significance of the Study 11 Chapter 2 Review of the Literature 2.0 Introduction 15 2.1 Etiology of Insulin-Dependent Diabetes Mellitus 16 2.2 The Triad of Diabetic Metabolic Control 21 2.2.1 Insulin 22 2.2.2 Dietary Intake 28 2.2.3 Exercise 33 2.2.4 Integration of the Triad 40 2.3 Conclusion 42 iv Chapter 3 Methods and Procedures 3.0 Sampling 44 3.1 Methods 45 3.1.1 The Questionnaire 45 3.1.2 Reminder Postcards 50 3.1.3 Additional Information 51 3.2 Statistical Analysis 52 Chapter 4 Results 4.0 Demographic Information 55 4.1 Hypothesis 1 57 4.1.1 Hypothesis 1A - Administration of Insulin by Injection 58 4.1.2 Hypothesis IB - Administration of Insulin by Pump 60 4.2 Hypothesis 2 . 62 4.3 Hypothesis 3 63 4.4 Research Question 1 68 4.5 Research Question 2 69 4.6 Research Question 3 71 4.7 Research Question 4 72 4.8 Research Question 5 73 4.9 Research Question 6 74 4.10 Research Question 7 76 Chapter 5 Discussion 5.0 Introduction 77 5.1 Questionnaire Return Rate 78 5.2 Hypothesis 1 80 5.2.1 Hypothesis 1A 80 5.2.2 Hypothesis IB 84 5.3 Hypothesis 2 86 5.4 Hypothesis 3 87 5.5 Research Question 1 91 5.6 Research Question 2 93 5.7 Research Question 3 93 5.8 Research Question 4 94 5.9 Research Question 5 95 5.10 Research Question 6 96 5.11 Research Question 7 97 5.12 Additional Information 98 v Chapter 6 Conclusions 6.0 Summary 99 6.1 Conclusion 101 6.2 Recommendations For Further Research 105 References 108 Appendix A - Questionnaire Package 114 Appendix B - Postcard Reminder 144 Appendix C - References Used For Questionnaire Construction 147 Appendix D - IDAA Newsletter Advertisement 151 Appendix E - Telephone Log 153 Appendix F - Return Rate Table 156 Appendix G - Questionnaire Return Table 159 vi LIST OF A C R O N Y M S A D A American Diabetes Association p Beta B G Blood glucose BMI Body mass index bpm Beats per minute CDA Canadian Diabetes Association CHO Carbohydrate C V D Cardiovascular disease DCCT Diabetes Control and Complications Trial DNQ Did not qualify FFA Free fatty acids HbA! c Hemoglobin A x c H L A Histocompatibility antigens IDAA International Diabetes Athletes Association IDDM Insulin-dependent diabetes mellitus MDI Multiple daily injections ND Non-diabetic N IDDM Non-insulin-dependent diabetes mellitus Q Qualified S/S Signs and symptoms SCII Subcutaneous insulin infusion S M B G Self monitoring of blood glucose vii LIST OF T A B L E S Table 1 Demographic Information on the IDDM Sample Population 57 Table 2 The Amount of Insulin Used on Non-Exercising Days 58 Table 3 The Decrease in the Amount of Insulin Used On Exercising Days 59 Table 4 Summary of Paired, One-Tailed T-Tests For Insulin Injection 60 Table 5 The Amount of Insulin Infused on Non-Exercising Days 60 Table 6 The Decrease in the Amount of Insulin Used On Exercising Days 61 Table 7 Summary of Paired, One-Tailed Probability T-Tests For Insulin Pump 62 Table 8 Summary Information on the Reference Sport 63 Table 9 Grams of CHO Consumed Before, During, and After Exercise 64 Table 10 Summary of ANOVAs For Total CHO Consumed and Duration of Exercise 68 Table 11 Signs and Symptoms of Hypoglycemia Recognized At Rest and During Exercise Table 12 Summary of the Amount of CHO Required To Treat An Insulin Reaction 69 70 Table 13 The Number of Subjects Who Used Each Food Group To Treat An Insulin Reaction 71 Table 14 Summary of the Number and Percent of Subjects Who Exercise Safely 74 Table 15 Summary of Diabetic Complications Versus the Number of Years With Diabetes 75 viii LIST OF F IGURES Figure 1 Pre-Exercise CHO Consumption and the Duration of the Reference Sport 66 Figure 2 The Amount of CHO Consumed During Exercise and the Duration of the Reference Sport 66 Figure 3 The Amount of CHO Consumed Before and During Exercise and the Duration of the Reference Sport 67 Figure 4 Postexercise CHO Consumption and the Duration of the Reference Sport 67 ix A C K N O W L E D G M E N T S This thesis is the result of considerable perseverance and determination on my part to overcome numerous barriers, both visible and invisible. In addition, it is the result of unending support and encouragement from numerous people involved in this study. Space does not allow for the special thanks that so many people deserve. I would, however, like to acknowledge some of the key players who made this project possible. I wish to thank the IDAA for their support of this project and for providing the mailing list that made this study possible. Robert Todd, Paula Harper, and Dr. A l Lewis were very helpful in getting this project started and offering encouragement. In addition, I wish to thank the members of the IDAA who took the time to complete and send back the questionnaires. I wish to acknowledge the help received from two U.B.C. Faculty Members. Firstly, to Dr. Reichl for his assistance with the questionnaire development and methodological considerations for this study. Secondly, to Dr. Berkowitz for his expertise with the data analysis and his patience in thoroughly explaining the results to me. I would like to thank my family members for their help in making this thesis possible. Special thanks go to my Mother for her endless patience and hours spent proof reading the manuscript in its various forms, and my Father for the hours he spent meticulously entering the data into the computer. Friends also played an important role in encouraging me to study, and lending an ear when the going got tough. One friend who stands out in this respect is Sue Laing, who always made time for "coffee" when either one of us needed a break to clarify projects we were working on, encouragement to keep going, or just to talk about 'things' in general. Special thanks go out to my committee members, Dr. Taunton (thesis advisor), Dr. Clement, Dr. Glick, and Dr. Hunt. Your constructive criticism and guidance in your respective areas of expertise was greatly appreciated. My thesis advisor, Dr. Taunton, continually provided encouragement, and direction for this study. I am indebted to him for his endless patience and understanding of the numerous difficulties that I encountered throughout my Masters degree. Words cannot begin to express the gratitude that I feel. His name ranks high on my list of mentors. Partial funding for this project was provided by the School of Human Kinetics Research Fund and an honorarium from The Allan McGavin Sports Medicine Centre. x DEDICAT ION This thesis is dedicated to my parents, Arleen and Charles Sankey, who provided me with continued support and guidance through the various stages of my life. You have helped me fulfill my dreams of attaining a higher level of education than even I had thought possible. You always wanted me to try to do my best and challenged me to strive for excellence in everything that I have chosen to accomplish. Your continued support and encouragement has been, and continues to be, invaluable. If I could try to describe to others what you have given me, I would say: "They gave me roots from which to grow to be strong, independent, and determined; then they gave me wings so that I could fly, to pursue the dreams and goals that I have set for myself." Thank you Mom. Thank you Dad. With out your help the road of life would have been a lot rougher. I would never have been able to get as far as I have without you! God bless! xi C H A P T E R 1 INTRODUCTION 1.0 Introduction In the early 1970's there was a dramatic increase in the awareness of the importance of exercise and diet in promoting overall health and preventing disease in the general population (Kemmer and Berger, 1984; Franz, 1992). Regular physical activity was cited as one of the lifestyle modification factors required to reduce morbidity and mortality (Blair, 1988). At the same time, the benefits of exercise for the person with insulin-dependent diabetes mellitus (IDDM) were also 'rediscovered' (Gonzalez, 1979; Kemmer and Berger, 1984; Vranic et al, 1990). Research has indicated that people with IDDM benefit from exercise in the same ways as their non-diabetic (ND) counterparts, both physiologically and psychologically (Franz, 1992). In addition, there are the potential benefits of improving insulin sensitivity, improving glucose tolerance, decreasing insulin requirements, and reducing the morbidity and mortality from long-term complications (Vranic et al, 1990; Franz, 1992). There are, however, contradictory recommendations concerning the benefits of exercise in the IDDM population. Exercise was shown to either improve or to further impair short-term metabolic control (Horton, 1988; Wallberg-Henriksson, 1989; Wasserman and Abumrad, 1989; Kemmer and Berger, 1992). Also, there is considerable controversy in the literature regarding the ability of regular physical activity to reduce the incidence of long-term complications. In the last two decades, there has been a significant increase in our knowledge of exercise physiology, biochemistry, and metabolism (Kemmer and Berger, 1992). As a result of this research, our understanding of the short and long-term effects of exercise has significantly increased. Today, 1 there is a greater understanding of the hormonal, biochemical, and physiological changes that occur before, during, and immediately following exercise in IDDM. In spite of this increased knowledge, there are still numerous and often conflicting recommendations on how to modify diet and insulin to meet the metabolic demands of exercise in this population (Horton, 1988; Wasserman and Abumrad, 1989; Wallberg-Henriksson, 1992; Young, 1995). There is, however, a paucity of research on what steps already active individuals with IDDM take to maintain metabolic control before, during, and after exercise. This study was designed to survey active individuals with IDDM to determine what steps they take in order to maintain metabolic control for exercise. A self-administered questionnaire was developed to ask general and specific questions on the modifications required in dietary intake and insulin administration for exercise. In addition, important information on blood glucose (BG) monitoring, personal safety, and frequency and severity of insulin reactions before, during, and after exercise was determined. It is hoped that the application of information obtained in this study will increase the understanding of the effects of exercise on insulin requirements and dietary intake. Specific recommendations on the adjustments of dietary intake and insulin adjustments for exercise could be proposed in order to narrow the range of recommendations currently in the literature. By narrowing the range of insulin and dietary requirements for exercise, people with IDDM who are considering an exercise program, or those who wish to increase activity, could do so with a reduced risk of short-term complications and the ability to maintain overall metabolic control. These recommendations would be beneficial in promoting overall health through exercise, as well as reducing the morbidity and premature mortality in this population. 2 1.1 Definition of Terms Insulin-Dependent Diabetes Mellitus (IDDM) - Also known as juvenile onset diabetes or type I diabetes. It is a chronic, metabolic syndrome characterized by severe hyperglycemia caused by the absolute deficiency of insulin. If the hyperglycemia is left untreated, ketoacidosis ensues that can lead to coma and death. IDDM is the result of the autoimmune destruction of the beta (P) cells of the pancreas (Landry and Allen, 1992; Ratner, 1992; Young, 1995). The daily administration of exogenous insulin injections or subcutaneous insulin infusion (SOI) is required to sustain life. Insulin - A hormone secreted by the p-cells of the pancreas that acts to regulate metabolism (Guyton, 1981). Insulin is "the major fuel-regulating hormone, [which] is secreted into the blood in response to a rise in concentration of blood glucose or amino acids. Insulin promotes the storage of glucose and the uptake of amino acids, increases protein and lipid synthesis, and inhibits lipolysis and gluconeogenesis" (Dorland's Medical Dictionary, 1982). Hypoglycemia - A deficiency of blood-borne glucose. A B G level below 4.0 mmol/L (Canadian Diabetes Advisory Board, 1992). Hypoglycemia may be the result of an excess of insulin, reduction in food intake, extra physical activity, or a combination of these three factors. Insulin Reaction - Hypoglycemia in a person with diabetes. Some of the signs and symptoms include: hunger, nausea, numbness of the lips or tongue, weakness, loss of coordination, confusion, anxiety, dizziness, drowsiness, or blurred vision (Canadian Diabetes Association [CDA], 1985; Bellenir and Dresser, 1994). Euglycemia - Blood glucose in the normal range (Dorland's Medical Dictionary, 1982). A preprandial B G level between 4.0 mmol/L and 7.0 mmol/L (Canadian Diabetes Advisory Board, 1992). 3 Hyperglycemia - An excess of glucose in the blood (Lehninger, 1982). A B G level above 7.0 mmol/L (Canadian Diabetes Advisory Board, 1992). Hyperglycemia may be the result of a relative deficiency of insulin, increase in food intake, a decrease in physical activity, or a combination of these three factors. Urinary Ketones (Ketonuria): - The presence of ketones in the urine is the result of persistent hyperglycemia caused by insufficient insulin or excessive food intake. Ketones are produced by the break down of fats for energy by the body. In the absence of adequate insulin, ketones are produced at a greater rate than can be metabolized, resulting in a spilling over of ketones into the urine (Santiago et al, 1992; Bellenir and Dresser, 1994). Hemoglobin A_,£ (HbA^) - Or glycosylated hemoglobin, refers to the non-enzymatic, irreversible attachment of free glucose molecules to the hemoglobin molecule. This measures the average B G level over the life span of the red blood cell, which is approximately 120 days (Cohen, 1986). The normal range of H b A l c is usually between 4 and 7 %, depending on the laboratory and method of analysis used (Brownlee, 1990). A H b A l c below 110 % for the lab normal values is considered to be optimal metabolic control, while a value below 140 % is considered acceptable (Canadian Diabetes Advisory Board, 1992). Long-Term Diabetic Complications - Medical conditions secondary to diabetes that are the result of prolonged hyperglycemia. The onset and progression of diabetic complications increases with the duration and magnitude of hyperglycemia (American Diabetes Association [ADA], 1995; Diabetes Control and Complications Trial [DCCT] Research Group, 1995). The major long-term complications include: retinopathy, nephropathy, neuropathy, and atherosclerotic disease (Skyler, 1990; ADA, 1995). 4 Meal Plan - A diet prescription using a food exchange system to distribute the daily nutrient needs into meals and snacks (Zeman, 1991). The food exchange system groups foods together based on the caloric, carbohydrate (CHO), protein, and fat content (Bellenir and Dresser, 1994). Questionnaire - Is any written document that is used as a method of collecting information from people about their ideas, feelings, and behaviors (Fink and Kosecoff, 1983; Woodward and Chambers, 1983). 1 . 2 Statement of the Problem This study used a self-administered, mailed questionnaire to obtain information on the adjustments in insulin and diet required for exercise in active people with IDDM. This study also obtained information on the self-monitoring of metabolic control, personal safety while exercising, the treatment of short-term complications, and the presence of long-term complications. 1 . 2 . 1 Subproblems This study specifically sought: 1) . To obtain demographic information on the study population. 2) . To obtain information on the daily insulin requirements and to determine the adjustments in insulin required prior to planned exercise. 3) . To obtain information on the frequency, intensity, duration, and types of exercise that a selected population of people with IDDM participate. 5 4) . To obtain information on the amount and type of food consumed for both non-exercising and exercising days. In addition, information On the amount of food and fluid consumed before, during, and after a specific exercise session was obtained. 5) . To obtain information on the signs and symptoms of hypoglycemia and the treatment required for mild, moderate, and severe insulin reactions during and after exercise. 6) . To determine the frequency of B G testing on both exercising and non-exercising days. 7) . To determine the criteria used to postpone exercise, and to determine if the criteria to postpone exercise differs for recreational exercise and competition. 8) . To obtain information on the safety practices used that are directly related to diabetes care during exercise. 9) . To determine the presence of long-term complications secondary to IDDM. 10) . To obtain general information on the following: a) , the adjustments required in dietary intake for unplanned exercise, b) . the use of exercise and B G diaries, c) . the use of CHO loading for endurance exercise, d) . helpful hints or 'secrets of exercise success' that study participants would give to people with IDDM who would like to become active, e) . the personal perceptions of the impact of an active lifestyle on metabolic control, and f) . additional comments related to the contents of the questionnaire, or IDDM and exercise in general. 6 1.3 Hypotheses 1). The insulin dose administered prior to planned exercise will be significantly lower than the insulin dose administered for a non-exercising day. 1 A). Insulin adjustments made for subjects who inject their insulin. IB). Insulin adjustments made for subjects who use an insulin pump. Rationale: In the ND population the insulin levels decrease during exercise, while the glucagon and catecholamine levels increase (Zinman and Vranic, 1985). This hormonal shift is necessary to provide endogenous fuel for muscular contraction during exercise. In the IDDM population the hormonal response will be different since insulin is not under physiological control and glucagon response is often blunted (Hough, 1994). If plasma levels of insulin remain elevated during exercise, the counterregulatory hormones do not increase sufficiently in response to increased energy demands. The result of excess insulin is the prevention of hepatic glucose production, and the enhanced uptake of glucose by exercising muscles (Landry and Allen, 1992; Wallberg-Henriksson, 1992). As a result B G will decrease significantly resulting in hypoglycemia and the cessation of exercise. In order to prevent the onset of hypoglycemia, pre-exercise insulin levels will be reduced in order to provide a low but permissive plasma insulin level (Wallberg-Henriksson, 1989; Sutton, 1991). This adequate level of serum insulin will closely resemble the hormonal profile of a ND during exercise. It is, therefore, hypothesized that the amount of insulin administered prior to exercise will be significantly reduced to prevent hypoglycemia during or immediately following exercise. 7 2). There will be a significantly greater amount of CHO consumed on exercising days. Rationale: The B G changes during exercise for a ND individual are closely regulated due to the hormonal and metabolic substrate shifts that occur over the duration of an exercise session (Zinman and Vranic, 1985; Wallberg-Henriksson and Wahren, 1989; Wasserman and Abumrad, 1989; Koivisto et al, 1992). In IDDM the hormonal response to exercise will be different since insulin is not under physiological control and glucagon response is often blunted (Hough, 1994). Carbohydrate ingestion before, during, and after exercise may be required to maintain B G in an acceptable range, and to prevent hypoglycemia (Landry and Allen, 1992; Hough, 1994; Young, 1995). Carbohydrate ingestion prior to exercise helps to optimize muscle and liver glycogen stores, and attain an optimal B G level (Costill, 1985; Applegate, 1989). During exercise, there can be a significant decrease in the B G levels as a result of increased metabolic demand, and enhanced insulin sensitivity during exercise (Horton, 1988; Hough, 1994; Young, 1995). Carbohydrate replacement during exercise will provide a metabolic substrate for energy production and help to reduce the risk of hypoglycemia. After exercise, CHO ingestion is required to prevent hypoglycemia, replete muscle glycogen stores, and counteract the increase in insulin sensitivity in previously active muscles (Costill, 1986; Costill and Hargreaves, 1992; Young, 1995). To counteract the effects of fuel requirements for exercise by the body, there will be a significant increase in the amount of CHO consumed in anticipation and response to exercise (Zinman et al, 1984). 8 3). There will be a significant positive relationship between the amount of CHO consumed and the duration of exercise. Rationale: Fuel substrate utilization changes dramatically from rest to exercise due to the hormonal, neurological, and metabolic demands on the body (Franz, 1992). The predominant metabolic substrate used by muscle during rest is free fatty acids (FFA) released by the adipose tissue (Wahren, 1979; Richter et al, 1981; Wasserman and Abumrad, 1989). At the start of exercise, the predominant fuel used is glucose from muscle glycogen (Wahren et al, 1978; Franz, 1992). With an increase in the duration of exercise, there is a gradual shift from the use of glucose from glycogen and the blood, to a greater reliance on FFAs (Wahren et al, 1978; Wallberg-Henriksson, 1989; Sutton, 1991; Franz, 1992; Hough, 1994). In the absence of a decrease in the insulin levels during exercise in IDDM, the fuel substrate shift from glycogen and B G , to FFAs may be blunted (Wahren et al, 1975; Coggan, 1991; Hough. 1994). As a result, there will be an increased requirement for CHO over the duration of exercise to maintain B G and to provide a continued energy substrate during exercise (Wahren et al, 1975; Coggan, 1991). Carbohydrate, then, will contribute more to the energy utilized during prolonged exercise in IDDM (Coggan, 1991). The CHO intake, therefore, must increase over the duration of an exercise session in order to provide an alternative energy source and to prevent the onset of hypoglycemia. 9 1.3.1 Research Questions 1) . Is there a difference in the signs and symptoms of hypoglycemia recognized while at rest and while exercising? 2) . How much, and what food groups are required when treating a mild, moderate, and severe insulin reaction, both during exercise and within 24 hours following an exercise session? 3) . How often is B G measured during exercise? 4) . What criteria are used to postpone exercise? How do the criteria to postpone exercise differ between recreational and competitive exercise? 5) . Do respondents ensure that provisions are available in order to exercise safely? 6) . Is there a relationship between the number of years with IDDM and the number of long-term complications? 7) . What adjustments are made in dietary intake to accommodate unplanned exercise? 1.4 Delimitations 1) . This study is delimited to members of the International Diabetic Athletes Association (IDAA) who reside in Canada and the United States. 2) . This study is delimited to IDAA members who are 19 years of age or older. 3) . This study is delimited to members of the IDAA who have IDDM. 4) . This study is delimited to the questionnaires that are received completed by the subject. 10 1.5 Limitations 1) . This study is limited to 300 members of the IDAA who were randomly selected from the IDAA mailing list. An additional 25 members were randomly selected to replace the questionnaires returned by Health Professionals, ND, and non-insulin-dependent diabetes mellitus (NIDDM) members who returned the questionnaire unmarked. 2) . This study is limited to the accuracy of the mailing list provided by the IDAA. 3) . This study is limited by the postal system to accurately deliver the questionnaires to the required destinations. 4) .. This study is limited by the subjects who do not return the questionnaire. 1.6 Significance of the Study There has been an extensive amount of research conducted in the past 20 years on the effect of exercise in the IDDM population. Research has focused primarily on the acute and long-term effects of exercise on IDDM (Berger et al, 1977; Krzentowski et al, 1981; Zinman et al, 1984; Wallberg-Henriksson, 1989). Recommendations for modifying insulin and diet to prevent hypoglycemia during and after exercise have been developed as a result of this research (Krzentowski et al, 1981; Schiffrin and Parikh, 1985; Campaigne et al, 1987). There are, however, a wide range of recommendations for modifications to diet and insulin for exercise that have been published. Carbohydrate ingestion during exercise has been consistently recommended to prevent hypoglycemia during and after an exercise session. There are, however, a wide range of recommendations that appear in the literature. The CDA (1985) recommended the consumption of 10 to 20 grams of CHO for every 30 minutes of strenuous activity, 10 grams CHO for every 11 30 minutes of moderate intensity exercise, and 15 grams of CHO for the entire session of light intensity activity. Similarly, Horton (1988) based the ingestion of CHO during exercise on the pre-exercise B G level, and on the intensity and duration of the exercise session. An estimate of caloric expenditure of the activity would result in a more accurate prediction of the amount of extra CHO that is required during exercise. Moderately intense exercise, such as jogging or cycling would require a snack of 30 to 40 grams of CHO for every 30 minutes of exercise (Horton, 1988). Franz (1992) recommended that a snack containing 10 to 15 grams of CHO may be required in moderate intensity events lasting longer than 60 minutes. Alternatively, Vitug and Coworkers (1988) recommended the consumption of 15 to 30 grams of CHO for every 30 minutes of moderately intense exercise. The range of CHO ingestion recommended for exercise in IDDM are quite varied and could cause a great deal of confusion for the active person with diabetes. Similarly, the recommendations for insulin adjustments prior to planned exercise are quite varied. Schiffrin and Parikh (1985) studied the effects of various reductions in insulin injections prior to planned exercise. They determined that a reduction in pre-exercise insulin dose of 30 to 50 percent resulted in a similar B G profde as a control rest day (Schiffrin and Parikh, 1985). Vitug and Coworkers (1988) recommended that the intermediate acting insulin be reduced by 30 to 40 percent, or for those individuals taking a combination of short and intermediate acting insulin to omit the regular insulin immediately prior to exercise. Horton (1988), however, recommended that intermediate acting insulin be reduced by 30 to 35 percent, or the regular insulin be reduced by 50 to 100 percent when short and intermediate acting insulin are administered together. In addition, for those individuals on SCII, the basal dose should be reduced and the pre-meal bolus decreased or eliminated (Horton, 1988). The reduction for SCII 12 prior to exercise should be between 33 to 50 percent (Wasserman and Abumrad, 1989). The CDA (1985) recommended that extra food be consumed for exercise and a physician be consulted if insulin dose changes are required. Despite the wide range of recommendations that have been proposed by various researchers on the adjustments that are required to insulin and CHO requirements for exercise, there appears to be consensus in the literature on numerous issues related to diabetes and exercise. Researchers agree that insulin should be administered at least one hour prior to an exercise session in a non-exercising limb or in the abdomen (Horton, 1988; Vitug et al, 1988; Wasserman and Abumrad, 1989; Franz 1992; Wallberg-Henriksson, 1992). Also, the pre-exercise insulin dose should be reduced when exercise is anticipated (Wasserman and Abumrad, 1989). A pre-exercise meal should be consumed between one and three hours prior to the start of the exercise session (Horton, 1988; Wasserman and Abumrad, 1989; Wallberg-Henriksson, 1992). Adjustments in food, insulin, or both are required for exercise in order to prevent hypoglycemia, especially for exercise of long duration. Exercise should be avoided when B G is elevated and metabolic control is compromised, and postponed when urinary ketones are present (Richter and Galbo, 1986; Horton 1988; Wasserman and Abumrad, 1989; Franz, 1992; Wasserman and Zinman, 1994). Stringent monitoring of B G is required before, during, and after exercise in order to prevent exercise induced hypoglycemia or hyperglycemia (Horton, 1988; Vitug et al, 1988; Wasserman and Abumrad, 1989; Wallberg-Henriksson, 1992). In addition, individuals with IDDM should carry adequate diabetic identification and a CHO source with them during and after every exercise session in order to prevent or treat diabetic emergencies (Richter and Galbo, 1986; Franz, 1992). 13 At present, there is a paucity of studies that look specifically at how active people with IDDM adjust their insulin and diet to maintain a healthy and active lifestyle. This study determined what adjustments were made to diet and insulin among this population. In addition, information on monitoring of B G before, during, and after exercise were analyzed to determine how metabolic control was maintained. It is hoped that the information obtained from this study will be applied to the practical recommendations for exercise in IDDM. Individuals with IDDM can, therefore, make the necessary changes required to dietary intake and insulin doses in order to safely participate in an active lifestyle. 14 CHAPTER 2 REVIEW OF THE LITERATURE 2.0 Introduction In the pre-insulin era, physical activity was considered to be beneficial in the treatment of IDDM. After the discovery of insulin the importance of exercise in the management of diabetes decreased, and at times was considered to be contraindicated (Zinman et al, 1984; Horton, 1988; Vitug et al, 1988; Franz, 1992). Exercise was considered to be adjunctive therapy and only encouraged after good metabolic control had been achieved by appropriate insulin therapy and rigid dietary intake. Recently, however, there has been a renewed interest and participation in exercise by the general population. In the same time frame, exercise was 'rediscovered' for the diabetic population (Gonzalez, 1979; Zinman et al, 1984; Franz, 1992). Insulin, diet, and exercise are now considered to be important and interrelated components essential in the treatment of IDDM. There are numerous metabolic and physiological changes that occur during an exercise bout and over time with continued training. For the person with IDDM, these changes add additional challenges to the overall maintenance of metabolic control. The hormonal levels during exercise in a ND person are carefully regulated to provide adequate fuel substrates for exercising muscles. In the person with IDDM, the insulin level during exercise is not under physiological control, therefore, the normal hormonal shifts and fuel substrates used during exercise may be different. Care must be taken to ensure proper adjustments to insulin and diet in order to prevent hypoglycemia or hyperglycemia during or shortly after an exercise session (Sutton, 1991). 15 There are a wide range of recommendations that have been published to assist the individual with diabetes to make the necessary adjustments in dietary intake and insulin administration in order to maintain metabolic control during exercise. There is general consensus that a reduction in insulin is required before participating in exercise, especially exercise of long duration. In addition, an increase in dietary intake has been recommended for exercise. The primary goal of adjusting insulin and dietary intake for exercise is to prevent hypoglycemia during and shortly after an exercise session (Campaigne et al, 1987; Wasserman and Abumrad, 1989; Wallberg-Henriksson, 1992). Monitoring B G before, during, and after exercise is recommended to assist in maintaining glucose homeostasis, by alerting the individual to a significant increase or decrease in B G levels. The maintenance of overall metabolic control while participating in an active lifestyle is the ultimate goal for people with IDDM. 2.1 Etiology of Insulin-Dependent Diabetes Mellitus Insulin-dependent diabetes mellitus (formerly known as juvenile onset diabetes or type I diabetes) is a chronic metabolic syndrome that currently has no cure. It is characterized by the absolute deficiency of insulin production by the p-cells of the pancreas, resulting in severe and persistent hyperglycemia (Tsalikian, 1990; Landry and Allen, 1992; Ratner, 1992; Bennett, 1994; Young, 1995). Insulin-dependent diabetes is the result of selective autoimmune destruction of the |3-cells (Rotter et al, 1990; Tsalikian, 1990; Ratner, 1992; Bennett, 1994). The resulting insulin deficiency produces a metabolic impairment in the storage and utilization of glucose, fats, and proteins by the body (Tsalikian, 1990; Young, 1995). The most profound of the metabolic impairments is the inability of the body to utilize CHO. This impairment leads to pronounced hyperglycemia that is diagnostic of IDDM. Since insulin is required for CHO metabolism, the 16 body must increasingly rely on fat and protein to provide its obligatory energy requirements. The combination of hyperglycemia and the rapid breakdown of fats results in urinary losses of glucose and the metabolic bi-products of fat metabolism, namely ketone bodies, P-hydroxybuterate, and acetoacetate (Bennett, 1994; Young, 1995). The increasing concentration of plasma glucose and ketone bodies leads to diabetic ketoacidosis that will progress to coma, and sometimes death if left untreated (Tsalikian, 1990; Bennett, 1994; Young, 1995). Treatment of ketoacidosis requires the administration of insulin to reverse the metabolic chaos resulting from insulinopenia (Tsalikian, 1990). Lifelong, daily subcutaneous injections of insulin are required to replace the insulin that is not being produced endogenously (Tsalikian, 1990; Franz, 1992; Young, 1995). The sudden onset of symptoms diagnostic of IDDM are the result of high blood plasma concentrations of glucose and ketone bodies. Polyuria, polydipsia, polyphagia, fatigue, and rapid unexplained weight loss are the most common signs and symptoms (Tsalikian, 1990; Ratner, 1992; Bennett, 1994). A random B G level greater than 11 mmol/L with the classical signs and symptoms of diabetes confirms a diabetes diagnosis (Ratner, 1992). Measuring the plasma c-peptide levels is the most sensitive test for determining the deficiency of endogenous insulin production (Wallum et al, 1992; Bennett, 1994). The diagnosis of IDDM is generally made in children and young adults, although it can occur at any age (Harris and Zimmet, 1992). The peak age at diagnosis is between 12 and 14 years (Palmer and Lernmark, 1990; Vadheim and Rotter, 1992). Females tend to develop diabetes slightly earlier than males, possibly due to the earlier onset of puberty in females (Palmer and Lernmark, 1990; Tsalikian, 1990). The prevalence rates for IDDM range from 1 in 400 to 1 in 1000 in the general population (Ratner, 1992). The highest incidence rates occur in the Caucasian population living in the Scandinavian region of 17 Europe, while the lowest rates occur in the Japanese population residing in Japan (Tsalikian, 1990; Vadheim and Ratner, 1992). The exact cause of IDDM has yet to be determined. Researchers now believe that the P-cells of the pancreas are selectively destroyed by a process that is autoimmune in nature (Palmer and Lernmark, 1990; Rotter et al, 1990; Tsalikian, 1990; Ratner, 1992; Bennett, 1994). The autoimmune destruction of the P-cells was previously believed to be rapid since the onset of symptoms of overt IDDM were acute. It is now known that a long pre-clinical period is required before significant hyperglycemia is observed. The slow autoimmune destruction develops over 3 months to 7 years (Palmer and Lernmark, 1990; Wallum et al, 1992). It is estimated that between 80 and 90 percent of the P-cells are destroyed before a diagnosis of IDDM is made (Palmer and Lernmark, 1990; Vadheim and Rotter, 1992; Wallum et al, 1992). Total destruction of the insulin producing cells gradually occurs several years after diagnosis (Rotter et al, 1990). Six stages in the development of IDDM have been proposed, namely 1). genetic predisposition, 2). triggering factors, 3). active immunity, 4). progressive destruction of the P-cells, 5). diagnosis of diabetes, and 6). complete destruction of the p-cells (Rotter et al, 1990; Ratner, 1992; Vadheim and Rotter, 1992). The genetic link to IDDM has focused on the histocompatibility antigens (HLA) on the sixth chromosome (Tsalikian, 1990; Harris and Zimmet, 1992; Ratner, 1992). Approximately 95 percent of people with IDDM have HLA-DR3, HLA-DR4, or both. The risk of developing IDDM is greater in those individuals who are heterozygous for DR3 and DR4 (Rotter et al, 1990; Vadheim and Rotter, 1992). These H L A alleles are thought to be the diabetogenic genes which promote the immune expression in individuals susceptible to IDDM (Vadheim and Rotter, 1992). 18 In studies of identical twins, it is estimated that there is a 30 to 40 percent concordance rate in the development of IDDM (Palmer and Lernmark, 1990; Rotter et al, 1990). The concordance rate in dizygotic twins is estimated to be between 3 and 37 percent (Palmer and Lernmark, 1990; Rotter et al, 1990). Similar to the dizygotic twins, there is a greater prevalence rate of IDDM when there is a positive first degree family history. In the United States the prevalence of IDDM in children is about 1.6 per 1000 (Vadheim and Rotter, 1992). It is estimated that approximately 35 percent of people who have the H L A genes for IDDM actually develop the disease, therefore, genetics do not explain the entire etiology (Rotter et al, 1990; Vadheim and Rotter, 1992). Other factors, then, are responsible for triggering the expression of the diabetogenic genes. Environmental factors have been implicated in the etiology of IDDM in individuals who are genetically predisposed. Environmental factors that have been identified include geographic location, seasonal changes, viruses and other infectious agents, drugs or chemicals, and nutrition. These factors can act to either initiate or precipitate the autoimmune destruction of the P-cells (Rotter et al, 1990; Vadheim and Rotter, 1992). In animal studies using rats who are genetically predisposed to diabetes, the manipulation of the diet, particularly certain essential fatty acids and proteins, has lead to a decrease in the incidence of IDDM (Palmer and Lernmark, 1990). Recently, epidemiological studies have shown a strong inverse relationship between breast feeding and IDDM. Evidence suggests that breast feeding provides some protection against the development of IDDM in later life (Palmer and Lernmark, 1990). To date, there are no research studies that provide conclusive evidence that dietary manipulation in humans will lead to reduced rates of IDDM. 19 Epidemiological studies have determined that there is a seasonal pattern in the diagnosis of IDDM. The highest incidence of diagnosis occurs in the fall and winter, with a dramatic decrease during the late spring and summer months (Palmer and Lernmark, 1990; Ratner, 1992; Vadheim and Rotter, 1992). The increased diagnosis in the fall and winter suggests that infectious agents, such as viruses play a role in the etiology of diabetes (Palmer and Lernmark, 1990; Ratner, 1992). Case reports and epidemiological evidence have frequently reported a 'virus like illness' preceded diagnosis (Rotter et al, 1990). There is also limited evidence that some infectious agents, such as mumps and rubella, may play a role in the later development of IDDM (Palmer and Lernmark, 1990; Rotter et al, 1990). The viral hypothesis in the development of IDDM, however, still remains controversial. This is due in part to the potentially long latency period between a viral infection and the clinical diagnosis of diabetes (Ratner, 1992). The exact role that environmental factors play in the etiology of IDDM has yet to be determined (Palmer and Lernmark, 1990). Viruses and other toxic agents may contribute to the expression of the genetic predisposition to IDDM by activating the mechanisms responsible for the autoimmune attack on the P-cells. Alternatively, these agents may accelerate the autodestruction of the P-cells once it has been initiated (Rotter et al, 1990; Vadheim and Rotter, 1992). The research to date indicates that IDDM is the result of selective autoimmune destruction of the P-cells of the pancreas in genetically susceptible individuals. The exact mechanisms responsible for initiating these responses are unknown. The ultimate consequences of the immunologic destruction of the P-cells is progressive hyperglycemia and overt clinical IDDM. 20 2.2 The Triad of Diabetic Metabolic Control Following the diagnosis of IDDM insulin, diet, and exercise become the three most important factors in establishing and maintaining metabolic control. These three factors are referred to as the 'triad of metabolic control' (Bar-Or, 1983). The therapeutic aim of diabetes care is to eliminate and control the signs and symptoms of uncontrolled diabetes while preventing the onset of long-term complications (Tsalikian, 1990; Canadian Diabetes Advisory Board, 1992). The goal of day to day diabetes care is to mimic the tightly regulated B G levels seen in ND individuals. This is achieved by the careful regulation of exogenous insulin doses, the timing and quantity of food intake, and the timing, duration, and intensity of exercise (Tsalikian, 1990). The careful, daily self monitoring of blood glucose (SMBG) can assist the individual with IDDM achieve glycemic control that closely mimics that of a ND individual. An increase or decrease in any one of these factors without an adjustment in one or both of the other factors, will lead to a deterioration of metabolic control. For example, an increase in physical activity without an increase in food intake, a decrease in insulin administration, or both would result in hypoglycemia. Alternatively, a decrease in planned physical activity without a decrease in food intake, an increase in insulin, or both would result in hyperglycemia. In order to evaluate metabolic control to ensure that adequate adjustments are made to the triad factors, multiple daily SMBG is required. Ideally, four B G determinations per day, before each main meal and before bed, are needed to assess metabolic control. In addition, a SMBG determination between 2 am and 3 am may be helpful in assessing the adequacy of nocturnal insulin levels (Caro, 1994). Periodic H b A l c levels are helpful in assessing longer-term B G control that will assist in determining what adjustments, if any, are required to optimize metabolic control. 21 The goal of treatment in IDDM, then, is to make adjustments in insulin, diet, and exercise to maintain overall metabolic control as close to the normal physiological range as possible. 2.2.1 Insulin Insulin is one of the major fuel-regulating hormones of the body. It acts on muscle, liver, and adipose tissue to promote anti-catabolic, as well as anabolic effects (Harrison et al, 1990; Kimball et al, 1990). It is a polypeptide that is produced and secreted by the P-cells of the Islets of Langerhans located in the pancreas (Guyton, 1981; Lehninger, 1982). Insulin is generally associated with CHO metabolism, particularly related to its B G lowering properties. This, however, is only one of the many functions of insulin in the body. Insulin is responsible for the stimulation of glycogen synthesis, inhibition of gluconeogenesis, inhibition of hormone sensitive lipase, stimulation of the formation of fatty acids, increased transport of amino acids into cells, and increased protein synthesis (Guyton, 1981; Lehninger, 1982; Grodsky, 1983; White and Campbell, 1992). Insulin is secreted in response to increased levels of glucose and amino acids in the blood (Cook and Taborsky, 1990). In the ND individual during the fasted state, insulin is secreted at a very low rate, known as the basal insulin secretion rate (Wallum et al, 1992). The basal insulin release is independent of any exogenous stimulation, such as dietary intake (Cook and Taborsky, 1990). Following a meal, insulin is secreted in response to the increase in amino acids and glucose concentrations in the blood. The magnitude of the insulin response is related to the rate of B G change (Cook and Taborsky, 1990; Wallum et al, 1992). The insulin response to blood-borne stimulus is broken down into two phases. The first phase, often called the acute phase, is secreted in response to a sudden increase in the B G levels. 22 This phase usually subsides within ten minutes of the initial stimulus (Cook and Taborsky, 1990; Wallum et al, 1992). The second phase of insulin secretion starts at the onset of the B G stimulus and increases gradually, then plateaus in order to prevent an increase in BG. The second phase of insulin secretion is responsible for the prolonged maintenance of B G levels following a meal, particularly one high in CHO (Cook and Taborsky, 1990; Wallum et al, 1992). The second phase of insulin secretion can last up to four hours (Cook and Taborsky, 1990). In the person with IDDM, insulin is not produced by the pancreas. Insulin must, therefore, be administered by exogenous insulin injection or by SCII on a daily basis. The goal of insulin administration is to mimic both the basal and the meal induced insulin response to food intake seen in the ND individual by minimizing significant postprandial hyperglycemia and to prevent fasting hypoglycemia (Caro, 1994; Rosenzweig, 1994). This is accomplished by one or more injections of a combination of short, intermediate, or long acting insulin preparations. These insulins each have a specific time of onset, peak action, and duration of pharmacological effect (White and Campbell, 1992; Canadian Pharmaceutical Association, 1996). For an individual using an insulin pump, a basal insulin infusion rate is determined that mimics the basal insulin release described earlier. In addition, a bolus insulin dose is administered just prior to the consumption of a meal or snack to counteract the postprandial B G rise (Rosenzweig, 1994). By using either one of these insulin administration techniques, there is the potential to reduce the excessively wide swings in B G from the fasted to fed states in the individual with IDDM. ( Exercise adds some additional considerations for the administration of insulin. To avoid hypoglycemia during or after exercise, it is recommended that the insulin dose be decreased prior to planned exercise (Wasserman and Abumrad, 1989; Rosenzweig, 1994). This is especially 23 important when the duration of exercise is longer than 30 minutes, and of moderate to high intensity. Exercise also increases peripheral insulin sensitivity during and after exercise so less insulin is required to have the same B G lowering effect (Wallberg-Henriksson, 1992). Exercise enhances insulin sensitivity by increasing the binding of insulin to receptor sites on the muscle cells, enabling greater glucose uptake (Wallberg-Henriksson, 1992; Hough, 1994). The short-term increase in insulin sensitivity, as a result of an exercise bout, can last for up to 24 hours (Kemmer and Berger, 1992; Hough, 1994; Rosenzweig, 1994). Insulin requirements during this period may need to be significantly reduced in order to prevent postexercise hypoglycemia. In addition to the short-term increase in insulin sensitivity, there is also an increase in the long-term tissue sensitivity to insulin in response to training (Landry and Allen, 1992; Wallberg-Henriksson, 1992). The total insulin requirements of an individual with IDDM will decrease over time with continued physical activity as overall insulin sensitivity increases (Zinman and Vranic, 1985; Landry and Allen, 1992; Hough, 1994). The daily dose of insulin would, therefore, need to be reduced even on non-exercising days following the participation in a regular exercise program. A further reduction in the insulin dose may also be required on exercising days. The literature on diabetes and exercise consistently recommends a decrease in insulin dose prior to planned exercise in order to prevent hypoglycemia both during and after exercise (Schiffrin and Parikh, 1985; Horton, 1988; Vitug et al, 1988; Wasserman and Abumrad, 1989; Landry and Allen, 1992; Hough, 1994). There is, however, a wide range of insulin adjustments recommended for planned exercise. The recommendations range from a reduction in insulin administration to completely omitting the pre-exercise insulin dose. 24 Schiffrin and Parikh (1985) studied four different insulin adjustments to planned exercise in thirteen IDDM adolescents with near normal H b A l c levels. Each subject completed, in random order, five test protocols. Four of the test protocols included exercise sessions where 1). the usual insulin dose, 2). two-thirds of the usual insulin dose, 3). one-half of the usual insulin dose, and 4). no insulin, was used prior to each exercise session. A rest day with the usual insulin dose was used as a control day. The test insulin dose was administered 2 hours before each exercise session. In addition, the subject's usual breakfast was consumed 30 minutes after the insulin injection was administered. With the exception of the rest day, the subjects exercised on a cycle ergometer for 45 minutes at 55 percent of their previously determined maximal work capacity. Blood glucose samples were taken throughout the study protocol. The usual pre-breakfast dose of insulin resulted in a significant drop in B G during the exercise session, while withholding the pre-breakfast insulin resulted in a significant increase in B G levels during and after exercise. Schiffrin and Parikh (1985) concluded that a 30 to 50 percent decrease in planned, postprandial exercise was appropriate to maintain near normal B G levels during and after exercise. Vitug and Colleagues (1988) have proposed three possible adjustments that can be made in insulin injections depending on the insulin regimen that is followed. For those who combine intermediate and short acting insulins, the general recommendation is to omit the regular insulin preceding planned exercise. When injections of intermediate insulin are used, a decrease of 30 to 40 percent of the total daily dosage is typical. Finally, for individuals on multiple daily injections (MDI) of short acting insulin, the pre-exercise dose should be reduced by 30 to 35 percent (Vitug et al, 1988). 25 Horton (1988) recommended that individuals who are on a single injection of intermediate acting insulin in the morning reduce this dose by 30 to 35 percent. Individuals who combine intermediate and short acting insulins should reduce the short acting insulin from 50 to 100 percent preceding exercise. Those who are on MDI using primarily short acting insulin should decrease the pre-exercise dose by 30 to 50 percent (Horton, 1988). There are also several recommendations on the insulin adjustments required by individuals on insulin pump therapy. Vitug and Colleagues (1988) recommended that the pre-meal bolus insulin be eliminated prior to exercise, and the basal infusion rate be maintained. Alternatively, Horton (1988) recommended that the basal infusion rate may be decreased and the pre-exercise meal dose be reduced or omitted. Another recommendation for the adjustment of insulin for a pump user was to reduce or omit the pre-meal bolus prior to exercise, and to reduce the basal insulin dose by one-third to one-half during exercise (Wasserman and Abumrad, 1989). Insulin is required during exercise to permit the uptake of glucose by working muscles. Due to the increased insulin sensitivity with training and during each exercise bout, a small but permissive amount of insulin is required. This lowered insulin level will permit adequate uptake of glucose by the muscles, while promoting gluconeogenesis and glycogenolysis by the liver (Wallberg-Henriksson, 1989; Sutton, 1991). Low levels of insulin will also permit a near normal increase in the counterregulatory hormones, especially glucagon and the catecholamines, that will promote hepatic glucose production (Zinman and Vranic, 1985; Wallberg-Henriksson and Wahren, 1989; Wasserman and Abumrad, 1989; Sutton, 1991; Hough, 1994). The net effect of lowered insulin levels during exercise is to promote euglycemia (Wallberg-Henriksson, 1989; Sutton, 1991; Hough, 1994). 26 The risk of exercise induced hypoglycemia can also be reduced by carefully considering the pre-exercise injection site and the timing of the injection. Insulin should be administered away from exercising muscle, since the absorption of insulin from the subcutaneous depot may be greater (Vitug et al, 1988; Wasserman and Abumrad, 1989; Rosenzweig, 1994; Wasserman and Zinman, 1994). In addition, there is always the possibility of accidental intramuscular injection of insulin when injecting into the thigh (Frid et al, 1990; Wasserman and Zinman, 1994). This would lead to a faster absorption of insulin into the blood and a rapid decrease in B G , that may lead to a severe insulin reaction (Frid et al, 1990). The abdomen is the recommended area of the body to administer pre-exercise insulin in order to prevent rapid insulin absorption, and to promote consistent insulin absorption (Caro, 1994; Rosenzweig, 1994). Insulin should not be injected within one hour of an exercise session, especially when short acting insulin is administered (Horton, 1988; Vitug et al, 1988; Wasserman and Abumrad, 1989). This will ensure that there is not a significant increase in insulin absorption from subcutaneous tissue during exercise, and will also avoid the peak action of regular insulin (Horton, 1988; Wasserman and Abumrad, 1989; Franz, 1992). A reduction in insulin administration is required prior to exercise to help reduce the risk of exercise induced hypoglycemia. Care must be taken in adequately reducing the insulin dosage for anticipated exercise to ensure that a low but permissive level of insulin is present for optimal metabolic control during exercise. Insulin should be injected into the abdomen at least one hour prior to the start of the exercise session. 27 2.2.2 Dietary Intake Dietary intake is the second important factor in the management of IDDM. Prescribing a diet for a person with diabetes is much more complicated than merely recommending the avoidance of foods that are high in simple sugars. In Canada and the United States, comprehensive dietary recommendations have been made for the nutritional care of diabetes (ADA, 1988; A D A , 1994; CDA, 1994). The aim of dietary management is to prevent extreme swings in the B G levels, and to promote adequate, nutritionally balanced food intake. The food intake recommendations for a diabetic are not significantly different from those for the general population (Heins and Beebe, 1992). The recommendations for the general population include: eat a variety of foods every day, attain and maintain a healthy body weight, choose foods that are low in fat, and high in dietary fiber, and use sugar, salt, caffeine, and alcohol in moderation (Health and Welfare Canada, 1990; Health and Welfare Canada, 1992; Heins and Beebe, 1992). The goals of nutritional management in the IDDM population are to provide adequate energy to achieve and maintain optimal body weight, to provide adequate nutrients for growth and repair of body tissues, and to maintain B G levels near physiologically normal levels (ADA, 1988; Vinik and Wing, 1990; Zeman, 1991; A D A , 1994). The energy prescription made reflects the lifestyle, activity, age, and gender of the individual. Protein intake recommended for adults is 0.8 grams of protein per kilogram of body weight per day. Fat is restricted to 30 percent of energy intake, with less than 10 percent contributed from saturated fat. Carbohydrates should contribute 55 to 60 percent of the total energy intake, with a large percentage in the complex form (ADA, 1988; Vinik and Wing, 1990; Zeman, 1991; Heins and Beebe, 1992; ADA, 1994). Simple sugars are not entirely omitted from the diabetic diet, provided their inclusion does not adversely affect the management of B G levels (Zeman, 1991; CDA, 1994). 28 Dietary recommendations are converted to a meal plan that utilizes a food exchange system. Each food exchange combines foods that contain similar macronutrient and energy profiles together. For example, The Good Health Eating Guide (CDA, 1994) contains 7 food exchange groups namely: starch foods, fruits and vegetables, milk, sugars, protein foods, fats and oils, and extras. The total number of exchanges from each group are determined based on energy and nutrient requirements. The food is then distributed throughout the day in the form of meals and snacks. The meal plan is coordinated with the peaks in insulin action and with the timing of exercise (ADA, 1988). The goal of a meal plan, then, is to promote consistency in the daily food intake, integrate insulin therapy, and to incorporate the individual's lifestyle. An active lifestyle for the person with IDDM adds an additional challenge for dietary management. Adjustments in food consumed before, during, and after exercise are required in order to prevent hypoglycemia during or following an exercise session (Horton, 1988; Landry and Allen, 1992; Hough, 1994; Young, 1995). Pre-exercise food intake will help to optimize endogenous fuel sources, particularly muscle and liver glycogen, and attain optimal B G levels (Costill, 1985; Applegate, 1989; Coggan and Coyle, 1991). A pre-exercise meal should be consumed one to three hours before the onset of exercise (Horton, 1988; Wasserman and Abumrad, 1989; Landry and Allen, 1992; Wallberg-Henriksson, 1992). The pre-exercise meal should contain primarily complex CHOs that will provide a readily available energy source during the exercise session. In the active ND individual, CHO intake during prolonged, endurance exercise enhances performance and delays the onset of fatigue by sparing muscle and liver glycogen stores (Coggan and Coyle, 1991; Franz, 1992). Carbohydrate intake in the individual with IDDM also enhances performance. In addition to this, a readily absorbable CHO source during exercise is required to 29 prevent hypoglycemia, especially for prolonged, endurance exercise (Wasserman and Zinman, 1994). The CHO replacement during exercise will provide a metabolic substrate for the exercising muscles and prevent a significant decrease in B G over the duration of the exercise session (Franz, 1992). Since the hormonal shifts during exercise in persons with IDDM are often blunted, there is a greater reliance on the glycolytic pathway for energy production (Berger et al, 1977; Landry and Allen, 1992). Also, the glycogen stores in the muscle and liver are also lower than ND individuals, which reduces the endogenous supply of glucose during exercise (Wahren, 1979; Hough, 1994). There is, therefore, a greater reliance on blood-borne energy substrates for exercise, particularly B G (Wahren et al, 1975; Coggan, 1991). In order to prevent hypoglycemia during exercise, CHO intake during exercise may be required. The recommendations for the amount of CHO required during exercise in people with IDDM varies considerably. There is a consensus that CHO consumption is required during exercise to prevent hypoglycemia during and after an exercise session, especially when the exercise is prolonged or intense. There is, however, no agreement of the amount of CHO that is required. The CDA (1985) recommended that the amount of CHO required during exercise depends on the intensity and duration of the exercise session. Light activity, such as walking or bowling, requires an extra 15 grams of CHO for the entire exercise session. Moderate intensity exercise, such as brisk walking, gardening, vacuuming, or bicycling, requires an extra 10 grams of CHO for every 30 minutes of exercise. Strenuous exercise requires the most CHO consumption during exercise. For activities such as hockey, tennis, swimming, or running, an extra 10 to 20 grams of CHO is required for every 30 minutes of exercise (CDA, 1985). 30 Horton (1988) based the consumption of CHO during exercise on the type, intensity, and duration of the exercise session. The energy requirements of the activity were estimated and converted into grams of CHO. Exercise of moderate intensity, such as jogging, cycling, or swimming are estimated to require between 30 and 40 grams of CHO for every 30 minutes of exercise. Carbohydrate should be consumed at least every 30 minutes when exercise is vigorous and of long duration. An estimate of the caloric expenditure of the exercise session would be predictive of the amount of CHO required during the activity. The pre-exercise B G is also considered before starting to exercise. If the B G reading is below 5.5 mmol/L, a pre-exercise snack must be consumed. Alternatively, if the B G level is above 14.0 mmol/L and urinary ketones are present, exercise should be postponed. When the B G value is between 5.5 and 14.0 mmol/L, it is safe to start exercising without a pre-exercise snack, provided CHO is consumed during activity (Horton, 1988). Franz (1992) also recognized the need to base exercise CHO consumption on the duration and intensity of the exercise session. Exercise of short duration and low intensity, such as walking, does not require the consumption of additional food, provided the activity is less than one hour in duration. Moderate intensity exercise, such as tennis, jogging, or swimming, requires 10 to 15 grams of CHO per hour. For strenuous exercise, such as hockey or basketball, 25 to 50 grams of CHO are recommended per hour (Franz, 1992). In addition to the intensity and duration of the exercise session, the pre-exercise B G is important in determining if additional CHO is needed. If the B G level is less than 5.5 mmol/L, additional CHO is needed. Low intensity exercise requires 10 to 15 grams, moderate intensity exercise 25 to 50 grams, and strenuous exercise requires 50 grams of CHO before starting to exercise. At each of these 31 intensities, the pre-exercise snack is in addition to the amount of CHO required during the exercise session (Franz, 1992). The exercise CHO intake recommendations vary considerably in the literature. The recommendations for low intensity exercise range from no increase in food intake for exercise to increasing intake by 15 grams CHO for the entire exercise session (CDA, 1985; Franz, 1992). Moderate intensity ranges from 20 to 40 grams per hour, and strenuous exercise ranges from 20 to 50 grams of CHO per hour (CDA, 1985; Horton, 1988; Franz, 1992). Caution should be used in implementing the CHO recommendations in the literature since the consumption of too much or too little food during exercise can lead to a deterioration of metabolic control leading to hypoglycemia or hyperglycemia (Wasserman and Abumrad, 1989). Estimation of the caloric expenditure of an exercise session may be helpful in determining the CHO requirements in order to prevent the deterioration in metabolic control during exercise (Wasserman and Abumrad, 1989). After exercise, the CHO requirements may remain elevated in order to prevent postexercise hypoglycemia. The risk of postexercise, late-onset hypoglycemia can last for up to 24 hours, especially when the exercise session was prolonged or intense (Landry and Allen, 1992; Wallberg-Henriksson, 1992; Hough, 1994; Young, 1995). It is the result ofjthe rapid repletion of muscle and liver glycogen stores, a significant increase in insulin sensitivity, and a blunted postexercise hormonal response (Campaigne et al, 1987; Vitug et al, 1988; Landry and Allen, 1992; Hough, 1994; Young, 1995). In order to prevent hypoglycemia, consumption of slowly absorbed CHOs are required after the exercise session (Wallberg-Henriksson, 1992; Hough, 1994; Wasserman and Zinman, 1994). An increase in dietary intake may be required for up to 24 hours to counteract the acute effects of the exercise session and to prevent late-onset 32 hypoglycemia (Horton, 1988; Wallberg-Henriksson, 1992). Complex CHOs consumed over this period can help to reduce the increased risk of hypoglycemia. Special attention is required to prevent nocturnal hypoglycemia by monitoring B G before bed and during the night. The consumption of additional food, primarily CHO may be required. Dietary intake, particularly CHO, is an essential component in the management of IDDM. The pre-exercise nutrition is essential in optimizing liver and muscle stores of glycogen. Carbohydrate supplementation during exercise provides energy for active muscles and prevents hypoglycemia. Food intake after exercise is required to maintain B G and to enhance glycogen repletion. Carbohydrate intake before, during, and after exercise, therefore, will help to maintain optimal metabolic control. 2.2.3 Exercise Exercise is the third factor that is important in the management of IDDM. The incorporation of exercise in the lifestyle of a person with IDDM adds numerous physiological and psychological benefits. Regular physical activity provides the same benefits for both the IDDM and ND populations. The physiological benefits of exercise for both groups include attaining and maintaining an ideal body weight, decreasing resting blood pressure, decreasing resting heart rate, increasing cardiorespiratory functioning including physical work capacity, and improved blood lipid profiles (Horton, 1988; Franz, 1992; Landry and Allen, 1992; Wasserman and Zinman, 1994). In addition to the physiological benefits, active people benefit from numerous psychological factors as well. There is an improvement in self-image, self-esteem, and an enhancement in the sense of well-being (Horton, 1988; Landry and Allen, 1992). Regular participation in exercise has also been associated with other positive lifestyle changes that 33 enhance quality of life, namely a reduction or elimination in smoking and alcohol consumption, and an increased ability to cope with stress (Wasserman and Zinman, 1994). The person with IDDM can also benefit from exercise in several additional ways. There is an increase in insulin sensitivity over the short-term with each exercise bout. With repeated bouts of exercise, there is an overall increased peripheral insulin sensitivity that is sustained even after the acute effects of physical activity have subsided (Wallberg-Henriksson, 1992). This increased insulin sensitivity leads to a decrease in the exogenous insulin required to meet the body's insulin requirements (Landry and Allen, 1992; Wasserman and Zinman, 1994). The increased insulin sensitivity can be beneficial in preventing cardiovascular disease (CVD) since hyperinsulinemia with insulin resistance are potential risk factors (Wasserman and Zinman, 1994). Other C V D risk factors that are reduced with regular physical exercise include: improved high density to low density lipoprotein cholesterol ratio, decreased very low density lipoprotein cholesterol, and decreased triglyceride levels (Horton, 1988; Landry and Allen, 1992; Horton, 1994; Wasserman and Zinman, 1994). Since the risk of developing C V D in IDDM is much greater than the ND population, reducing known and potential risk factors are beneficial in reducing morbidity and early mortality. One of the important factors that exercise can promote is enhanced glycemic control. In well insulinized individuals, there is a significant decrease in the B G in a single exercise bout (Wasserman and Zinman, 1994). This observed decrease in B G with exercise is beneficial in reducing elevated B G levels, provided the decrease does not lead to a hypoglycemic episode. One would anticipate that a reduction in B G with each exercise session would lead to improved long-term B G control with regular physical activity. Unfortunately, increased long-term metabolic control has not been observed in longitudinal studies on the effects of physical training 34 on B G control (Wallberg-Henriksson et al, 1982; Zinman et al, 1984). Although regular physical activity has not demonstrated improvement in long-term metabolic control, measured by H b A l c , it should not be ruled out as beneficial in the treatment in IDDM (Wasserman and Zinman, 1994). Indeed, a significant worsening of long-term metabolic control has also not been observed, therefore, individuals with IDDM should exercise for the same beneficial effects as their ND counterparts. Also, improved physical fitness and a positive psychological outlook will enhance the ability of a person to cope with the daily stresses of living with IDDM. Wasserman and Zinman (1994) speculate that the beneficial effects of exercise on glycemic control can be realized with intensified insulin and diet treatment. In order to benefit from the long-term effects of regular exercise, the person with IDDM must overcome the extra challenges that each exercise session places on their metabolic control. In general, the person with IDDM is able to meet the increased energy demands of exercise. The goal during exercise is to maintain, as closely as possible, normal B G control. Since there is a drastic change in the physiological, hormonal, and biochemical responses from rest to an exercising state, numerous adaptations are required to provide exercising muscles with an optimal energy supply. If the body fails to make the necessary adjustments in the energy supply, premature termination of the exercise session will occur due to hypoglycemia or hyperglycemia (Horton, 1988; Wasserman and Zinman, 1994). The hormonal and fuel substrate changes that occur in a ND individual, demonstrate the metabolic adaptations that are required in order to meet the energy demands of each exercise session. It is estimated that there is a 10 to 20 fold increase in the overall metabolic rate during exercise (Sutton, 1991). This increase in fuel use during exercise is mediated by a series of endocrine responses (Wasserman and Zinman, 1994). Over the duration of the exercise session 35 there is a significant decrease in the plasma insulin levels with a concurrent increase in glucagon and the catecholamine levels (Zinman and Vranic, 1985; Wasserman and Abumrad, 1989; Franz, 1992). The decrease in insulin levels during exercise serves to inhibit glycogen synthesis in the muscles and liver, decrease glucose utilization by non-exercising tissues, promote lipolysis in the adipose tissue, and stimulate the uptake of glucose by the exercising muscle (Zinman and Vranic, 1985; Sutton, 1991; Franz, 1992). The concurrent increase in glucagon and the catecholamines promotes glycogenolysis in the muscles, increases glycogenolysis and gluconeogenesis in the liver, stimulates lipolysis in the adipose tissue, and inhibits the secretion of insulin (Sutton, 1991; Franz, 1992). Hepatic glycogenolysis and gluconeogenesis provides the glucose necessary to maintain euglycemia during long-term exercise (Horton, 1988; Sutton, 1991). The shift in the hormone levels during exercise facilitates the changes in the energy substrates over the duration of each exercise session. The primary fuels used as an oxidative substrate during rest are FFAs (Richter et al, 1981; Zinman and Vranic, 1985; Franz, 1994). At the start of moderate intensity exercise glucose oxidation increases significantly, with muscle glycogen becoming the primary source of energy for working muscles for the first 5 to 10 minutes of exercise (Horton, 1988; Wallberg-Henriksson, 1989; Sutton, 1991; Franz, 1992). The oxidation of muscle glycogen slows after the first 10 minutes of exercise as other metabolic substrates become increasingly available (Wahren et al, 1978). With the increase in the duration of the exercise session, there is a gradual shift from the use of muscle glycogen as an energy source, to a greater reliance on FFAs and blood-borne glucose (Wasserman and Abumrad, 1989; Koivisto et al, 1992). There is also a gradual shift from the use of glycogen and glucose for energy, to a greater reliance on FFAs as the duration of the exercise session increases (Wahren et al, 1978; Franz, 1992). Between 30 and 36 40 minutes of exercise, there are approximately equal amounts of glucose and FFAs being oxidized. Exercise longer than 90 minutes demonstrates an increasing reliance on FFAs for energy and a decline in the use of glucose (Wahren et al, 1978; Sutton, 1991; Franz, 1992). Even though there is a decline in the oxidation of glucose during prolonged exercise, it is still required as an energy source for the duration of the exercise session (Zinman and Vranic, 1985; Franz, 1992). The hormonal changes that occur from rest to exercise, and over the duration of exercise mediate the energy substrate shift that is observed. The energy shift from predominantly muscle glycogen to a combination of glycogen, circulating glucose, and FFAs are the result of a decrease in insulin levels with a concurrent increase in glucagon and catecholamine levels. The liver, in the presence of increasing glucagon levels, increases its release of glucose into the blood through glycogenolysis. In addition, metabolic bi-products of exercise, lactate, pyruvate, and glycerol, are converted into glucose by gluconeogenesis (Sutton, 1991; Franz, 1992; Landry and Allen, 1992). Glucagon is estimated to be responsible for up to 75 percent of the increase in hepatic glucose production during exercise. The amount of glucose produced by the liver is tightly regulated during exercise and matches the glucose uptake and oxidation by active muscle (Wasserman and Abumrad, 1989). Insulin is considered to play an important role in matching hepatic glucose production with muscle uptake and oxidation (Horton, 1988; Wasserman and Abumrad, 1989). The release of FFAs from the adipose tissue is mediated by the catecholamines. Increasing levels of epinephrine and norepinephrine stimulate adipose tissue to increase lipolysis resulting in increased levels of FFAs and glycerol in the blood (Franz, 1992). The FFAs released are increasingly relied upon as an energy substrate by the muscles. The decrease in insulin levels with the concurrent increase in glucagon and catecholamine levels over 37 the duration of the exercise session produce the changes in energy substrate use necessary to provide energy to working muscles and maintain euglycemia. In the person with IDDM, the hormonal profile during exercise may be considerably different than that seen in a ND individual, which could promote the use of alternative fuel sources during exercise. Since insulin is not under physiological control, the hormonal changes during exercise are dependent on the circulating insulin levels at the onset of exercise (Wasserman and Zinman, 1994). Insulin deficiency at the onset of exercise will greatly exacerbate the hyperglycemia and promote the development of ketosis (Wasserman and Abumrad, 1989; Wasserman and Zinman, 1994). During exercise there is an increase in glucagon and catecholamine levels which stimulate the hepatic production of glucose and the release of FFAs from adipose tissue. In the absence of adequate levels of insulin, the inhibitory effect of insulin on hepatic glucose production is blunted (Wasserman and Zinman, 1994). There is also a decreased ability of the exercising muscle to utilize increasing levels of B G (Wasserman and Abumrad, 1989; Sutton, 1991). The exercising muscle relies more on its glycogen stores and the incomplete oxidation of FFAs for energy. The result is a rapid deterioration of metabolic control from increasing B G concentration and the production of ketones from incomplete FFA oxidation (Horton, 1988; Wasserman and Zinman, 1994). The metabolic control will also be compromised when there is an excess of circulating insulin, either relative or absolute, at the onset of exercise. The increased concentration of insulin in the blood may inhibit the release of glucagon and catecholamines in response to exercise. The major effect of overinsulinization during exercise is its inhibitory effect on hepatic glycogenolysis and gluconeogenesis to produce B G for use by exercising muscles (Horton, 1988; Hough, 1994). It also acts to increase glucose uptake and oxidation by exercising muscles 38 (Zinman and Vranic, 1985; Sutton, 1991; Franz, 1992). Insulin inhibits adipose tissue lipolysis, therefore, plasma FFA levels will remain low. The result of overinsulinization is a greater reliance on B G by active muscles over the duration of the exercise session, and a failure of the body to switch to FFA oxidation (Wasserman and Abumrad, 1989; Koivisto et al, 1992). The hepatic glucose production cannot match the increased peripheral oxidation of glucose as a fuel source, resulting in a decrease in B G levels and hypoglycemia (Zinman and Vranic, 1985; Sutton, 1991; Franz, 1992; Hough, 1994). Optimal metabolic control during exercise can be achieved by a low but permissive level of plasma insulin (Wallberg-Henriksson, 1989; Sutton, 1991). The low levels of plasma insulin at the start of exercise will closely mimic the decrease in plasma insulin concentration observed in ND individuals during exercise. The low levels of insulin will stimulate the uptake and oxidation of glucose by active muscle. The increase in glucagon and catecholamines will increase the hepatic glucose production and an increase in adipose tissue lipolysis. The optimal hormonal balance will permit the utilization of B G and allow for the fuel substrate shift from glycogen to FFAs over the duration of the exercise session (Sutton, 1991). Therefore, the appropriately insulinized person with IDDM will respond to exercise in much the same way as a ND individual (Wasserman and Abumrad, 1989; Wasserman and Zinman, 1994). Careful consideration of insulin levels before exercise will prevent the deterioration in metabolic control by optimizing fuel availability during exercise (Wallberg-Henriksson, 1989; Sutton, 1991). Exercise in an individual with IDDM in good metabolic control is not without its risks. Unexpected hypoglycemia can occur at any time during or after an exercise session, even when insulin levels have been reduced for anticipated exercise. A readily absorbable CHO source should be available at all times during exercise (Franz, 1992; Hough, 1994). When symptoms of 39 hypoglycemia are identified, the CHO source can be consumed to prevent a further decrease in BG. The individual should stop exercising and not resume the activity until adequate metabolic control has been re-established. Monitoring B G during this period is important to determine the concentration of glucose in the blood following CHO consumption. The value attained will assist the individual in assessing the need for further treatment. A necklace or bracelet identifying the person as having IDDM should be worn at all times in the event of a diabetic emergency (Franz, 1992; Hough, 1994). Regular exercise for the person with IDDM improves the overall fitness level, while increasing insulin sensitivity and decreasing daily insulin requirements. With insulin levels not under physiological control, each exercise session places extra challenges on the body to meet the increased energy demands of exercise. The metabolic substrates used are dependent on the insulin level during exercise. Optimal energy use and metabolic control is achieved by a slightly diminished but permissive level of insulin. 2.2.4 Integration of the Triad Insulin, diet, and exercise comprise the triad of metabolic control for the person with IDDM. Each of these factors have closely interrelated functions crucial to the maintenance of day to day metabolic control (Tsalikian, 1990). For the active individual with IDDM, many factors must be considered before participating in exercise. The overall metabolic picture must be considered in order to minimize short-term and long-term problems associated with exercise (Campaigne and Lampman, 1994). Adjustments in diet and insulin requirements are necessary to maintain optimal metabolic control in anticipation and response to exercise. It is important to reduce insulin dose or to increase dietary intake on exercising days. Both an increase in food 40 intake and a decrease in insulin dosage may be required to prevent exercise induced hypoglycemia, especially during a prolonged exercise session (Campaigne et al, 1987; Rosenzweig, 1994). The risk of hyperglycemia or hypoglycemia during an exercise session is a real threat to the health and well-being of the person with diabetes. Exercise, therefore, must be planned ahead and incorporated into the daily routine. This is required in order to ensure that participation in an active lifestyle does not negatively affect metabolic control and place the individual at increased risk of hypoglycemia or hyperglycemia. Self monitoring of B G on a daily basis is important in order to assess short-term glycemic control. Usually patients are requested to test their B G four times per day, before each main meal and at bedtime (Caro, 1994). Additional tests should be performed before, during, and after exercise to assess B G response to exercise (Wasserman and Abumrad, 1989; Franz, 1992; Wasserman and Zinman, 1994). The values attained from frequent S M B G associated with exercise can be used in planning adjustments in diet and insulin for future exercise sessions (Wasserman and Abumrad, 1989; Wasserman and Zinman, 1994). Determining how the intensity and duration of an exercise session affects BG, will help the individual with IDDM reduce the risk of hypoglycemia or hyperglycemia during and after exercise (Franz, 1992). The pre-exercise determination of B G will provide feedback on the possible effect of exercise on glycemic control. In the event of a B G reading below 5.5 mmol/L, exercise should be postponed due to the increased risk of hypoglycemia. Exercise can be safely participated in after extra CHO has been consumed and B G increases (Horton, 1988; Wasserman and Zinman, 1994). Exercise should be postponed if B G is greater than 14.0 mmol/L and urinary ketones are present, or if B G is greater than 16.5 mmol/L irrespective of the presence of urinary ketones (Horton, 1988; Wasserman and Zinman, 1994). Participating in exercise when B G levels are 41 elevated greatly exacerbates the hyperglycemia and increases the rate of development of ketoacidosis. Using SMBG during an exercise session, especially of long duration, would help the individual assess not only the current B G concentration, but the rate of B G change. When B G is decreasing rapidly, the ingestion of additional CHO may be indicated, even when BG levels are still within a safe range (Wasserman and Abumrad, 1989; Wasserman and Zinman, 1994). Monitoring B G after exercise can prevent late-onset hypoglycemia by increasing awareness of the postexercise effects on BG. A B G determination between 2 am and 3 am may help to prevent nocturnal hypoglycemia (Caro, 1994). Additional SMBG, therefore, is required before, during, and after exercise to determine the effect of exercise on glycemic control. Integrating insulin, diet, and exercise in the day to day management of IDDM is essential in maintaining optimal metabolic control. With careful adjustments in the triad factors, the person with IDDM can enjoy all of the physiological and psychological benefits of participating in an active lifestyle. 2.3 Conclusion The recent research into the effects of exercise in persons with IDDM has concluded that this population benefits from exercise in the same way as the ND population. In addition, there is the potential for the added benefits of improving insulin sensitivity, decreasing insulin requirements, and preventing or delaying the onset of long-term diabetic complications (Vranic etai, 1990). The person with IDDM must be able to modify the insulin and diet components of diabetic care in order to exercise safely. The triad of diabetic metabolic control must be carefully considered when initiating an exercise program or when participating in a new sport. The 42 availability of energy substrates during exercise will be greatly affected by the amount of plasma insulin, the metabolic state prior to exercise, and the amount of food eaten both prior to and during an exercise session. Postexercise, extra CHO may be required to optimize muscle and liver glycogen resynthesis, and prevent late-onset hypoglycemia. Careful attention to the individual's response to exercise is required to make exercise an enjoyable and risk reduced part of everyday life for people with IDDM. There are a wide range of recommendations in the literature on the diet and insulin adjustments that are required to maintain metabolic control before, during, and after exercise. This research project, therefore, was designed to determine what adjustments in diet and insulin already active individuals with IDDM make in order to maximize the benefits of exercise and minimize the risk of hypoglycemia or hyperglycemia. 43 CHAPTER 3 METHODS AND PROCEDURES 3.0 Sampling The sample population was selected from the International Diabetic Athletes Association (IDAA) mailing list that was updated in August, 1996. The world wide IDAA membership is comprised of people interested in diabetes and exercise. There were numerous logistical problems in getting the questionnaires returned from the subjects that reside outside of Canada and the United States, therefore 321 International members were deleted from the mailing list before subjects were selected for the study. In addition, numerous listings were excluded before subjects were selected for the following reasons: 1). there were 2 duplicate entries, 2). five potential subjects had direct involvement with the study, 3). there were 3 entries with insufficient information to mail the questionnaires, 4). nine entries had two names per address, and 5). there were 300 diabetes product companies listed. The original IDAA mailing list contained 1925 members, of which a total of 1285 qualified for this study. The subjects were selected for the study using a simple random sampling technique. A l l potential subjects were assigned a number from 1 to 1285, then a computerized random number generator was used to select 325 of the 1285 possible numbers. Each of the numbers in the group was only selected once, therefore, each of the 1285 potential subjects had an equal and independent chance of being selected for the study. The numbers selected were matched to the corresponding subject on the mailing list and all others were deleted from the 44 text file. The first 300 names on the computer generated list were sent questionnaires. The remaining 25 subjects were held in a queue pending the return of unmarked questionnaires from Health Professionals, ND, and NIDDM members, who did not qualify for the study. A total of 44 Canadians and 281 Americans were selected to participate. The IDAA membership is comprised of Health Professionals, ND, IDDM, and NIDDM people who are interested in the relationship of exercise and diabetes. Unfortunately, the IDAA mailing list did not differentiate between members who do or do not have diabetes. The subjects who were required for this study must have IDDM in order to participate. Subjects who were ND or N IDDM were requested to return the questionnaire package unmarked in the return envelope provided. Three hundred questionnaires were originally sent out to the subjects who were selected to participate in this study. An additional 25 questionnaires were sent out to partially compensate for the subjects who did not qualify for the study, or for those subjects who had moved while the questionnaires and mailing lists were prepared. The subjects who completed and returned the questionnaires were considered to be volunteers for this study. 3.1 Methods 3.1.1 The Questionnaire This study used a self-administered questionnaire that was mailed to each individual selected to participate in the study. The questionnaire was developed by the investigator to obtain information on the adjustments in diet and insulin required for exercise in already active people with IDDM. In addition, information on self-monitoring of metabolic control, 45 personal safety, treatment of insulin reactions, and effects of long-term complications on the ability to exercise was obtained. The questionnaire was developed and administered using established questionnaire design guidelines. Please see Appendix C for the references used in the preparation of the questionnaire. The questionnaire package contained a personalized covering letter, a letter of endorsement from the IDAA, a questionnaire title page, an instruction sheet, the questionnaire, and a pre-addressed, stamped return envelope. Please see Appendix A for a copy of the questionnaire package, excluding the return envelope. The covering letter was printed on original School of Human Kinetics letterhead. Each letter was personally addressed to the potential subject using the name included in the mailing list. The letter briefly introduced the background and purpose of the study, and the future use of the data. The amount of time required to complete the survey was included as an estimate of the time commitment required by each participant. The subjects were informed that their responses were strictly confidential and were requested not to write their name or other identifying marks on the questionnaire. They had the right to refuse to participate in the study and could withdraw at any time. Subjects who did not have IDDM were requested to return the questionnaire unmarked in the return envelope provided. A toll free telephone number was included in the covering letter in order to answer any questions or concerns the participants had. A l l of the covering letters were hand signed in blue ink in order to further personalize the letter. A photocopy of the letter of endorsement from the IDAA was included in each questionnaire package. The purpose of including this letter in the package was to further 46 encourage potential respondents to complete and return the questionnaire, since the IDAA was aware of and supported the research being conducted. The letter briefly outlined the purpose of the study, the investigators involved with the study, and included information on the feedback that would be sent to the IDAA after the project was completed. Again the issue of confidentiality of individual responses was addressed. The letter was printed on IDAA letterhead and signed by the IDAA President. The questionnaire component of the mailed package contained a title page, an instruction sheet, as well as the questionnaire. The title page was included to make the questionnaire look professional. An instruction sheet was included with the questionnaire in order to further explain the criteria for subject selection and to provide detailed information on how to complete the survey. Respondents who did not have IDDM were once again requested to return the questionnaire unmarked in the envelope provided. Subjects who qualified for the study were informed that their participation in the study was important due to the small number of IDAA members selected to participate. Since there was no way of tracking individual questionnaires, subjects were encouraged to answer the questions as accurately and honestly as possible. They were given information on how to complete the questionnaire by placing a check mark in the appropriate box(es), to circle the units of measure where appropriate, or to neatly print their answers in the space provided. Subjects were requested to complete the survey in the order that the questions were presented. In addition, they were instructed that, depending on the answers to certain questions, they might be required to skip one or more questions. The respondents were requested to complete and return the survey within two weeks. Again, the toll free telephone number was included so 47 that any questions or concerns could be addressed. Subjects were thanked for their participation in the study. The questionnaire was 25 pages long, printed on both sides of the page, and was divided into 9 comprehensive sections. The first page of the questionnaire was sequentially numbered in order to track each returned survey. For statistical analysis purposes, Canadian respondents were assigned numbers that started with 1700, while the American respondents were assigned numbers that started with 2700. Section A was designed to ask questions related to the subjects' demographics. Questions related to diabetes and metabolic control were included in this section. Section B was divided into two subsections depending on the method of insulin administration. Respondents who injected their insulin completed the first set of questions, while those on insulin pump therapy completed the second set of questions. Each of these sections were mutually exclusive. Section C asked questions about the frequency, intensity, time, and type of exercise participated in by subjects. The questions progressed from very general questions at the beginning, to more specific questions at the end of the section. Section D was designed to obtain information on the daily food intake for both exercising and non-exercising days. Questions relating to the food and fluid consumption before, during, and after exercise were included. The recognition and treatment of mild, moderate, and severe insulin reactions was covered in Section E. Section F looked at the frequency of blood glucose and urinary ketone testing on both exercising and non-exercising days. Included in this section was a series of questions on the metabolic testing that occurred prior to, during, and after exercise. Safety issues related to exercising with diabetes were addressed in Section G. Section H asked 48 subjects about the presence of any long-term complications related to diabetes and other unrelated medical conditions, and how these impacted on the types of exercise in which they could participate. Finally, Section I covered any additional information related to IDDM and exercise, and any feedback or comments related to the questionnaire. This section allowed the subjects to write their answers in the space provided after each of the questions. At the end of Section I, subjects were thanked for their participation, instructed to enclose the completed questionnaire in the envelope provided, and to mail it at their earliest convenience. The questionnaire was pre-tested by two members of the IDAA when it was in the final draft stage of its development. The purpose of pre-testing the questionnaire was to ensure the questions were as clear and concise as possible, and to determine how long it would take a subject to complete the survey. The two volunteers were given two copies of the questionnaire each. They were instructed to complete one of the questionnaires using the instructions provided in the questionnaire package. They were asked to keep track of the time required to complete the questionnaire. The second questionnaire was provided so that comments and suggestions for improvements to the questionnaire package could be made. The constructive criticism provided was used to revise and update the questions, to enhance the clarity of some of the questions, and to eliminate redundancy or ambiguity of other questions. The survey was revised and the final copy was formatted and printed. The IDAA members used to pretest the survey were removed from the IDAA mailing list due to their involvement in the study, as previously indicated. The protocol proposed for this study required 300 surveys to be sent out initially with a reserve list of 25. Due to technical difficulties, the initial 300 questionnaires were sent out 49 in two rounds. On September 11, 1996, 271 questionnaires were mailed out, with the balance of 29 mailed out on September 19, 1996. By September 25, 1996, more than 25 questionnaire packages had been returned that did not qualify for the study, therefore, the additional 25 surveys were prepared and mailed out on that date. 3.1.2 Reminder Postcards Two reminder postcards were developed to remind subjects to complete and return the questionnaires, and to thank those who had already completed and mailed their packages. The postcards were sent out to subjects two and four weeks after the original mailings, or two and four weeks after the supplemental mailing. The first postcard was sent out to all of the subjects, even if their questionnaire had already been returned. The second postcard was only sent out to those respondents whose surveys had not been returned four weeks after each of the mailings. Both of the postcards outlined the purpose and the importance of the study to the understanding of IDDM and exercise. The postcard reminders had the toll free telephone number included, so that the subjects could call and have any of their questions or concerns answered. In addition, subjects were instructed that they could request an additional copy of the survey in the event that it had been misplaced or misdirected in the mail. The front of the postcard contained the subjects full name and address, as well as a return address. The back contained the written information. A l l of the postcards were hand signed in blue ink by the investigator. Please see Appendix B for a copy of the wording and format used for the postcard reminders. The postcards were printed on Avery® Laser Post Cards. 50 The first postcard was sent out to 271 subjects on September 25, 1996, while 29 were sent out on October 01, 1996. An additional 25 postcards were sent out on October 11, 1996 to the remaining subjects. The second postcard reminder was sent out to 109 subjects on October 11, 1996; 19 subjects on October 18, 1996; and 12 subjects on October 23, 1996. 3.1.3 Additional Information An advertisement was sent out to the IDAA in July, 1996 to be included in the Summer 1996 edition of the IDAA newsletter "The Challenge". The purpose of including the advertisement in the newsletter was to introduce the research project to the IDAA membership. The advertisement was designed to promote an increase in the response rate by raising the awareness of the upcoming research project. A copy of the IDAA newsletter advertisement is included in Appendix D. A toll free telephone number was set up to allow subjects to call and have any questions or concerns about the study or questionnaire answered. Telephone calls were answered most days between 9 am and 8 pm, Pacific Time. A telephone log was kept for all of the completed calls. The information contained in the telephone log included the date and time of each call and the reason for the call. A total of 35 calls were received on the toll free line. Of these calls, 29 calls were completed and 6 calls were not answered. See Appendix E for the telephone log. A variety of tables were created in order to keep track of the returned questionnaires. A returns table was kept to record the number of questionnaires returned per day. This table included the date, the number of questionnaires returned, the percent returned, the number of 51 questionnaires that did (Q) and did not (DNQ) qualify for the study, and the adjusted percent return rate. The first questionnaire that qualified for the study was returned on September 17, 1996, six days after the first mail out. Please see Appendix F for the Return Rate Table. A questionnaire return table was kept to track individual questionnaires. This list initially contained the subject number, the questionnaire number, the subject's name, and the status of the questionnaire. The subject's name was included in the original table in order to facilitate telephone inquiries made by the subject, and to assist in the preparation of the second postcard reminder. This list was later revised to exclude the subject's name. The original list was incinerated in order to ensure anonymity and confidentiality of all of the selected subjects. A copy of the revised Questionnaire Return Table can be found in Appendix G. 3.2 Statistical Analysis The data were coded and then analyzed using the SPSS statistical package, after all of the questionnaires had been returned. To ensure consistency in the coding, one section at a time was coded for all of the questionnaires before continuing on to the next section. The following statistical calculations were performed: 1). Descriptive statistics, including frequencies, percentages, means, standard deviations, and ranges, were calculated for the demographic information in Section A of the questionnaire. This analysis provided information on the population of subjects surveyed. 52 Hypothesis 1 was tested using a variety of statistical analyses. Descriptive statistics provided general information on the type and amount of insulin used. Hypothesis 1A (insulin administered by injection) and Hypothesis IB (administrating of insulin by pump) were formally tested using paired, one-tailed t-tests to determine if there was a significant reduction in insulin for exercising days. Hypothesis 2 was tested using a paired, one-tailed t-test to determine if there was a significant increase in CHO consumption on exercising days. Hypothesis 3 was tested using four simple regression analyses to determine if there was a significant positive relationship between the amount of CHO consumed and the duration of the exercise session. Regressions were calculated for the CHO consumed before exercise, CHO consumed during exercise, CHO consumed both before and during, and CHO consumed after exercise. In addition, four analysis of variances were calculated to show the difference in the means for the CHO consumed for each of the aforementioned conditions. Research question 1 was tested using a chi-squared test to determine if the signs and symptoms of hypoglycemia recognized are different while at rest and during exercise. Research question 2 was tested using three, two-tailed t-tests to determine the amount of CHO that was required to treat insulin reactions during exercise and within 24 hours of an exercise session. T-tests were calculated for the CHO consumed for a mild, moderate, and severe insulin reaction. A tally of the food groups used to treat the three severities of insulin reactions were also obtained. 53 7) . For research question 3, descriptive statistics, including frequencies, percentages, means, standard deviations, and ranges, were calculated to determine the number of times subjects tested their B G during exercise, and the number of minutes between tests. 8) . Research question 4 used descriptive statistics, including frequencies, means, and standard deviations, to determine what criteria were used to postpone exercise, and how the criteria to postpone exercise differed between recreational and competitive exercise. 9) . Research question 5 used descriptive statistics, including frequencies and percentages, to determine the number of respondents who ensured that provisions were available in order to exercise safely. 10) . Research question 6 was tested using a series of paired, two-tailed t-tests to determine if there was a difference between the subjects who reported having diabetic complications and each type of diabetic complication. A regression analysis was used to determine if there was a correlation between the number of years with diabetes and the number of long-term diabetic complications. 11) . Research question 7 used descriptive statistics, including frequencies and percentages, to determine what adjustments were made in dietary intake to accommodate unplanned exercise. The level of significance was set at p < 0.05 for all of the statistical tests. 54 CHAPTER 4 RESULTS 4.0 Demographic Information The sample consisted of 325 members of the IDAA who were randomly selected from the members' mailing list. A total of 238 questionnaires were returned, with 87 returned that did not qualify (DNQ) and 151 returned that did qualify (Q) for the study. The response rate for the mailing was 73.2 %, while the adjusted return rate, based on the questionnaires that qualified for the study, was 63.4 %. One of the questionnaires was received incomplete and was included with the DNQ subjects. Of the subjects who DNQ for the study, 20 indicated that they were health professionals, 10 indicated that they were ND, 4 indicated that they were NIDDM, 27 were returned as moved or undeliverable, 1 was returned by a parent stating that the subject was 7 years old, and the remaining 25 did not indicate why they returned the survey unmarked. See return rate table in Appendix F and questionnaire return table in Appendix G. The IDAA had indicated that the membership was comprised of adults, so responses from children and adolescents were not expected. The study was limited to subjects who were 19 years of age or older, therefore, 14 subjects under 19 years of age were removed from the analysis. The youngest under age subject was 9 years old and the oldest under age subject was 18 years old. The data on the under age subjects were coded for analysis as a subpopulation at a later date. Data analysis for this project was based on a total of 137 subjects. The youngest subject included in the study was 19 years of age and the oldest subject was 72 years old. A total of 44 subjects selected from the mailing list were Canadian. There were 22 questionnaires returned that qualified from Canada, representing British Columbia, Alberta, 55 Manitoba, Ontario, and Quebec. There were 281 questionnaires sent to the United States, with 115 returned that qualified for the study, representing 32 states. There were no respondents from the Canadian North, the Maritimes, or from Alaska. There were also two large pockets of the United States missing, including the north central states, and the south eastern states bordering Mississippi. Most of the American questionnaires were returned from the eastern states, the southern seaboard states, and the western seaboard states. The sample consisted of 60 female (43.8 %) and 77 male (56.2 %) subjects. The primary ethnic background of the subjects was Caucasian (131 subjects, 96.3 %). Four other ethnic groups were also represented, including: Asian (1 subject, 0.7 %), Black (2 subjects, 1.5 %), First Nations (1 subject, 0.7 %), and Hispanic (1 subject, 0.7 %). A majority of subjects were married or living common-law (62.0 %). The other subjects were single (27.0 %), divorced or separated (9.5 %), or widowed (1.5 %). Subjects were requested to indicate their latest H b A l c level. The normal range for H b A l c is between 4 % and 7 %, with a value below 110 % of normal considered optimal control, and 140 % of normal considered to be acceptable metabolic control (Brownlee, 1990; Canadian Diabetes Advisory Board, 1992). In the subjects studied 64.2 % were considered to be in optimal control, while 28.5 % were considered to be in acceptable metabolic control. Only 8 subjects (7.3 %) had a H b A l c above 140 % of the normal range. The subjects reported that their lower target H b A l c level was between 3.0 % and 9.0 %, while their upper target range was between 5.0 % and 13.0 %. Most of the subjects had their most recent H b A l c levels analyzed in 1996 (94.9 %), while several subjects had their latest levels tested in 1995 (4.3 %). Only one subject (0.8 %) had his/her latest H b A l c level last determined in 1992. The comparison of H b A l c levels between the subjects was difficult to make due to the different laboratory methods 56 used in the determination of the H b A l c values. The normal H b A l c range for each lab varies depending on the technique used. For the purposes of this study the normal range is 4 % to 7 %, with the optimal and acceptable values of metabolic control calculated based on this normal range (Brownlee, 1990; Canadian Diabetes Advisory Board, 1992). Additional demographic information for the study sample is summarized in Table 1. Table 1: Demographic Information on the IDDM Sample Population Characteristic Mean Standard Deviation Range Age (years) 40.1 11.7 19-72 Height (cm) 172.6 9.6 145.0-191.0 Weight (kg) 70.9 13.0 43.0-119.0 Body Mass Index (BMI) 23.7 3.0 15.6-35.2 Years with IDDM 16.8 11.6 1.0-54.0 H b A l c (%) 7.5 1.4 4.8-12.0 H b A l c (%) target - upper 7.4 1.1 ' 5.0-13.0 H b A I C (%) target - lower 5.7 1.1 3.0-9.0 4.1 Hypothesis 1 It was hypothesized that the insulin dose administered prior to planned exercise would be significantly lower than the insulin dose administered for a non-exercising day. This hypothesis was assessed using paired, one-tailed t-tests. The IDDM population was divided into two groups based on the type of insulin administration used. Of the 137 subjects who were used in this study, 102 (74.5 %) injected their insulin (hypothesis 1A), while 35 (25.5 %) used an insulin pump (hypothesis IB). 57 4.1.1 Hypothesis 1A - Administration Of Insulin By Injection Insulin injection was the most frequent method of insulin administration in this study population. Traditional syringes were used by 72.5 % of the subjects, while 3.9 % used insulin pen injectors, and a further 23.5 % of the subjects used a combination of both traditional syringes and pen injectors. None of the subjects used an insulin jet injector to administer insulin. The number of insulin injections administered per day ranged from 1 to 5 or more times per day. The percentage of people who injected insulin once per day was 2.9 %, twice per day 23.5 %, three times per day 27.5 %, four times per day 32.4 %, and 5 or more times per day 13.7 %. The amount and type of insulin injected on a non-exercising day is summarized in Table 2. Table 2: The Amount of Insulin Used on Non-Exercising Days Type of Insulin No. of Subjects Mean (units) Standard Deviation Range (units) Short Acting 90 16.9 10.0 2.0-51.0 Intermediate Acting 72 22.4 10.7 1.5-48.0 Long Acting 34 16.4 9.8 4.5-48.0 Split Mix 4 33.0 12.9 20.0 - 50.0 Total Used 102 37.8 14.3 6.0-91.0 The insulin dose prior to exercise was adjusted by 58 (56.9 %) of the subjects, while 44 (43.1 %) of the subjects indicated that they did not adjust the insulin dose prior to planned exercise. Of the subjects who reported adjusting their insulin, 7 subjects reported that the amount of insulin reduced prior to planned exercise was dependent on the type and duration of the exercise session, 6 reported that the amount of insulin administered depended on the B G reading prior to administration, and 1 reported that they only reduced insulin for competition. Of the 40 subjects who reported a reduction in the insulin dose prior to exercise, 35 subjects reported reducing the short acting insulin by an average of 4.8 units, 10 reported reducing 58 intermediate acting insulin by 8.6 units, and 5 reported reducing long acting insulin by 3.2 units. Of these subjects, 25 reduced short acting insulin only, 3 reduced intermediate insulin only, 2 reduced long acting insulin only, 7 subjects reported adjusting both short and intermediate insulin, and 3 subjects reported adjusting short and long acting insulin. The four subjects who used split mix insulin did not adjust the insulin dose before planned exercise. Table 3 summarizes the amount of insulin reduced prior to planned exercise. Table 3: The Decrease in the Amount of Insulin Used On Exercising Days Type of Insulin No. of Subjects Mean (units) Standard Deviation Range (units) Short Acting 35 4.8 4.0 1.0-15.5 Intermediate Acting 10 8.6 7.2 1.0-24.0 Long Acting 5 3.2 3.0 1.0- 8.0 Total Reduction 40 6.7 6.8 1.0-31.5 Hypothesis 1A was assessed using paired, one-tailed t-tests to determine if the insulin administered prior to planned exercise was significantly lower than the insulin administered for a non-exercise day. The amount of short acting insulin adjusted prior to exercise was significantly lower (p < 0.001) than the amount of short acting insulin used on a non-exercising day. Similarly, before exercise the amount of intermediate acting insulin was also significantly lower (p = 0.006) than the same type of insulin used on a non-exercising day. Although the reduction in long acting insulin prior to physical activity was not as large, the reduction was still significant (p = 0.042). None of the four subjects who used split mix insulin adjusted their dosage before planned exercise. The reduction in the total amount of insulin used for an exercising day compared to a non-exercising day was significant (p < 0.001). A summary of the paired, one-tailed t-tests for hypothesis 1A appears in Table 4. 59 Table 4: Summary of Paired, One-Tailed T-Tests For Insulin Injection Type of Insulin Mean (units) Standard Deviation P Value Significant Usual Exercise Usual Exercise Short Acting 15.7 11.7 10.4 9.3 p< 0.001 yes Intermediate Acting 14.4 12.3 14.9 13.2 p = 0.006 yes Long Acting 7.1 6.7 9.2 9,0 p = 0.042 yes Total Insulin 37.2 30.8 14.1 13.2 p< 0.001 yes 4.1.2 Hypothesis IB - Administration Of Insulin By Pump Insulin was administered using SCII by 35 of the subjects surveyed. The average basal insulin used on a non-exercising day was 26.5 units, while the average total bolus used was 15.0 units. The amount of insulin infused on a non-exercising day is summarized in Table 5. Table 5: The Amount of Insulin Infused on Non-Exercising Days Type of Insulin No. of Subjects Mean (units) Standard Deviation Range (units) Basal Infusion 35 26.5 12.2 3.5-68.2 Bolus Dose 24 15.0 6.7 4.1-30.0 Total Used 35 36.7 16.8 8.5-97.2 The insulin dose prior to exercise was adjusted by 30 (85.7 %) of the subjects who used the insulin pump. Before exercise, 6 (20.0 %) subjects reported adjusting the bolus dose, 8 (26.7 %) subjects reported adjusting the basal dose, and of these subjects, 16 (53.3 %) reported adjusting both the basal and bolus doses. There was incomplete or missing data for 11 of the subjects. Table 6 has the summary of the reduction in the insulin dose. There were 16 (45.7 %) subjects who disconnected their pump during exercise. A multiple response question was used to determine the reasons that the insulin pump was 60 disconnected during exercise. There were a total of 25 (166.7 %) responses given. Since more than one response could be given, the percentage was greater than 100. The most frequently cited reason for disconnecting the pump during exercise was increased risk of hypoglycemia. Thirteen subjects (86.7 %) indicated that this was one reason to disconnect the pump. Other reasons identified included: pump got in the way (40.0 %), pump could get damaged (33.3 %), and risk of injury to the needle site (6.7 %). Table 6: The Decrease in the Amount of Insulin Used On Exercising Days Type of Insulin No. of Subjects Mean (units) Standard Deviation Range (units) Basal Infusion 20 1.7 2.6 0.3 - 9.0 Bolus Dose 14 1.8 1.1 0.3 - 4.5 Total Reduction 19 2.3 2.7 0.3 - 12.0 Analysis of the data using one-tailed, paired t-tests determined that there was a significant reduction in the amount of insulin used for exercise in the subjects who used the insulin pump. The basal infusion rate was decreased an average of 1.7 units over the duration of the exercise session. When the infusion rate during exercise was compared to the usual infusion rate, there was a significant reduction (p = 0.024) in the amount of insulin infused. The pre-exercise bolus insulin dose was reduced a mean of 1.8 units. The bolus insulin dose was also significantly reduced (p < 0.001) prior to planned exercise. The total amount of insulin reduced for exercise was, therefore, also significantly reduced (p < 0.001) from the non-exercise dose by a mean of 2.3 units. Results of the paired, one-tailed t-tests for hypothesis IB are summarized in Table 7. 61 Table 7: Summary of Paired, One-Tailed Probability T-Tests For Insulin Pump Type of Insulin No. of Subjects Mean (units) Standard Deviation P Value Significant Usual Exercise Usual Exercise Basal infusion 11 26.4 24.6 16.1 15.9 p = 0.024 yes Bolus Dose 13 14.1 12.3 4.4 4.4 p< 0.001 yes Total Used 19 38.5 36.2 18.5 18.2 p < 0.001 yes 4.2 Hypothesis 2 It was hypothesized that there would be a significant increase in CHO intake on exercising days. Subjects were requested to write down the number of servings of each food group that they consumed on a non-exercising day. The CHO equivalent was then calculated for each food group. The average energy intake on a non-exercising day was 2195 kcals, with a range of 1200 to 5000 kcals per day. The mean CHO intake for a non-exercising day was 224.0 grams, with a range from 100 grams to 473 grams per day. The CHO intake for an exercising day was determined by asking the subjects to indicate the number of extra servings of each food group that they consumed. Again, the CHO equivalent was calculated for each of the food groups. The mean increase in CHO consumption was 56.8 grams, with a range of 10 to 403 grams per day. Nine subjects indicated that they did not increase the amount of CHO on an exercising day. Of these subjects 3 reported that they exercised every day so there were no non-exercising days for comparison, and 3 subjects reported that they adjusted the pre-exercise insulin dose rather than increasing food intake for exercise. The analysis of the data for this section was based on a sample of 64 subjects (46.7 %). The first part of the dietary intake section (Section D) was not completed well by more than half 62 of the subjects who participated in this study. In order to obtain accurate results for this hypothesis, only the subjects who completed the questions referring to usual daily non-exercise food intake and extra food consumed for exercise were used in the data analysis. Hypothesis 2 was tested using a one-tailed, paired t-test and determined that the amount of CHO consumed on an exercising day was significantly greater (p < 0.001) than the amount consumed on a non-exercising day. 4.3 Hypothesis 3 It was hypothesized that there would be a significant positive relationship between the amount of CHO consumed and the duration of the exercise session. A reference sport was chosen by each of the subjects including the type of sport, the number of times per week, the duration of each exercise session, and the target heart rate. The subjects surveyed participated in the reference sport on average 4.2 times per week, with a range of 1 to 12 times per week. The duration of the exercise sessions averaged almost an hour and a half per session (88.5 minutes). There were peak frequencies at 30 minutes (7 subjects), 45 minutes (12 subjects), 60 minutes (24 subjects), 90 minutes (17 subjects), and 120 (10 subjects) minutes. A target heart rate was obtained for 34 subjects and the mean target heart rate was 146, ranging from 115 to 190 beats per minute (bpm). The descriptive statistics for the reference sport are summarized in Table 8. Table 8: Summary Information on the Reference Sport Reference Sport No. of Subjects Mean Standard Deviation Range No. of Times/Week 112 4.2 1.8 1.0-12.0 Duration/Session (min.) 107 88.5 66.8 13.0-510.0 Target Heart Rate (bpm) 34 146 16.6 115 - 190 63 Subjects were requested to write down the type and amount of food and beverages that they consumed before, during, and after their reference sport. There were a total of 112 subjects (81.8 %) that completed this part of Section D well, and were included in the data analysis. The CHO content of the foods and beverages were then calculated. The mean total CHO consumed before exercise was 34.3 grams, with the range between 5 and 130 grams. During exercise there was an average of 39.9 grams of CHO consumed, with a range of 3 to 207 grams. After exercise there was a mean total of 32.2 grams consumed, with a range of 5 to 115 grams of CHO consumed. Table 9 summarizes the amount of CHO consumed in food and beverages before, during, and after exercise. Table 9: Grams of CHO Consumed Before, During, and After Exercise Exercise Mean (grams) Standard Deviation Range (grams) Food Drink Total Food Drink Total Food Drink Total Before 28.7 20.6 34.3 21.0 10.7 25.0 5 - 130 8-43 5 - 130 During 27.9 37.4 39.9 20.2 36.4 37.3 3-88 8 - 192 3-207 After 25.6 28.0 32.2 15.3 20.3 21.5 5-90 10-55 5 - 115 Hypothesis 3 was tested using simple regression analysis to determine if there was a significant positive relationship between the amount of CHO consumed and the duration of the exercise session. A regression was calculated for each of the following consumption measures: CHO consumed before exercise, CHO consumed during exercise, CHO consumed both before and during exercise, and CHO consumed after exercise. For the respective consumption measures, Figures 1, 2, 3, and 4 show mean CHO consumption as a function of exercise duration. Corresponding to each figure, a one-way analysis of variance was used to test significance of the 64 mean CHO differences for the duration intervals as shown. Table 10 summarizes these analysis of variance results. There was a weak positive linear correlation between the amount of CHO consumed before the exercise session, and the duration of the exercise session (r = 0.42; p < 0.001). As the duration of the exercise session increased, the amount of CHO consumed before exercise also increased. For every minute of exercise there was an additional 0.16 grams of CHO consumed. Therefore, for every 60 minutes of exercise there was a mean increase of 9.6 grams of CHO consumed before exercise. The CHO consumed during exercise also increased significantly with an increase in the duration of the exercise session (r = 0.19; p = 0.046). As the duration of the exercise session increased the amount of CHO consumed during exercise also increased, resulting in a 0.09 gram increase in CHO consumption for every minute of exercise. For every hour of exercise there was an increase of 5.4 grams of CHO consumed during exercise. The regression also showed that the combined amount of CHO consumed before and during exercise had a significant positive linear relationship to duration of exercise (r = 0.35; p < 0.001). The amount of CHO consumed per minute of exercise was 0.25 grams, resulting in a 15.0 gram increase in CHO consumed before and during exercise for a one hour exercise session. However, there was no significant correlation between the amount of CHO that was consumed after the exercise session and the duration of the exercise session (r = 0.017; p = 0.859). The amount of CHO consumed after exercise was the same irrespective of the duration of the reference activity. There was 0.006 grams of CHO consumed per minute of exercise after the exercise session. The amount of CHO consumed after exercise was 0.36 grams per hour of exercise. 65 0 - 30 31 - 4 5 46 - 60 61 - 90 91 - 120 Exercise Duration (minutes) 120 Figure 1. Pre-exercise CHO consumption and the duration of the reference sport. The mean CHO intake from food and beverages before exercise for each incremental increase in exercise duration. The number within the bars indicates the number of subjects in each group. 50 "JS 40 42.6 28.6 20.7 -«-1 r r" . 11.5 -+-12.1 — 0.6 16 • 30 23 15 —t-14 0 - 30 31 - 4 5 46 - 60 61 - 90 91 - 120 120 + Exercise Duration (minutes) Figure 2. The amount of CHO consumed during exercise and the duration of the reference sport. The mean CHO intake from food and beverages during exercise for each incremental increase in exercise duration. The number within the bars indicates the number of subjects in each group (missing value for 0 - 30 minutes was 9 subjects). 66 U) E re re k_ •o >, JZ o re O 100 90 80 4-70 • -60 50 40 30 20 10 T 7 . 3 •+-32.2 16 35.2 30 46.7 •+-23 15 • -+-94.7 0 - 30 31 - 45 46 - 60 61 - 90 91 - 120 120 Exercise Duration (minutes) Figure 3. The amount of CHO consumed before and during exercise, and the duration of the reference sport. The mean CHO intake from food and beverages before and during exercise for each incremental increase in exercise duration. The number within the bars indicates the number of subjects in each group. (A E re TO » 2 T3 >. f O £1 L _ re O 0 - 30 31 - 45 46 - 60 61 - 90 91 - 120 Exercise Duration (minutes) 120 + Figure 4. Postexercise CHO consumption and the duration of the exercise session. The mean CHO intake from food and beverages after exercise for each incremental increase in exercise duration. The number within the bars indicates the number of subjects in each group. 67 Table 10: Summary of ANOVAs for Total CHO Consumed and Duration of Exercise Summary of F-statistic P Value Significant Before Sport F = 3.88* p = 0.003 yes During Sport F = 2.96** p = 0.016 yes Before & During Sport F = 4.67* p< 0.001 yes After Sport F = 0.05 p = 0.998 no * F crit ical a = 0 0 1 . 5 . 1 2 0 = 3.17; ** F crit ical a = 0 0 5 ; 5 . 1 2 0 = 2.29 The analysis of the data using four simple regression analyses determined that there was a weak positive linear correlation between the amount of CHO consumed and duration of exercise for CHO before exercise (r = 0.42; p < 0.001), during exercise (r = 0.19; p = 0.046), or combining before and during exercise (r = 0.35; p < 0.001). There was no significant positive linear relation between the amount of CHO consumed after exercise and the duration of the exercise session (r = 0.017; p = 0.859). 4.4 Research Question 1 A multiple response question was set up to determine if the signs and symptoms of hypoglycemia recognized were different while at rest or during exercise. At rest there were, on average, 5 signs and symptoms recognized. The signs and symptoms recognized most frequently during rest were excessive sweating (67.9 %), confusion (62.0 %), and shaking/trembling (56.2 %). Three subjects reported that they did not recognize the onset of a hypoglycemic episode while at rest. During exercise the subjects recognized, on average, 3 signs and symptoms of hypoglycemia. The most frequent symptoms recognized during activity were weakness (64.2 %), loss of coordination (40.1 %), and confusion (35.8 %). Nine subjects reported that they were hypoglycemic unaware during exercise. Of the nine subjects who were 68 hypoglycemic unaware during exercise, only one was also hypoglycemic unaware at rest. The signs and symptoms of hypoglycemia that were recognized both when exercising and at rest, and at rest but not while exercising are summarized in Table 11. Table 11: Signs and Symptoms of Hypoglycemia Recognized At Rest and During Exercise Symptom Number of Cases S/S of Both* S/S of Usual** Usual Exercise Number Percent Number Percent Hunger 53 26 24 45.3 29 54.7 Nausea 14 9 5 35.7 9 64.3 Headache 29 13 9 31.0 20 69.0 Shaking/Trembling 77 48 43 55.8 34 44.2 Blurred Vision 49 30 21 42.9 28 57.1 Dizziness 25 18 11 44.0 14 56.0 Drowsiness 43 11 11 25.6 32 74.4 Weakness 68 88 54 79.4 14 20.6 Loss of Coordination 38 55 25 65.8 13 34.2 Numb Lips/Tongue 44 18 15 34.1 29 65.9 Confusion 85 49 42 49.4 43 50.6 Anxiety 40 15 12 30.0 28 70.0 Excessive Sweating 93 33 31 33.3 62 66.7 Other 25 21 7 28.0 18 72.0 Cannot Recognize 3 9 1 33.3 2 66.7 * S/S of Both = The signs and symptoms that are recognized at rest and during exercise; ** S/S of Usual = The signs and symptoms that are recognized at rest but not while exercising. 4.5 Research Question 2 The goal of research question 2 was to determine how much, and what type of food groups were required to treat a mild, moderate, and severe insulin reaction, both during exercise and within 24 hours following an exercise session. This question was assessed using three, 69 two-tailed t-tests to determine the amount of CHO that was used to treat an insulin reaction during exercise and within 24 hours following an exercise session. There was significantly more CHO consumed within 24 hours following an exercise session to treat a mild insulin reaction (p = 0.027). There was a slight increase in the amount of CHO that was consumed for moderate and severe insulin reactions within 24 hours following an exercise session. The difference for moderate (p = 0.080) and severe (p = 0.627) insulin reactions, however, did not reach significance. Table 12 summarizes the means, standard deviations, and t-test results for the amount of CHO required to treat a mild, moderate, and severe insulin reaction. Table 12: Summary of the Amount of CHO Required To Treat An Insulin Reaction Reaction Severity No. of Subjects Mean (grams) Standard Deviation P Value Significant Usual Exercise Usual Exercise Mild 66 27.7 23.8 17.8 18.7 0.027 yes Moderate 54 33.9 30.5 21.9 19.8 0.080 no Severe 13 43.0 39.4 25.4 22.9 0.627 no The food groups used to treat an insulin reaction were tallied based on the severity of the insulin reaction. The starch, fruit/vegetable, and sugars food choices were the food groups that were used the most in treating an insulin reaction. Table 13 shows the tally of the food groups used to treat a mild, moderate, and severe insulin reaction during exercise and within 24 hours of an exercise session. A multiple response question was used to determine the number of food groups that were consumed to treat an insulin reaction, therefore, more than one food group could be used to treat an insulin reaction. The starch and fruit/vegetable choices were used more frequently within 24 hours of an exercise session. The sugars choice was used more frequently during exercise for mild, and moderate insulin reactions. 70 Table 13: The Number of Subjects Who Used Each Food Group To Treat An Insulin Reaction Food Group Grams of CHO Mild Reaction Moderate Reaction Severe Reaction Usual Exercise Usual Exercise Usual Exercise Starch 15 110 83 82 57 22 13 Fruit/V egetable 10 127 90 105 99 32 21 Milk 6 26 16 35 28 5 6 Protein 0 16 4 10 5 2 0 Fats/Oils 0 0 7 0 2 3 2 Free 2.5 13 12 11 11 2 0 Sugars 10 31 88 31 66 27 22 Mixed Foods Varies 43 29 52 31 18 7 None Specified - 23 52 23 50 9 94 4.6 Research Question 3 Research question 3 set out to determine how often B G was measured during exercise. Subjects were asked how many times during exercise they tested their B G and how much time elapsed between tests. There were a total of 32 subjects who indicated how many times during exercise they tested their BG. Of these 32 subjects, 18 (56.3 %) tested once, 10 (31.3 %) tested twice, 2 (6.3 %) tested three times, 1 (3.1 %) tested four times, and 1 (3.1 %) tested five times. The mean number of tests during exercise was 1.7 times. The time between tests ranged from 15 minutes to 120 minutes, with a mean of 53.1 minutes between tests. There were peak frequencies at 30 minutes (7 subjects), 45 minutes (10 subjects), and 60 minutes (6 subjects) of exercise. 71 4.7 Research Question 4 The goal of research question 4 was to determine the criteria to postpone exercise, and to determine if the criteria to postpone exercise differed between recreational and competitive events. Forty-one of the subjects reported that they did not compete. For recreational exercise only 16 subjects postponed exercise, 4 did not postpone exercise, 16 postponed exercise for treatment, 4 postponed exercise only when i l l , and 1 subject did not indicate a reason for postponing exercise. Of the subjects who participated in both recreation and competition, 29 subjects postponed exercise, 1 subject did not postpone exercise, 11 subjects postponed exercise only for treatment, and 7 subjects postponed exercise only when il l . Five subjects reported that they would postpone exercise for recreation, but continue exercise when competing. Two of the subjects who competed indicated that they would postpone exercise when competing only for treatment. The B G levels used to postpone exercise were obtained for both the upper and lower levels. The mean low B G level used to postpone exercise during recreation was 5.2 mmol/L, while the low B G level used to postpone exercise during competition was 4.9 mmol/L. The mean high B G level used to postpone exercise for recreation was 14.5 mmol/L, while the high B G level used to postpone exercise for competition was 15.2 mmol/L. The presence of urinary ketones was an indication for postponing exercise by 7 subjects for both competition and recreation. Most of the subjects (101) did not indicate that the presence of urinary ketones was a factor that they considered when deciding to postpone exercise when hyperglycemia was present. 72 4.8 Research Question 5 Research question 5 was designed to determine the percentage of respondents who ensured provisions were available in order to exercise safely. There were 88 (64.2 %) subjects who always wore a diabetic ID necklace or bracelet during exercise. Thirty-nine (28.5 %) subjects reported never wearing diabetic ID during exercise. The primary reason why diabetic ID was not worn was because subjects did not have one. Some of the other reasons cited were: ID could get caught on clothing or other objects (10 subjects), ID could hurt subject or another person (6 subjects), and referees wanted the ID removed (1 subject). Refer to Table 14 for the number and percent of subjects who used diabetic ID and other safety provisions during exercise. A sugar source was always available during exercise for 98 (71.5 %) of the subjects. The most frequently reported reason that sugar was not available was that the subject was B G stable at the time of exercise (21 subjects). Other reasons included: forgot (13 subjects), difficult to carry (6 subjects), subject chose not to (3 subjects), and subject would get help if needed (3 subjects). Subjects were also asked how often they had a B G meter or visual B G strips available during exercise. The responses for this question were spread over the 5 possible percentage categories (0 %, 25 %, 50 %, 75 %, and 100 %). Thirty-six subjects (26.5 %) reported that a meter was always available, while 40 subjects (29.4 %) reported that a meter was never available during exercise. There were numerous reasons that a B G meter was not available during exercise. Some of these responses included: difficult to carry (43 subjects), chose not to (20 subjects), only for extended exercise sessions (16 subjects), B G was stable during exercise (15 subjects), and subject was aware of the onset of hypoglycemia (10 subjects). 73 Subjects were asked if they frequently exercised alone. There were 102 subjects who reported frequently exercising alone. Of these subjects, 34 (34.0 %) reported always telling someone where they were going and when they would be back. Again, the number of subjects who reported not telling someone where they were going was spread evenly over the 5 percentage categories. The primary reason that the subjects did not tell someone where they were going was because they lived alone (47 subjects). Other reasons included: no babysitter needed (14 subjects), B G stable (5 subjects), forgot (4 subjects), carried safety supplies during exercise (3 subjects), and exercised near people (1 subject). Table 14: Summary of the Number and Percent of Subjects Who Exercise Safely Safety Factor Used Percent of Subjects Who Exercise Safely 100 % 75% 50% 25 % 0 % No. % No. % No. % No. % No. % Diabetic ID 88 64.2 5 3.6 1 0.7 4 2.9 39 28.5 Sugar Present 98 71.5 23 16.8 7 5.1 7 5.1 2 1.5 Meter Present 36 26.5 19 14.0 12 8.8 29 21.3 40 29.4 Inform Others 34 34.0 11 11.0 19 19.0 17 17.0 19 19.0 4.9 Research Question 6 Research question 6 determined if there was a correlation between the number of years with diabetes and the number of long-term complications. Section H of the questionnaire was used to determine how many subjects had long-term complications, and if yes, the type(s) of complications present. Of the total sample, 96 subjects (70.1 %) reported that they did not have any diabetic related complications, while 41 (29.9 %) indicated that they had complications. There were 20 subjects who reported having 1 complication, 10 reported having 2 complications, 74 6 reported having 3 complications, while 4 subjects reported having 4 complications, and 1 reported having 5 complications. On average, these subjects reported having 2 complications. The most frequently cited complications were: retinopathy (22 subjects), neuropathy (17 subjects), hypertension (10 subjects), and foot problems (8 subjects). Table 15 summarizes the number, means, standard deviations, and the t-test values of the subjects who reported having complications. A series of paired, two-tailed t-tests were performed to determine if there was a difference between the subjects who reported having diabetic complications and each type of diabetic complication. There was no significant difference noted for any of the complications studied. A regression analysis determined that there was no correlation between the number of years with diabetes and the number of diabetic complications present (r = - 0.16). Table 15: Summary of Diabetic Complications Versus the Number of Years With Diabetes Complication No. of Subjects Mean Std. Deviation P Value Significant Yes No Yes No Retinopathy 22 26.8 21.2 14.0 13.0 0.19 No Nephropathy 6 21.8 24.6 10.0 14.3 0.65 No Neuropathy 17 20.8 26.9 13.1 13.8 0.19 No Hypertension 10 23.5 24.4 12.6 14.2 0.86 No Postural Hypotension 7 25.6 23.9 7.6 14.7 0.77 No Heart Disease 3 15.7 24.9 16.3 13.4 0.27 No Hyperlipidemias 3 11.0 25.2 8.5 13.5 0.08 No Skin Problems 3 16.0 24.8 17.3 13.4 0.29 No Foot Problems 8 24.3 24.2 18.5 12.6 0.99 No 75 4.10 Research Question 7 The final research question was asked to determine what adjustments were made in dietary intake to accommodate unplanned exercise. The survey question was open-ended and the information obtained was not specific enough to draw any conclusions. Four basic questions were addressed. Firstly, subjects were asked if they participated in unplanned exercise. A total of 132 subjects answered this question, with 116 answering in the affirmative, and 16 answering in the negative. Secondly, some information was obtained on the adjustments to diet, insulin, and B G monitoring. A total of 99 subjects reported adjusting diet, 50 reported adjusting insulin, and 53 reported testing B G more. More information may have been obtained if the open-ended question had been a series of short answer or fill-in-the-blank type questions. 76 CHAPTER 5 DISCUSSION 5.0 Introduction The primary purpose of this study was to determine the adjustments that were made in insulin and diet to accommodate planned exercise in active people with IDDM. Section B of the questionnaire was designed to determine the method of insulin administration, the type of insulin used, and the amount used for both non-exercising and exercising days. Section D provided information on the dietary intake for a typical non-exercising day, a typical exercising day, and the amount of food and beverages consumed during a specific reference activity. Analysis of the data contained in these sections provided information on the adjustments that were made in dietary and insulin changes for exercise. A secondary purpose of the study was to obtain other information on the adjustments and precautions that were taken by active individuals with IDDM in order to participate in exercise. In addition to the three hypotheses, seven research questions were asked to determine: how often B G was monitored during exercise, how much CHO was used to treat insulin reactions, the signs and symptoms of hypoglycemia that were recognized at rest and during exercise, what criteria were used to postpone exercise, how many subjects ensured that they exercised safely, how many subjects had long-term complications, and what adjustments to dietary intake were made to include unplanned exercise. 77 5.1 Questionnaire Return Rate The adjusted response rate was 63.4 % with 137 subjects qualifying for the study. The anticipated return rate was 75.0 %. Although the total return rate (73.2 %) approached the estimated rate, this study fell short of the anticipated number of completed questionnaires returned. The number of subjects who moved or had undeliverable addresses were greater than anticipated, since only an additional 25 questionnaires were sent out to cover questionnaires returned unmarked for any reason. In addition, the number of Health Professionals, ND, and NIDDM subjects were greater than that estimated by the IDAA. A total of 87 questionnaires were returned unmarked by the subjects. Although the adjusted return rate was disappointing, the number and return rate of the questionnaires was considered to be good when compared to the overall return rate of mailed questionnaires (Dillman, 1978). Since a modification of the Total Design Method (Dillman, 1978) for mailed survey research was used, the return rate was well within the acceptable range. See Appendix F for the return rate table. A majority of the questionnaires were returned with complete or near complete data. In some of the questionnaires data were not specific or detailed enough to properly code, therefore, these questions were omitted from the data analysis. Section D, designed to obtain information on dietary intake, had the highest proportion of missing or incomplete answers. A selecting code was entered into both parts of this section to select only those subjects who completed that part well. The data were analyzed for these subjects only. The difficulty with this section was twofold. Firstly, the open-ended questions could have been worded differently in order to obtain more complete information. Open-ended questions are generally used in questionnaires where the answers to the questions are unanticipated or non-exhaustive (Bourque and Fielder, 1995). In numerous open-ended questions in this survey, several answers were 78 required per question requiring the subject to carefully read and respond to all of the requests made for information. Closed-ended questions are more efficient, easier for the subject to complete, and the answers tend to be more complete and reliable than open-ended questions (Fink, 1995). In parts of the questionnaire where the data were incomplete or missing, a combination of short and specific fill-in-the-blank type questions, and closed-ended questions would have produced better results. In other sections of the survey that used this approach, a higher or total completion rate was noted. Secondly, the nutrition knowledge of the exact type, number, and size of food servings consumed on a daily basis could be lacking in this population, particularly in the United States where health care, including nutritional counseling, is costly. Past personal experience with people with IDDM indicated that they were aware of the food required to maintain adequate metabolic control. They were, however, unable to accurately estimate the food group, number, and size of portions as it relates to either the national food guide or the diabetic food choices system. This appears to be especially evident in people who have had diabetes for an extended period of time, where they have a 'feel' for the effects of food intake on B G levels. The latter explanation appears to be the case since the first part of Section D was not completed well, while the second part of this section had a greater number of completed answers. The first part of Section D, used closed-ended and fill-in-the-blank type questions to determine the number of servings of each food group. The second part of Section D obtained information on the food and beverages consumed before, during, and after exercise. See Appendix A , Section D of the questionnaire pages 9 to 12. 79 5 . 2 H y p o t h e s i s 1 It was hypothesized that the insulin dose administered prior to planned exercise would be significantly lower than the insulin dose administered for a non-exercising day. There was a significantly lower amount of insulin administered on an exercising day, both for subjects who injected their insulin and subjects who used an insulin pump. Hypothesis 1 is discussed separately due to the different recommendations for insulin adjustments in the literature, and the different physiological profiles of insulin injection (hypothesis 1 A) and insulin pump (hypothesis IB) use. 5.2.1 H y p o t h e s i s 1A Forty of the 58 subjects who reported adjusting their injected insulin dose prior to exercise significantly decreased their total insulin dose on an exercising day (p < 0.001), compared to a non-exercising day. There were also significant reductions in short acting insulin (p < 0.001), intermediate acting insulin (p = 0.006), and long acting insulin (p = 0.042). None of the four subjects who administered split mix insulin adjusted their insulin dose prior to planned exercise. Review Table 4 in Chapter 4 for a summary of the results. A reduction in the amount of insulin administered prior to planned exercise was anticipated in order to reduce the risk of hypoglycemia. In the ND population the level of insulin drops during exercise with a concurrent increase in glucagon and catecholamine levels (Zinman and Vranic, 1985; Wasserman and Abumrad, 1989; Franz, 1992). This observed change in the energy regulating hormones facilitates the change in endogenous fuels used from reliance on muscle glycogen stores, to blood-borne glucose and FFAs, and then to a greater reliance on FFAs to match the energy used by the 80 working muscles as the duration of exercise increases (Wahren et al, 1978; Wasserman and Abumrad, 1989; Franz, 1992; Koivisto et al, 1992). In the individual with IDDM insulin is not under physiological control, therefore, careful attention to the level of serum insulin during exercise is important. In order to mimic the hormonal and energy substrate shifts seen in a ND, the individual with IDDM must reduce the exogenous insulin administration to provide a low but permissive insulin level (Wallberg-Henriksson, 1989; Sutton, 1991). If the relative or absolute insulin levels are elevated during exercise, the risk of hypoglycemia during and after exercise is increased (Zinman and Vranic, 1985; Franz, 1992; Hough, 1994). Schiffrin and Parikh (1985) studied four different insulin reductions during exercise in 13 adolescent male subjects. They concluded that a decrease of 30 to 50 percent of the usual insulin dose was sufficient to maintain near normal B G levels during and after exercise. The subjects in this study reduced only the pre-breakfast regular insulin dose, as the intermediate acting insulin was given in one dose either before supper or bed (Schiffrin and Parikh, 1985). Horton (1988) also recommended that the short acting insulin dose be reduced by 30 to 50 percent prior to planned exercise. In the current study 25 subjects reduced only their short acting insulin, which represented a 29.1 % decrease (4.9 units). For all of the subjects who decreased short acting insulin, the average reduction was 28.4 % (4.8 units). The data obtained in this study supports the 30 % reduction in insulin dose prior to planned exercise recommended by the aforementioned researchers. Other researchers have also given recommendations for the adjustment in insulin required prior to planned exercise when short and intermediate acting were combined, and when only intermediate acting insulin was used. Vitug and Coworkers (1988) recommended when short and intermediate acting insulins were combined, the short acting insulin could be omitted before 81 exercise. They also recommended that when only intermediate acting insulin was used, the pre-exercise dose should be reduced by 30 to 40 percent (Vitug et al, 1988). Horton (1988) recommended that the short acting insulin be reduced by 50 to 100 percent when a combination of short and intermediate acting insulins were administered. For individuals who only used intermediate acting insulin the morning dose should be reduced by 30 to 35 percent (Horton, 1988). Due to the low number of subjects used to determine the reduction in insulin dose, a comparison of the insulin regimen and the type of insulin reduced with exercise would provide limited additional information. This study did, however, determine that there was a reduction of 38.4 % in intermediate acting insulin used prior to exercise. There were three subjects who adjusted only the intermediate insulin, while seven subjects adjusted both the short and intermediate acting insulins prior to planned exercise. There were no recommendations in the literature that suggested long acting insulin be reduced for exercise. Interestingly, two subjects reported decreasing only their long acting insulin, while three subjects reported decreasing both their short and long acting insulins. There was a 9.7 % (3.2 unit) reduction in the long acting insulin administered prior to planned exercise. There were 34 subjects who reported using long acting insulin on non-exercising days with the mean dose of 16.4 units per day. The long acting insulin used has an onset of 4 hours, a peak duration of 8 to 24 hours, and a maximum duration of 28 hours (Canadian Pharmaceutical Association, 1996). The reduction in B G due to the action of long acting insulin will occur hours after the exercise session has been completed. A reduction in the long acting insulin prior to planned exercise may help to prevent late-onset, postexercise hypoglycemia. A reduction in the long acting insulin was not anticipated in this population since none of the research or review 82 articles that have made recommendations for insulin adjustment for exercise included long acting insulin. Similarly, there is no literature on the adjustments that a person taking split mix insulin should make prior to planned exercise. None of the 4 subjects who used split mix insulin adjusted their insulin prior to planned exercise, therefore, there was a non-significant decrease in this type of insulin administered. The reduction in the total amount of all three types of insulin used on an exercising day was significantly lower than the insulin administered on a non-exercising day (p < 0.001). The total insulin reduction was 17.7 % of the usual insulin administered for a non-exercising day. There were 14 subjects who did not report an actual quantity and type of insulin that they reduced for exercise. They indicated that the reduction in the amount of insulin varied depending on the duration and the type of sport that they were participating in, the B G level before insulin administration, and the level of competition. For these subjects a reference sport such as the one used for the dietary adjustments before, during, and after exercise (Hypothesis 3) would have given additional information on the insulin adjustments that were made. The pre-exercise insulin dose was not adjusted by 44 (34.1 %) of the subjects who injected their insulin. A question was not included in the survey to obtain information on the reasons that insulin was not adjusted prior to planned exercise by these subjects. Possible reasons that could have been cited include: subjects exercised every day so adjustments in insulin were not needed, subjects consumed CHO instead of decreasing insulin to prevent hypoglycemia, and subjects exercised only after a meal so they did not require a decrease in insulin. Additional information outlining why the insulin dose was not decreased would have been beneficial in the analysis of the data. 83 The data supported the hypothesis that the insulin dose administered prior to planned exercise would be significantly lower than the insulin dose administered for a non-exercising day. There was, however, no change in the split mix insulin dose from a non-exercising day to an exercising day. 5.2.2 Hypothesis IB It was hypothesized that there would be a reduction in the amount of insulin infused on an exercising day. The total insulin dose for subjects who used SCII for insulin administration was significantly lower (p < 0.001) on an exercising day than the insulin infused on a non-exercising day. Thirty of the 35 subjects who reported using an insulin pump decreased the insulin administered on an exercising day. On an exercising day the basal infusion rate and the bolus dose were also significantly reduced (p = 0.024 and p < 0.001, respectively). Review Table 7 in Chapter 4 for a summary of the t-test results for the insulin pump. The rationale for reducing the pre-exercise insulin dose for subjects using SCII was the same as previously discussed in hypothesis 1A for subjects who injected their insulin. A reduction in serum insulin during exercise would facilitate the hormonal and fuel substrate shifts to permit optimal energy substrate availability during exercise. The most important purpose for reducing the insulin dose is to prevent hypoglycemia related to exercise (Horton, 1988; Vitug et al, 1988; Wasserman and Abumrad, 1989; Hough, 1994). The recommendations for reducing insulin prior to exercise for insulin pump users were quite varied. Vitug and Colleagues (1988) recommended that the pre-exercise meal bolus insulin dose be eliminated prior to planned exercise and the basal infusion rate be maintained. Alternatively, Wasserman and Abumrad (1989) recommended that the pre-meal bolus dose prior 84 to exercise be reduced or omitted, and the basal infusion rate be reduced during exercise. Horton (1988) also recommended that the pre-exercise meal bolus insulin dose be reduced or omitted, and the basal infusion rate be decreased during exercise. These adjustments in insulin for exercise would help to prevent hypoglycemia both during and after exercise. In the current study 30 of the 35 subjects who used SCII reduced the amount of insulin used for exercise. Complete data on the reduction of insulin for exercise was obtained for 19 of these subjects. The basal insulin dose for exercise was reduced by 11 of the subjects. The average reduction was 1.7 units representing a 6.4 % reduction in the basal insulin dose. A total of 14 subjects reduced the pre-exercise meal bolus insulin dose a mean of 1.8 units or by 12.0 %. The total mean reduction in pre-exercise insulin was 2.3 units representing a 6.3 % reduction. Vitug and Colleagues (1988) recommended that only the pre-exercise meal bolus dose be reduced prior to planned exercise. Six of the subjects (20.0 %) in this study reported only reducing the pre-exercise bolus insulin dose. Alternatively, several researchers recommended reducing both the basal and the bolus insulin for exercise (Horton, 1988; Wasserman and Abumrad, 1989). A total of 16 subjects (53.3 %) reported adjusting both the basal and the bolus insulin dose for exercise. The amount of insulin to be reduced was not quantified in the literature (Horton, 1988; Vitug et al, 1988; Wasserman and Abumrad, 1989). Interestingly, there were no recommendations in the literature to support a reduction in only the basal insulin infusion. In this study 8 subjects (26.7 %) reported only adjusting the basal insulin dose for planned exercise. Sixteen subjects indicated that they discontinued the insulin pump during exercise, thereby eliminating the basal insulin infusion dose during exercise. There were numerous 85 reasons why subjects removed the pump for exercise. The primary reason cited was an increased risk of hypoglycemia during exercise. None of the recommendations for adjustment of insulin for pump users indicated that the basal insulin level be suspended for exercise. Horton (1988), and Wasserman and Abumrad (1989) recommended that the basal and bolus insulin doses be reduced for exercise. Other reasons indicated by the subjects included: risk of damage to the insulin pump, risk of injury to the needle site, and the pump got in the way during exercise. The data obtained from the subjects who used SCII supported the hypothesis that the insulin dose administered prior to planned exercise would be significantly lower than the insulin dose administered on a non-exercising day. There was a significant reduction in basal (p = 0.024), bolus (p < 0.001), and total (p < 0.001) insulin infused on an exercising day. 5.3 Hypothesis 2 It was hypothesized that there would be a significant increase in CHO intake on exercising days when compared to the CHO consumed on non-exercising days. The data analyzed confirmed that there was a significant increase in CHO consumed on an exercising day (p < 0.001). The mean CHO intake on a non-exercising day was 224.0 grams, while on an exercising day there was a mean increase of 56.8 grams. As indicated earlier, the section on dietary intake was not completed well by many of the subjects. In this part of Section D, 64 of the 137 subjects (46.7 %) did not complete this part well, and therefore, were eliminated from the analysis of the data. The increase in CHO intake on an exercising day was required to optimize stored energy substrates before exercise, and to prevent hypoglycemia before, during, and after exercise (Horton, 1988; Applegate, 1989; Coggan and Coyle, 1991; Landry and Allen, 1992; Young, 86 1995). The CHO consumed immediately before and during exercise will provide a metabolic substrate for exercising muscles, and also help to prevent a significant decrease in B G during exercise (Franz, 1992). After exercise, especially following prolonged events, the CHO requirements remain elevated in order to provide the CHO required to replete muscle and liver glycogen stores (Landry and Allen, 1992; Hough, 1994; Young, 1995). In addition, the increase in insulin sensitivity, as a result of exercise, will also increase the CHO requirements postexercise (Wallberg-Henriksson, 1992). An increase in CHO requirements postexercise may be required for up to 24 hours to prevent late-onset hypoglycemia (Horton, 1988; Wallberg-Henriksson, 1992). The increase in CHO intake on exercising days is required in order to maximize glycogen stores pre-exercise, provide blood-borne glucose for energy and prevent a significant decrease in B G during exercise, and to prevent hypoglycemia following an exercise session. The hypothesized increase in CHO consumption on an exercising day was supported by the data that were analyzed. The mean increase in CHO on an exercising day was 56.8 grams, and the t-test analysis produced significant results (p < 0.001). 5.4 Hypothesis 3 It was hypothesized that there would be a significant positive relationship between the amount of CHO consumed and the duration of the exercise session. Analysis of the data using four simple regression analyses determined that there was a weak positive linear relationship between the amount of CHO consumed and the duration of the exercise session for CHO consumption before exercise (r = 0.42; p < 0.001), during exercise (r = 0.19; p = 0.046), or combining before and during exercise (r = 0.35; p < 0.001). The amount of CHO consumed after 87 exercise was not significantly different when compared to the duration of the exercise session (r = 0.017; p = 0.859). A reference sport was used to obtain information on the adjustments to food intake for a specific sport using the usual length of time spent participating in the activity. The amount of CHO consumed for this reference activity obtained specific information on the dietary adjustments that were made in order to optimize energy intake and to prevent hypoglycemia during exercise. See Table 8 for information on the reference sport. There were 112 subjects (81.8 %) who completed the CHO adjustments for the exercise part of Section D well, therefore, only these subjects were used in the data analysis for this hypothesis. Pre-exercise nutrition is important to optimize muscle and liver glycogen stores (Applegate, 1989; Costill and Hargreaves, 1992). Carbohydrate intake during exercise in the ND individual enhances performance and delays the onset of fatigue by preventing the rapid depletion of glycogen stores (Coggan and Coyle, 1991). The CHO consumed during exercise provides a readily available and easily metabolizable energy source. Carbohydrate intake after exercise will enhance the rate of resynthesis of glycogen stores (Costill, 1985; Costill and Hargreaves, 1992). Carbohydrate intake for exercise in an individual with IDDM will also enhance performance and delay fatigue by providing an exogenous fuel supply. More importantly, however, CHO consumption before, during, and after exercise may be required to prevent hypoglycemia (Franz, 1992; Wasserman and Zinman, 1994). The pre-exercise CHO consumption will optimize B G levels and provide a readily available energy source during exercise. Carbohydrate consumed during exercise will prevent a significant decrease in B G during exercise, especially when the exercise bout is prolonged or intense (Franz, 1992; 88 Wasserman and Zinman, 1994). After an exercise session, CHO consumption is required to replete muscle and liver glycogen stores, and prevent late-onset hypoglycemia (Landry and Allen, 1992; Hough, 1994). The literature recommended that there be an increase in the amount of CHO consumed for exercise in this population. The recommendations range from 20 to 40 grams of CHO per 60 minutes of moderate intensity exercise, to 20 to 50 grams of CHO for every 60 minutes of strenuous exercise (CDA, 1985; Horton, 1988; Franz, 1992). The intake of CHO recommended in the literature was dependent on the duration of the exercise session. The data analyzed for this study determined that there was a significant increase in the amount of CHO consumed before exercise and the duration of the exercise session. In addition, the CHO intake during exercise was also significantly greater over the duration of the exercise session. The recommendations in the literature outlined that the CHO intake was required based on the duration of the exercise session (CDA, 1985; Horton, 1988; Franz, 1992). In this study, the pre-exercise CHO consumed per minute of exercise was 0.16 grams, therefore, for a 60 minute exercise session there was a mean increase of 9.6 grams of CHO consumed before exercise. Similarly, the CHO consumed per minute during exercise was 0.09 grams. For every 60 minutes of exercise, there was a mean increase of 5.4 grams of CHO consumed during exercise. When the data for the amount of CHO consumed before and during exercise were analyzed, there was a significantly greater amount of CHO consumed as the duration of the exercise session increased. The CHO consumed per minute of exercise was 0.25 grams, therefore, for every 60 minutes of exercise there was a 15.0 gram increase in the amount of CHO consumed before and during exercise. The recommendations in the literature range from a minimum of 20 grams of CHO for 60 minutes of moderate intensity exercise, to a maximum of 89 50 grams of CHO for 60 minutes of strenuous exercise (CDA, 1985; Horton, 1988; Franz, 1992). The amount of CHO consumed for exercise in this study was lower than the amount of CHO intake recommended in the literature. The duration of the exercise session explained only 12 % of the variability in the CHO intake during exercise in this population. Other factors, such as the type of exercise, intensity of exercise, and the pre-exercise reduction in insulin dosage could explain more of the variability in the CHO consumed for exercise. The intensity of the exercise session may be more important than the duration of exercise in determining CHO requirements for exercise. A greater exogenous CHO intake may be required when the exercise is of greater intensity, since energy expenditure is greater. Analysis of the data only considered the duration of the exercise, which may have underestimated the CHO requirements for exercise in these subjects. Incorporating a measure of intensity, such as heart rate, would help to determine the variability in CHO consumed based on the intensity of the exercise session. The duration of the exercise session, therefore, may not be the single most important indicator of the CHO requirement for exercise. After exercise, the amount of CHO required may remain elevated due to repletion of the glycogen stores. Late-onset hypoglycemia may occur for up to 24 hours after an exercise session, especially one that was prolonged or intense (Landry and Allen; 1992; Wallberg-Henriksson, 1992; Hough, 1994; Young, 1995). There were, however, no recommendations on the amount of CHO required to prevent hypoglycemia after exercise. It was hypothesized that there would be a significant increase in the amount of CHO consumed after exercise, since exercise of longer duration could increase the risk of late-onset, postexercise hypoglycemia. The amount of CHO consumed after exercise was not significantly different when compared to the duration of the exercise session. A non-significant increase in the CHO after exercise may have 90 been the result of the consumption of a meal after the event, since subjects were requested to exclude meals and snacks that they usually consumed. With the exclusion of the food consumed as a meal or snack, the data may not accurately represent a possible increase in the food consumed after exercise. In addition, subjects who exercised for an extended period of time may have reduced the insulin dose after exercise to prevent late-onset hypoglycemia resulting from a greater insulin sensitivity that occurs following exercise. Subjects were not asked if they reduced their insulin dose after exercise, nor were they asked if prolonged or intense exercise necessitated an increase in CHO consumption during the period when late-onset hypoglycemia was likely to occur. The analysis of the data for hypothesis 3 does not entirely support the hypothesis that there would be a significant positive relationship between the amount of CHO consumed and the duration of exercise. The simple regression analyses found that there was a significant increase in the CHO consumed and the duration of the exercise session, for CHO consumption before exercise, during exercise, and a combination of before and during exercise. There was no significant difference in the amount of CHO consumed after exercise and the duration of the exercise session. 5.5 R e s e a r c h Q u e s t i o n 1 Research question 1 set out to determine if there was a difference in the signs and symptoms of hypoglycemia recognized while at rest and while exercising. On average there were 5 signs and symptoms that were recognized at rest, while on average there were 3 signs and symptoms recognized during exercise. There were less signs and symptoms recognized during exercise, and the signs and symptoms that were recognized were different than the ones 91 recognized at rest. The excessive sweating was indicative of a symptom that one would not observe during exercise, since exercise promotes sweating to dissipate heat. Excessive sweating was the most frequently cited symptom at rest (93 at rest subjects versus 33 exercising subjects). Weakness and loss of coordination were the two symptoms that were recognized most frequently during exercise. These signs could be the result of a decrease in the amount of CHO that was available for oxidation by the exercising muscles. A depletion of glycogen stores in ND individuals results in the onset of fatigue (Coggan and Coyle, 1991; Costill and Hargreaves, 1992). Likewise, a decrease in the B G during exercise in IDDM can promote fatigue, weakness, and a loss of coordination by reducing the oxidative substrate available for exercising muscles. In addition, the loss of coordination may be the result of a decrease in B G supplying the brain. Confusion was one of the symptoms that was recognized both at rest and during exercise. This may also be the result of a decrease in B G supply to the brain. One of the potentially dangerous problems with hypoglycemia is the inability to recognize any signs and symptoms either at rest or during exercise. Three subjects reported being hypoglycemia unaware at rest, while 9 subjects reported being hypoglycemic unaware during exercise. Subjects who are unaware of the onset of hypoglycemia should take extra precautions to ensure that an insulin reaction does not occur during exercise. Frequent monitoring of B G and additional attention to reductions in insulin and/or an increase in dietary intake for exercise are required. Subjects should be cautioned that the signs and symptoms that may be easily recognized at rest are not necessarily the signs and symptoms that are recognized during exercise. 92 5.6 Research Question 2 The goal of research question 2 was to determine how much, and what type of food groups were required to treat a mild, moderate, and severe insulin reaction, both during exercise and within 24 hours following an exercise session. There was a significant increase in the amount of CHO required to treat a mild insulin reaction within 24 hours of an exercise session (p = 0.027). The CHO intake for moderate (p = 0.080) and severe (p = 0.627) insulin reactions was not significantly different during exercise or within 24 hours of an exercise session. During exercise, the amount of CHO consumed to treat an insulin reaction was anticipated to be greater than the amount of CHO used to treat a reaction at rest. This is, in part, due to the increased energy requirements and the increase in insulin sensitivity that occurs during exercise. In addition, there is a propensity to over treat insulin reactions. A significant increase in the amount of CHO consumed for an insulin reaction during exercise was expected. The results obtained determined that there was a significantly greater amount of CHO consumed within 24 hours of an exercise session for a mild insulin reaction. Although the increase in CHO consumed for a moderate and severe insulin reaction did not reach significance, there was an increase in the amount of CHO consumed within 24 hours after exercise. 5.7 Research Question 3 This research question was designed to determine how often B G is measured during exercise. A total of 32 subjects responded to the question indicating that they measured their BG on average 1.7 times during exercise. Testing B G during exercise is important to determine if the B G level is decreasing, especially for subjects who are not aware of the signs and symptoms of hypoglycemia. Athletes sometimes test their B G several times before exercise to determine 93 the rate and direction of B G change before exercise (Wasserman and Zinman, 1994). The same procedure can be used for individuals with IDDM during exercise to determine their current B G level, and to determine the rate of change. Monitoring B G during exercise, especially exercise that is of long duration or of high intensity, will help the individual prevent the onset of hypoglycemia by determining the current B G level and possibly the rate of change. A B G meter or visual B G strips are not always practical to carry at a sporting event; When access to a B G meter during exercise is not practical, multiple B G reading before exercise may provide information on B G changes prior to activity, while postexercise B G readings will give information on the decrease in B G in response to exercise. 5.8 Research Question 4 Research question 4 determined what criteria were used to postpone exercise, and to determine if the criteria to postpone exercise was different between recreational and competitive exercise. The recommendations in the literature indicated that exercise should be postponed when B G was above 14.0 mmol/L, and urinary ketones were present (Horton, 1988; Franz, 1992; Hough, 1994). Wasserman and Zinman (1994) also recommended that exercise should be postponed when B G was above 16.7 mmol/L regardless of the presence of urinary ketones, until acceptable metabolic control was attained. In addition, when B G was below 5.5 mmol/L, exercise should be postponed until additional CHO was consumed, and a subsequent B G measurement was between 5.5 and 8.3 mmol/L (Horton, 1988; Franz, 1992; Hough, 1994). Seven subjects indicated that the presence of urinary ketones was a criteria used to postpone exercise. Most of the subjects did not state that ketones were a criteria used to postpone exercise. A lower level of B G was used as a criteria to postpone exercise for 94 competition (4.9 mmol/L) than for recreational exercise (5.2 mmol/L). Similarly, a higher B G level was used to postpone exercise for competition (15.2 mmol/L) than for recreational exercise (14.5 mmol/L). One would expect that subjects who are competing would try to compete even when metabolic control is compromised. Of the subjects who competed, 9 indicated that they did not postpone exercise, while 20 subjects indicated that they would only postpone exercise to treat high or low BG. Conversely, 2 subjects who exercised for recreation did not postpone exercise, while 14 subjects postponed exercise only for treatment. The criteria used to postpone exercise were high and low B G levels. The subjects who competed had, on average, set lower and higher B G levels in order to postpone exercise. Recreational exercise had the most number of subjects who postponed exercise when metabolic control was compromised. 5.9 Research Question 5 Exercise safety is an issue for all people who participate in an exercise program. The individual with IDDM must take extra precautions in order to ensure that she/he has adequate provisions available to ensure that a diabetic emergency can be easily treated and reversed without extensive medical intervention. Subjects were requested to write down the estimated percentage of time that diabetic ID was worn, sugar was available, a B G meter was available, and that others were informed of their whereabouts, during exercise. There were 88 subjects (64.2 %) who reported always wearing a diabetic ID while exercising, 98 subjects (71.5 %) who reported always having a source of sugar available for exercise, 36 subjects (26.5 %) had a B G meter present during exercise, and 34 (34.0 %) subjects who exercised alone informed others where they were going. The literature recommended that a 95 diabetic ID be worn at all times, in the event of an emergency (Franz, 1992; Hough, 1994). In addition, a readily available and easily absorbable CHO source should also be available at all times to prevent and treat hypoglycemia during exercise (Franz, 1992; Hough, 1994). There were also numerous recommendations in the literature that suggested subjects have a B G meter or visual B G strips available during exercise (Wasserman and Abumrad, 1989; Franz, 1992; Hough, 1994; Wasserman and Zinman, 1994). Blood glucose testing during exercise will provide essential feedback to the individual on the current B G level and to help determine the B G trend over the duration of exercise, especially exercise of long duration (Wasserman and Zinman, 1994). Monitoring of B G during exercise will help to prevent hypoglycemia by giving the person with IDDM important information on B G levels. One safety aspect that was considered to be important, but not cited in the literature, was informing another person where she/he was going and when she/he would be back from an exercise session. The purpose of this safety factor was to get help for the person exercising if she/he failed to return within the specified time. A search of the area where the person was exercising could help the individual in trouble, whether related to a diabetic emergency, or other problems that may have occurred. 5.10 Research Question 6 Research question 6 determined if there was a correlation between the number of years with diabetes and the number of long-term complications. Analysis of the data showed that there was no correlation between the number of years with diabetes and the number of long-term complications. Of the subjects who participated in this study, 41 subjects reported having one or more diabetic complications. Diabetic complications are the result of prolonged hyperglycemia, with the rate of progression increasing with the severity and duration of chaotic metabolic control 96 (Tsalikian, 1990; ADA, 1995; DCCT, 1995). An increased awareness of metabolic control for exercise may help to prevent the onset of long-term complications in this sample, by maintaining a near normal B G profile. The subjects who participated in this study were exercising on a regular basis and most of the subjects (92.7 %) had a H b A l c within the acceptable range. Exercise in the general population helps to prevent CVD, hypertension, hyperlipidemias, and other medical problems associated with a sedentary lifestyle. For the IDDM population, exercise has the same benefits as ND individuals and may also have the added benefits of increasing insulin sensitivity, reducing insulin requirements, and potentially improving long-term metabolic control (Landry and Allen, 1992; Wallberg-Henriksson, 1992; Wasserman and Zinman, 1994). The non-significant increase in the number of long-term complications and the number of years with diabetes may be the result of an increased awareness of the diet and insulin adjustments that are required to maintain metabolic control for exercise. In addition, the beneficial effects of regular exercise may be demonstrated here with a low number of complications reported. 5.11 Research Question 7 The purpose of research question 7 was to obtain information on the dietary adjustments that are required to accommodate unplanned exercise. Ninety-nine of the 132 subjects that indicated that they participated in unplanned exercise adjusted dietary intake. There was insufficient information obtained to determine the amount and the types of foods that were consumed for unplanned exercise. 97 5.12 Additional Information Subjects were asked, in general, if they thought that their diabetic control was better, the same, or worse than if they did not participate in an active lifestyle. A total of 99 subjects (73.9 %) reported that their metabolic control was better as a result of an active lifestyle. There were 21 subjects (15.7 %) who reported that it was the same, 3 subjects (2.2 %) who reported that it was worse, and 11 (8.2 %) who did not know if their metabolic control was different. Studies on the effects of exercise on metabolic control have determined that there was no improvement with training (Wallberg-Henriksson et al, 1982; Zinman et al, 1984). Based on the anecdotal evidence provided by the subjects, a majority of the subjects believed that their metabolic control was better or the same as a result of their active lifestyle. 98 CHAPTER 6 CONCLUSIONS 6.0 Summary The purpose of this study was to use a self-administered, mailed questionnaire to obtain information on the adjustments in insulin and diet used for exercise in active people with IDDM. This study also obtained information on the self-monitoring of metabolic control, personal safety while exercising, treatment of short-term complications, and the presence of long-term complications. The sample consisted of 325 randomly selected members of the IDAA who resided in Canada and the United States. A 25 page questionnaire was sent out to each potential subject in September, 1996. Two postcard reminders were also developed. The first postcard was sent out to all subjects two weeks after the original mailing, and the second postcard was only sent to subjects who had not returned their questionnaire four weeks after the original mailing. A total of 238 questionnaires were returned, with 87 sent back unmarked, and 151 that were returned completed. Out of the questionnaires that were returned completed, 137 subjects met all of the criteria for the study, and therefore, these questionnaires were coded and analyzed using SPSS statistical software. The adjustments in insulin administration prior to planned exercise were analyzed using a series of paired, one-tailed t-tests. The t-tests supported the research hypothesis that the amount of insulin administered prior to planned exercise would be significantly lower than the insulin dose administered for a non-exercising day, both for subjects who injected their insulin and subjects who used an insulin pump. The subjects who injected their insulin significantly reduced 99 their short acting insulin (p < 0.001), intermediate acting insulin (p = 0.006), long acting insulin (p = 0.042), and total insulin (p < 0.001) used on an exercising day. Subjects who used an insulin pump significantly reduced their basal insulin infusion (p =0.024), bolus insulin dose (p < 0.001), and total insulin dose (p < 0.001) on an exercising day. The CHO intake on an exercising day was hypothesized to be significantly greater than the amount of CHO consumed on a non-exercising day. On average, the subjects that participated in this study increased their CHO intake by 56.8 grams on an exercising day. This represented a significant increase in the amount of CHO that was consumed (p < 0.001). The amount of CHO consumed for exercise was hypothesized to be positively correlated to the duration of an exercise session. The analysis of the data using simple regression analyses determined that there was a weak positive linear correlation between the amount of CHO consumed and the duration of the exercise session for CHO consumed before exercise (r = 0.42; p < 0.001), during exercise (r = 0.19; p = 0.046), or combined before and during exercise (r = 0.35; p < 0.001). There was no positive linear correlation in the amount of CHO consumed after exercise and the duration of the exercise session (r = 0.017; p = 0.859). In addition to the hypotheses that looked at the adjustments in insulin and dietary intake, seven research questions were asked to obtain additional information related to exercise and IDDM. 1) . The signs and symptoms of hypoglycemia during exercise were different than the signs and symptoms that were recognized at rest. 2) . The amount of CHO used to treat an insulin reaction was significantly greater for a mild insulin reaction experienced within 24 hours following an exercise session (p = 0.027). 100 The moderate and severe insulin reactions showed no difference in the CHO intake used to treat these reactions (p = 0.080 and p = 0.627, respectively). 3) . Blood glucose was measured an average 1.7 times during an exercise session. 4) . Subjects who competed in sporting events tended to use lower and higher B G levels as criteria to postpone an exercise session. 5) . The percentage of time that safety provisions were always available, such as wearing a diabetic ID, carrying a readily absorbable sugar source, having a B G meter available during exercise, ranged from 71.5 % to 26.5 %. 6) . There was no significant correlation between the number of complications and the number of years with diabetes (r = - 0.16). 7) . Due to the lack of data collected in Section D, no conclusions can be drawn regarding the change in dietary intake for unplanned exercise. 6.1 Conclusions Exercise was once considered to be adjunctive therapy for people with IDDM, and considered only when good metabolic control had been achieved through diet and insulin. In the past two decades, the importance of exercise in overall health and wellness has increased. Insulin, diet, and exercise are being increasingly recognized as the three factors essential for the attainment of optimal metabolic control. The current study set out to determine what changes to diet and insulin an already active person with IDDM made in order to maintain metabolic control. It was hypothesized that the insulin dose administered on an exercising day would be significantly lower than the insulin dose administered on a non-exercising day. The insulin 101 dosage was significantly reduced by the subjects who reported adjusting their insulin for exercise. The decrease in short and intermediate acting insulin injected supports the recommendations in the literature for the reduction of insulin prior to planned exercise. On average the subjects who reduced their insulin prior to exercise decreased the short acting insulin by 28.4 %, and the intermediate acting insulin by 38.4 %. There were no recommendations in the literature on the adjustments that should be made to long acting insulin for exercise, yet the subjects in this study reported decreasing their long acting insulin prior to exercise by 9.7 %. The total insulin reduced by subjects who injected their insulin was 17.7 %. Subjects who used SCII also significantly reduced both their basal and bolus insulin on an exercising day. Although the literature recommended that insulin pump users decrease the insulin infused for exercise, the amount of insulin to be reduced has not yet been quantified. The results of this study indicate that the basal insulin was reduced by 6.4 %, the bolus insulin dose was reduced by 12.0 %, and the total amount of insulin reduced was 6.3 %, prior to exercise. The results indicated that 64.2 % of subjects significantly decreased their insulin dose prior to exercise. This study, however, did not determine why the remainder of subjects did not reduce their insulin for exercise. Additional questions outlining the reasons why subjects did not reduce their insulin before exercise would have provided valuable information. The CHO intake on an exercising day was hypothesized to be greater than that consumed on a non-exercising day. There was a significant increase in the amount of CHO consumed on an exercising day. The additional CHO consumed on an exercising day would help to maximize pre-exercise energy stores and to prevent hypoglycemia during and after exercise. The subjects consumed, on average, 56.8 grams more CHO on an exercising day. 102 In addition, it was hypothesized that the CHO consumed before, during, and after exercise would be positively correlated to the duration of the exercise session. Indeed, there was a significant increase in the CHO consumed before exercise, during exercise, and before and during exercise. The amount of CHO consumed before and during exercise for each minute of exercise was 0.25 grams, resulting in a 15.0 gram increase in CHO consumed for 60 minutes of exercise. There was, however, no difference in the amount of CHO consumed after an exercise session. There was less than 1 gram of CHO consumed after exercise for 60 minutes of exercise. It was concluded that the CHO required before and during exercise increased with an increase in the duration of the exercise session. The research questions add some additional information related to diabetes and exercise. 1) . Research question 1 determined that there were different signs and symptoms of hypoglycemia recognized at rest and while exercising. On average, there were 2 more symptoms recognized at rest. In addition, the symptoms recognized at rest were different than those recognized during exercise. The three most reported symptoms recognized during exercise were weakness (64.2 %), loss of coordination (40.1 %), and confusion (35.8 %). There were 9 subjects who reported being hypoglycemia unaware during exercise. 2) . Research question 2 determined that there was no significant difference in the amount of CHO required to treat a moderate or severe insulin reaction during exercise or within 24 hours following an exercise session. There was, however, a significant increase in the CHO consumed to treat a mild insulin reaction within 24 hours following an exercise session. The sugars food choice was used most frequently to treat an insulin reaction during exercise. 103 3) . Research question 3 determined how often B G was measured during exercise. Blood glucose was measured an average of 1.7 times during exercise, with a mean of 53.1 minutes between tests. 4) . Research question 4 determined that the criteria to postpone exercise was different when the subjects participated in recreation and competitive sports. In general, the subjects who competed would postpone exercise at a lower (4.9 mmol/L) and a higher (15.2 mmol/L) BG level than for recreation (5.2 mmol/L and 14.5 mmol/L, respectively). Subjects who were competing would generally postpone exercise only long enough to treat hypoglycemia and hyperglycemia. 5) . Research question 5 determined the percentage of subjects who ensured that there were provisions available in order to exercise safely. There were 64.2 % of subjects who always wore diabetic ID, 71.7 % always had a source of sugar available, 26.5 % always had a B G meter available, and 34.0 % of those who exercised alone reported always telling someone where they were going. 6) . Research question 6 determined that there was no significant correlation between the number of years with diabetes and the number of long-term complications (r = - 0.16). A total of 41 subjects reported having diabetic complications. The three most commonly reported long-term complications were retinopathy (53.7 %), neuropathy (41.5 %), and hypertension (24.4 %). 7) . Research question 7 was designed to determine what adjustments were made in dietary intake to accommodate unplanned exercise. The information obtained for. this question was not specific enough to determine what adjustments were made. 104 This study, fell short of the primary goal, which was to provide specific recommendations in the adjustments to dietary intake and insulin administration for exercise in active people with IDDM. This study does confirm that adjustments were made in insulin and diet to prevent hypoglycemia during and after exercise. The information obtained from members of the IDAA, however, posed numerous additional areas where research was required to assist individuals with IDDM make the necessary adjustments in diet and insulin in order to participate in an active lifestyle. 6.2 Recommendations For Further Research This study has raised numerous additional questions and areas for future research. These areas of additional research will assist the individual with IDDM make appropriate adjustments in diet and insulin for exercise. Also, areas that have not been studied in the past can provide additional information that will make exercise in this population safer and more enjoyable. 1) . The insulin adjustments for exercise requires additional research to determine what adjustments in insulin are made by already active people with IDDM in a prospective rather than a retrospective study. Specifically, there were no recommendations in the literature on the amount of long acting insulin that was adjusted for exercise. Studies should look at the amount of insulin adjusted by subjects who use this type of insulin. In addition, quantification of the amount of insulin reduced for subjects who use the insulin pump is also required. 2) . More research is required to determine the amount of CHO that is consumed before, during, and after exercise for the type, duration, and intensity of the exercise session. 105 Special attention should be placed on the amount of extra CHO that is consumed after prolonged or intense exercise to prevent late-onset hypoglycemia. 3) . A research project that looks at the best type(s) of foods consumed before, during, and after exercise to maximize performance and minimize hypoglycemia. In the current literature, research has looked at fluid and solid CHO replacement for exercise in ND athletes. Further research in this area that looks at the CHO requirements in the person with IDDM would be advantageous. 4) . A research project should be designed that combines the CHO intake and the insulin adjustments made based on the intensity and the duration of the exercise session. Currently in the literature, the sports that are considered to be mild, moderate, and severe in intensity are different among the researchers. A standardized intensity and duration chart would assist people with IDDM to more closely estimate the amount of insulin and/or CHO that needs to be adjusted. Age adjusted heart rate would be a good predictor for these adjustments. 5) . Information on the signs and symptoms of hypoglycemia that are recognized at rest and during exercise would be helpful in increasing awareness of the signs of hypoglycemia that are more likely to be recognized during exercise. This would be helpful for people with IDDM who wish to exercise but are reluctant to do so because of the increased risk of hypoglycemia. 6) . A study that would look at the adjustments made for unplanned exercise, with special emphasis on the dietary intake before, during, and after exercise would provide valuable information to help people with IDDM exercise when the opportunity presents itself. 106 Additional research in IDDM and exercise would assist these people to participate in an active lifestyle, and minimize the short-term complications associated with exercise. With an increased awareness of the adjustments required in insulin and diet, exercise can be safely incorporated into their lifestyle with a minimum of risk. Past studies have determined that there was no improvement in metabolic control after IDDM subjects participated in a regular exercise program. A majority of the subjects who participated in this research project either reported that their diabetic control was better or the same as a result of an active lifestyle. 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Exercise prescription for individuals with metabolic disorders: practical considerations. Sports Medicine 19(l):43-54. Zeman, F. (1991). Clinical Nutrition and Dietetics. MacMillan Publishing Company, New York, New York. Pages 398-450. Zinman, B., Zuniga-Guajardo, S., and Kelly, D. (1984). Comparison of the acute and long-term effects of exercise in glucose control in type I diabetes. Diabetes Care 7(6):515-519. Zinman, B., and Vranic, M. (1985). Diabetes and exercise. Medical Clinics of North America 69(1):145-157. 113 APPENDIX A QUESTIONNAIRE PACKAGE 114 T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A School of Human Kinetics 210, War Memorial Gym 6081 University Boulevard Vancouver, B . C . Canada V6T 1Z1 Tel: (604) 822-3838 Fax:(604) 822-6842 September 11, 1996. Dear Mr. John Smith: RE: Exercise and Insulin-Dependent Diabetes Mellitus Questionnaire. In the last 20 years the importance of exercise in the treatment of insulin-dependent diabetes has been studied extensively. In spite of this, there is still a wide range of recommendations in the exercise, diet, and insulin prescriptions made by Health Professionals for physical activity in the diabetic population. Presently, little is known about how individuals with diabetes modify their diet, and insulin levels in order to live active lives. The purpose of this study is to obtain information from individuals with insulin-dependent diabetes on the diet, insulin, and exercise adjustments that are required to maintain an active and healthy lifestyle. In addition, information on blood glucose testing, diabetic complications, and exercise safety will be obtained. The results obtained from the study will be used to increase awareness of the modifications that are required for exercise in the insulin-dependent diabetic population. Your participation in this study is greatly appreciated. Only a small number of members of the International Diabetes Athletes Association have been randomly selected to participate in the study. It will take approximately 45 to 60 minutes to complete the enclosed survey. Each survey has been given an identification number for mailing purposes only. Your responses are strictly confidential. Do not write your name or other identifying marks on the survey. When the survey is returned, the questionnaire number will be checked off our mailing list. The mailing list numbers will be destroyed as soon as the surveys have been returned to prevent the tracking of individual responses. You have the right to refuse to participate, and you may withdraw from the study at any time without consequence. Your consent to participate in this study is assumed by completing and returning the survey. If you do not have insulin-dependent diabetes, please return this questionnaire unmarked in the pre-addressed, stamped envelope provided. This research project is being carried out by The School of Human Kinetics at The University of British Columbia, Vancouver, Canada in order to complete the requirements of my Master of Science Degree. The project is being supervised by Dr. Jack Taunton, MD (Sports Medicine). If you have any questions about this research project or how to complete the survey, please feel free to contact me toll free at 1-888-000-0000. I will be available to accept calls most days from 9 am to 8 pm, Pacific Time. Sincerely; Willa Sankey, BHEc. Project Coordinator 115 EXERCISE AND INSULIN-DEPENDENT DIABETES MELLITUS QUESTIONNAIRE: MODIFICATIONS REQUIRED IN DIET AND INSULIN ADMINISTRATION FOR THE ACTIVE PERSON WITH INSULIN-DEPENDENT DIABETES RESEARCH PROJECT CONDUCTED B Y : Willa Sankey, Project Coordinator The School of Human Kinetics The University of British Columbia Vancouver, B.C., Canada 117 INSTRUCTIONS N o t e : T h i s questionnaire is on ly to be completed by respondents w i th insu l in -dependent diabetes. I f you have non-insulin-dependent diabetes (Type II), or are a Hea l th Care Professional , please return this questionnaire as soon as possible i n the pre-addressed, stamped envelope provided. A s far as w e are aware, this insulin-dependent diabetes and exercise survey is the first project o f its k i n d . Y o u r part icipation i n this study is greatly appreciated since o n l y a smal l number o f members o f the International Diabet ic Athletes Assoc ia t ion w i t h insu l in -dependent diabetes have been recruited for this research project. Y o u r responses w i l l help us learn a great deal about the interaction o f diet, insu l in , and exercise for the active diabetic. In addit ion, w e are interested i n the prevention and treatment o f insu l in reactions, personal safety when exercis ing, b lood glucose moni tor ing , and other informat ion that is relevant to exercise i n the person wi th diabetes. W e are interested i n obta ining accurate and honest answers to the enclosed questions. S ince there is no w a y o f t racking ind iv idua l questionnaires, your answers cannot be judged i n any way and your anonymity is assured. Instructions for each section o f the questionnaire are inc luded at the beginning o f each new set o f questions. A d d i t i o n a l instructions are p rov ided throughout the questionnaire as required. F o r each question, place a check mark (0) beside the appropriate answer or f i l l i n the blank by neatly pr in t ing your answer. Several questions require y o u to c i rc le the units o f measure that y o u use. T h i s is necessary since Canada and the U n i t e d States use different units o f measurement. Depend ing on your answers to certain questions, y o u may be instructed to skip one or more o f the questions i n the survey. T h e instructions provided w i l l indicate where to resume answering the questions. Comple te the survey i n the order that the questions are presented. Please note that the survey is printed on both sides o f the page. W h e n y o u have completed the survey, place it i n the self-addressed, stamped envelope that is provided i n the questionnaire package, and m a i l it at your earliest convenience. Please complete and return the questionnaire w i th in two weeks . I f at any point i n comple t ing the survey y o u have questions or concerns, feel free to contact W i l l a Sankey, Project Coordina tor to l l free at 1-888-000-0000 between 9 a m and 8 p m , Pac i f ic T i m e . Thank y o u for your t ime i n comple t ing this survey. T h i s study w o u l d not be possible without your help. 118 1713 S E C T I O N A - D E M O G R A P H I C I N F O R M A T I O N This first set of questions are designed to provide us with background information, and to obtain some general information regarding your diabetes. Please check (0) the appropriate box or fill in the blanks for each question. Where applicable, circle (O) the units of measure used. A1. What is your birth date? Year Month A2. What is your gender? • Female • Male A3. How tall are you? Please circle units. feet / inches / centimetres A4. How much do you weigh? Please circle units. pounds / kilograms A5. In what Province/State do you currently reside? A6. What is your current marital status? Mark only one response. • Single • Married or living with a common law partner • Divorced or separated • Widowed A7. What is your primary ethnic background? Mark only one response. • Asian • Black/African American • Caucasian • East Indian • First Nations/American Indian/Eskimo/other Native Group • Other (please specify) 1 119 A8. How long have you had diabetes? years A 9 . What was your latest hemoglobin AiC level? Please circle units. %org/L • Don't know A 1 0 . When was your last hemoglobin A i C test done? month year • Don't know A l l . What is the target range for your hemoglobin AiC? Please circle units. to %org/L • Don't know 2 120 SECTION B - INSULIN This next section asks questions related to the amount, and type of insulin that you require on a daily basis, as well as the modifications of insulin requirements for planned exercise. One set of questions are for those participants who inject their insulin, while a second set of questions are for insulin pump users. You will be instructed to skip the set of questions that does not apply to you. B1. How do you administer your insulin? • Injection • Insulin pump, go to question B8 on page 4 The following questions (B2 to B7) only apply to those respondents who inject their insulin. B2. How do you inject your insulin? Mark all that apply. • traditional syringes • insulin pen injectors • insulin jet injector B3. How many insulin injections do you administer per day? • 1 injection per day • 2 injections per day • 3 injections per day • 4 injections per day • More than 4 injections per day B4. Write down the time of day, type of insulin, and the number of units used for each injection. Time of Day Insulin Type Number of Units 3 121 B5. Where do you typically inject the insulin dose prior to physical activity? Mark only one of the following responses. a Arm • Stomach • Buttocks • Thigh a Other (please specify) B6. Do you adjust your insulin dose(s) prior to planned exercise? • Yes • No, go to Section C, page 6 B7. Indicate the insulin injection(s), the type of insulin, and the number of units adjusted prior to planned exercise. Time of Insulin Injection Insulin Type Number of Units Please go to Section C, page 6 The following questions (B8 to B16) apply to those respondents who use an insulin pump to administer their insulin. B8. Write down the type of insulin pump you are currently using. B9. Write down the type of basal insulin used and the amount used per day. If your insulin pump is programmable, give the details of your program. 4 122 BIO. Write down the time of day, type of insulin, and the number of units used for each bolus dose. Time of Day Insulin Type Number of Units BI 1. Do you adjust your bolus insulin dose prior to planned exercise? • Yes • No, go to question B13 B12. How much do you change your bolus insulin dose prior to planned exercise. B13. Do you adjust your basal insulin dose prior to planned exercise? • Yes • No, go to question B15 B14. How much, and for how long do you change your basal insulin dose prior to or after planned exercise? B15. Do you disconnect your insulin pump during exercise? • Yes • No, go to Section C on page 6 B16. Why do you disconnect your insulin pump during exercise? Mark all that apply. • Reduced risk of low blood sugar • Risk of injury to the needle site • Insulin pump gets in the way • Insulin pump could get damaged • Other (please specify) 123 5 SECTION C - EXERCISE The following questions deal with your exercise patterns. These questions will provide information on the types of activities that you like to participate in, and the level of participation. We would like to get information on the length, intensity, time of day, and the number of times per week you exercise. CI. Do you exercise for recreation or competition? • Recreation only, go to question C3 • Competition only • Both for recreation and competition C2. List the sports that you are competitive in and include the class and ranking where applicable. C3. On average, how many times a week do you exercise? times C4. On average, how long is your typical exercise session? minutes and/or hours C5. Why do you like to exercise? Mark as many as apply. • Fun • Excitement • Social oudet • Reduces stress • Competition • Total body fitness • Improves my diabetic control a Reduces my insulin needs • Makes me look my best • Makes me feel my best a Helps me lose weight • Helps to maintain my body weight a Others (please specify") 6 124 The next 2 questions ask you to indicate sports that you participate in on a regular basis. For the purposes of this study, regular basis is defined as a sport or activity that you participate in at least once a week, or a total of four times per month. Some of the sports listed are activities that are seasonal in nature, such as skiing. If you participate in this sport on a regular basis during the season it is offered, please check the box for that sport. C6. On a regular basis which of the following individual activities do you participate in? Mark all that apply. • Walking/hiking • Downhill skiing • Golf • Cross country skiing • Jogging/running • Figure skating • Swimming • Ballet dancing a Cycling • Aerobics classes • Weight training • Others (please specify) C7. Do you participate in any of the following team sports on a regular basis? Mark all that apply. • Basketball • Ice hockey • Volleyball • Ringette • Football • Field hockey • Soccer • Baseball/softball • Rugby • Lacrosse • Racquetball/squash • Rowing • Tennis • Bowling • Others (please specify) C8. Below, list the three sports that you participate in the most. If you participate in only one or two sports, only include these. Indicate the number of times each week, and the amount of time spent in each activity per session. Again, if a sport is seasonal and you participate in the sport frequently in the season it is offered, you may want to include it. 125 7 C9. Do you monitor or check your heart rate during exercise? • Yes • No, go to question C12 CIO. Do you use a heart rate monitor during exercise? • Yes • No CI 1. What is your target heart rate or heart rate range during exercise? beats per minute CI2. What time(s) during the day do you prefer to exercise? Circle appropriate time. am or pm am or pm am or pm C13. Why do you prefer to exercise during these time(s)? Mark all that apply. • Low risk Of hypoglycemia • Insulin levels are lower at these time(s) • I am at my physical peak during these time period(s) • Fits into my daily work schedule • Fixed times for team sports • Others (please specify) CI4. What time(s) during the day do you avoid exercise? Circle appropriate time. am or pm am or pm am or pm CI5. Why do you avoid exercising during these time(s)? Mark all that apply. • Increased risk of hypoglycemia • Insulin levels peak during these time(s) • Others (please specify) 8 126 SECTION D - DIETARY INTAKE The next set of questions are designed to give us some information on your daily food intake, both for exercising and non-exercising days. In addition, questions related to additional food or fluid intake requirements before, during, and after an exercise session will be asked. D1. What meal plan do you follow? • Dietary Guidelines for Americans • Canada's Food Guide • Healthy Food Choices • Good Health Eating Guide • Other (please specify) D2. Approximately how many calories do you consume on a daily basis? Please circle units. calories or kilojoules • Don't know D3. Please indicate the number of servings for each of the following food groups that you consume on a typical non-exercising day. 1. Starch or bread choices servings per day 2. Fruit and vegetable choices servings per day 3. Milk choices servings per day 4. Protein or meat choices servings per day 5. Fats and oils choices servings per day 6. Extra or free food choices servings per day 7. Sugar choices servings per day D4. Mark off the meals and snacks that you consume on a daily basis. Exclude extra snacks or small meals eaten for exercise. Mark all that apply. • Breakfast • Morning snack • Lunch • Afternoon snack • Dinner • Bedtime snack 127 9 D5. Do you take \4tomin anoVor mineral supplements? • Yes • No, please go to question D7 D6. What vitamin and/or mineral supplements do you take? Include the brand(s) and the amount(s) taken per day. D7. Indicate the number of extra servings for each of the following food groups that you consume on a typical exercising day. 1. Starch or bread choices servings per day 2 . Fruit and vegetable choices servings per day 3. Milk choices servings per day 4. Protein or meat choices servings per day 5. Fats and oils choices servings per day 6. Extra or free food choices servings per day 7. Sugar choices servings per day D8. What type of sugar source do you have available when you exercise? Mark all that apply. a Dextrose tablets • Hard candy a Glucose gel • Milk • Fruit juice • Regular pop • Chocolate bars • Sport drinks • Power bars or other sports cookies • Others (please specify) 10 128 D9. Which of the following beverages do you use for fluid replacement before, during, and after exercise? Mark all that apply. • Water • Gatorade • Powerade • Al l Sport • Fruit juice • Milk • Regular pop • Diet pop a Others (please specify) In Section C, question G8 you listed up to three sports that you participate in the most. Choose one of these sports and answer the following questions using this sport as a reference. For the following questions, fill in the answer that best describes what you do before, during, and after exercise. If a question is not relevant to you or does not apply, indicate this in the space provided. D10. Write down the sport that you have chosen as a reference activity for this section. DI 1. For the sport that you have chosen above, indicate the number of times you participate in this activity per week, the amount of time spent in the activity per session, and the target heart rate during this activity (if known). D12. Write down the types of extra food and the total amount that you eat before participating in this activity. If possible, include the food group and the number of servings eaten. D13. Approximately how many minutes before participating in this activity would you eat extra food? minutes D14. Write down the beverages that you would consume before this activity, and include the total amount that you would drink. 129 11 D15. Write down the extra food and the total amount that you eat while participating in this activity. If possible, include the food group and the number of servings eaten. D16. How frequently during this activity do you eat extra food? Approximately every minutes D17. Write down the beverages that you would consume during this activity, and include the total amount that you would drink. D18. How frequently during this activity do you drink fluids? Approximately every minutes D19. Write down the extra food and the total amount that you eat after participating in this activity. If possible, include the food group and the number of servings eaten. D20. How frequently after this activity do you consume extra food? Approximately every minutes D21. Write down the beverages that you would consume after this activity, and include the total amount that you would drink. D22. How frequently after this activity do you drink fluids? Approximately every minutes 12 130 SECTION E - INSULIN REACTIONS AND TREATMENT The following questions are related to how you treat insulin reactions during and after exercise. We are interested in the symptoms of an insulin reaction that you usually recognize when you are and are not exercising. In addition, we are interested in how you treat mild, moderate, and severe insulin reactions, both during and within 24 hours following an exercise session. E1. What symptoms of hypoglycemia (low blood sugar) do you usually recognize when you are not exercising? Mark all that apply. a Hunger • Weakness • Nausea • Loss of coordination • Headache • Numbness of lips or tongue • Shaking or trembling • Confusion • Blurred vision • Anxiety a Dizziness • Excessive sweating • Drowsiness • Others (please specify) • I do not recognize symptoms of hypoglycemia. E2. What symptoms of hypoglycemia (low blood sugar) do you recognize while you are exercising? Mark all that apply. • Hunger • Weakness • Nausea • Loss of coordination • Headache • Numbness of lips or tongue • Shaking or trembling • Confusion • Blurred vision • Anxiety • Dizziness • Excessive sweating • Drowsiness • Others (please specify) • I do not recognize symptoms of hypoglycemia during exercise. E3. At what blood sugar level do you first recognize symptoms of hypoglycemia (low blood sugar). Please circle units. mmol/L / mg/dL 131 13 For the following set of questions use the following definitions: 1) . A mild insulin reaction requires no interruption of exercise, except for the consumption of extra sugar; 2) . A moderate insulin reaction requires the discontinuation of activity for more than 15 minutes, or for the rest of the exercise session, and consumption of extra sugar; and 3) . A severe insulin reaction is an unrecognized insulin reaction requiring the assistance of another person to treat. E4. Indicate the number of mild, moderate, and severe insulin reactions you have had in the last year during exercise. If you are unsure of the exact number, indicate the approximate number of times. Start with the present (G months) and work backwards in 3 month intervals. For each interval, specify the number of insulin reactions under each heading in the table below. Time Intervals Mild Reactions Moderate Reactions Severe Reactions 0 to 3 months 3 to 6 months 6 to 9 months 9 to 12 months E5. Indicate the number of mild, moderate, and severe insulin reactions that you have had within 24 hours after an exercise session in the past year. If you are unsure of the exact number, indicate the approximate number of times. Again start with the present (0 months) and work back in 3 month intervals. For each interval, specify the number of insulin reactions under each heading in the table below. Time Intervals Mild Reactions Moderate Reactions Severe Reactions 0 to 3 months 3 to 6 months 6 to 9 months 9 to 12 months E6. How do you treat a mild insulin reaction during exercise? Include the type and amount of food consumed. 14 132 El. How do you treat a mild insulin reaction within 24 hours after an exercise session? Include the type and amount of food consumed. E8. How do you treat a moderate insulin reaction during exercise? Include the type and amount of food consumed, and how long you would discontinue exercise. E9. How do you treat a moderate insulin reaction within 24 hours after an exercise session? Include the type and amount of food consumed. E10. What type of treatment do you receive for a severe insulin reaction during exercise? Include the type and amount of food consumed, and how long you would discontinue exercise. Also, include other treatment required. E l l . What type of treatment do you receive for a severe insulin reaction within 24 hours after an exercise session? Include the type and amount of food consumed. Also, include other treatment required. 15 133 S E C T I O N F - B L O O D G L U C O S E A N D U R I N E T E S T I N G The questions in the following section are designed to provide us with information on how often you test your blood glucose and urine for ketones on both exercising and non-exercising days. In addition, questions on the frequency of blood glucose testing during and immediately after an exercise session will be asked. F l . Write down the type of blood glucose monitor that you are now using. F2. On an average non-exercising day, how many times a day do you test your blood sugar? • None, go to question F4 • Three times a day • Once a day • Four times a day • Twice a day • More than four times a day F3. On a non-exercising day, when do you usually test your blood sugar? Mark all that apply. • Before breakfast • Before morning snack • Before lunch • Before afternoon snack • Before dinner • Before bed time snack • In the early hours of the morning (i.e. 2 or 3 am) • When I think my blood sugar is low • When I think my blood sugar is high • When I want to know what my blood sugar is • Others (please specify) F4. On an average exercising day, how many times a day do you test your blood sugar? Exclude blood sugar tests that you obtain for exercise. • None, go to question F6 • Three times a day • Once a day • Four times a day • Twice a day • More than four times a day 16 134 F5. On an exercising day, when do you usually test your blood sugar? Mark all that apply. Please exclude blood sugar tests that you obtain for exercise. • Before breakfast • Before morning snack • Before lunch • Before afternoon snack • Before dinner • Before bed time snack • In the early hours of the morning (i.e. 2 or 3 am) • When I think my blood sugar is low • When I think my blood sugar is high • When I want to know what my blood sugar is • Others (please specify) F6. Do you test your urine for ketones? • Yes • No, go to instructions following question F8 F7. Do you test for urinary ketones before exercise? • Yes • No F8. Do you test for urinary ketones after exercise? • Yes • No In Section D, question D10, you chose a sport that you participated in frequently and answered a series of questions on food intake required before, during, and after exercise. For this next set of questions on blood glucose testing, use the same sport to answer the following questions. Mark off or fill in the answer that best describes what you do before, during, and after exercise. If a question is not relevant to you or does not apply, indicate this in the space provided. F9. Do you test your blood sugar before you exercise? • Yes • No, go to question FI3 F10. How frequently do you check your blood sugar before exercise? time(s) • If you answered 1 time, go to question F13 FI 1. Do you test your blood sugar several times before exercise in order to determine if your blood sugar is increasing, decreasing, or staying the same? • Yes • No 135 17 F12. How long do you wait between blood sugar readings before exercise? Approximately every minutes Fl3. Do you test your blood sugar during exercise? • Yes • No, go to question Fl6 F14. How frequently do you check your blood sugar during exercise? time(s) F15. How long do you wait between blood sugar readings during exercise? Approximately every minutes F16. Do you test your blood sugar after exercise? • Yes • No, go to question F19 F17. How frequently do you check your blood sugar after exercise? time(s) F18. How long do you wait between blood sugar readings after exercise? Approximately every minutes F19. What criteria do you use to postpone exercise? Include information related to blood sugar levels, presence of urinary ketones, or other indications you would use to postpone exercise. F20. How does the criteria to postpone exercise differ for recreational exercise or for competition. Again include information related to blood glucose, urinary ketones, or other information you would use to postpone exercise. 18 136 SECTION G - SAFETY Exercise safety is an issue for all people who are active to avoid hazardous situations and injury. Exercise for people with insulin-dependent diabetes poses some extra issues related to safety during exercise. We are interested in what extra measures you take to avoid problems while exercising. Please answer the questions honesdy by stating what you actually do, rather than what you think you should do, or what you have been instructed to do by your Health Care Team. G l . On average, what percent of the time do you wear a medical alert bracelet or necklace (diabetic identification) during exercise? • 0% • 25% • 50% • 75% • 100 %, go to question G3 G2. Why do you not wear a medical alert bracelet or necklace (diabetic identification) during exercise? Mark all that apply. • I do not have one • The bracelet or necklace could get caught on clothing or other objects • The bracelet or necklace could hurt me or someone else • I have been instructed by game officials to remove it • Others (please specify) G3. On average, what percent of the time do you have a source of sugar readily available for use during exercise? • 0% • 25% • 50% • 75% • 100 %, go to question G5 G4. Write down reason(s) why a source of sugar is not always available during exercise? G5. On average, what percent of the time do you have your blood glucose monitor or visual blood glucose strips available for use during exercise? • 0% • 25% • 50% • 75% • 100 %, go to question G7 G6. Write down reason(s) why a blood glucose meter or visual blood glucose strips is not available during exercise. 137 19 G7. Do you exercise with a someone who knows you have diabetes? • Yes • No, go to question G9 G8. Does this person know how to treat an insulin reaction? • Yes • No G9. Do you frequently exercise alone? • Yes • No, go to question G i l G10. When you exercise alone, what percent of the time do you tell someone where you are going and approximately when you will be back? • 0% • 25% • 50% • 75% • 100%, go to question G12 G i l . Write down reason(s) why you do not tell someone where you are going and when you will be back. G12. Do you have a glucagon injection available when you exercise for severe insulin reactions? • Yes • No, go to question G14 G13. Does the person you exercise with know how to administer a glucagon injection? • Yes • No G14. Do you check your feet every day? • Yes • No G15. Do you check your feet after each exercise session? • Yes • No 20 138 S E C T I O N H - L O N G - T E R M C O M P L I C A T I O N S This section asks you about the presence of any long-term complications related to insulin-dependent diabetes, and how these complications impact on the types of exercise that you can participate in. HI. Which of the following long-term complications of diabetes do you have, if any? Mark all that apply. • Retinopathy (eye problems) • Nephropathy (kidney problems) • Neuropathy (nerve problems, numbness and/or tingling) • Hypertension (high blood pressure) • Postural hypotension (low blood pressure or feeling faint on standing) • Cardiovascular disease (heart problems) • Hyperlipidemias (high blood fat levels, including cholesterol) • Skin problems (ulcers, cuts that will not heal) • Foot problems (calluses, ulcers, frequent blisters, numbness and/or tingling) • None, go to question H6 H2. Have you been instructed by your doctor to avoid certain types of exercise due to diabetic complications? • Yes • No, go to question H6 H3. What types of exercise have you been instructed by your doctor to avoid as a result of long-term diabetic complications? H4. Why have you been instructed to avoid these exercises? 139 21 H5. List any sports or activities that you enjoyed participating in at one time and now are unable to because of the complications of diabetes. H6. Have you been instructed by your doctor to avoid certain types of exercise due to a medical condition not related to diabetes? • Yes • Noj go to Section I on page 23 H7. What types of exercises have you been instructed by your doctor to avoid as a result of these other medical problems not related to diabetes? 22 140 SECTION I • ADDITIONAL INFORMATION In this section, we would like you to give us some additional information related to insulin-dependent diabetes and exercise. Space is provided at the end of this section to give you the opportunity to give us some feedback and comments on the questionnaire. If a question does not apply to you, print "not applicable" in the space provided. Please neatly print your answers. II. How do you adjust your food intake, and blood glucose testing for unplanned exercise? Also, indicate if you adjust your insulin dose following unplanned exercise and by how many units. 12. Do you use an exercise diary to keep track of your activities, blood glucose levels, and insulin needs for specific sports? If you do, indicate what information you include in your diary and how you use this information to plan for future events. 141 23 13. Many athletes use carbohydrate loading to increase performance during long-term events. If you have tried to carbohydrate load in the past, give details on how you accomplished this. Write down any problems that you had and how you overcame them. 14. If you were introduced to someone who indicated that they had insulin-dependent diabetes and were interested in starting to exercise on a regular basis, what suggestions or helpful hints would you give to this person? What "secrets to exercise success" would you share? 24 142 15. In general, do you think that your diabetic control is better, about the same, or worse than if you did not pursue an active lifestyle? Why do you think your control is better, the same, or worse? If possible, include information on changes in blood glucose and hemoglobin Aic levels. 16. The space below is provided for any additional comments that you may have related to the contents of the questionnaire, or to insulin-dependent diabetes and exercise in general. We would like to thank you for the time and patience required to complete this questionnaire. Please place the completed questionnaire in the self-addressed, stamped envelope that was provided with the questionnaire, and mail it at your earliest convenience. Once again thank you! 143 25 APPENDIX B POSTCARD REMINDERS 144 P O S T C A R D R E M I N D E R #1 Front of Postcard #1 Willa Sankey <Street Address> <City, Province> <Country> <Postal Code> <Subject's Full Name> <Street Address> <City, Provin.ee/State> <Canada/U.S.A.> <Postal/Zip Code> Back of Postcard #1 September 25, 1996. Approximately two weeks ago, surveys on insulin-dependent diabetes and exercise were sent out to a random sample of members of the International Diabetic Athletes Association. The research project on diabetes and exercise is presently being conducted at the University of British Columbia to determine how diet, insulin, and exercise are modified for an active lifestyle If you have already completed and mailed the survey back to me, I would like to take this opportunity to thank you for your participation in this study. If you have not completed the survey, please consider doing so today. Only a small number of people have been included in the study, so your reply is extremely important to the success of this study. If you require additional information about the research project, or require another copy of the survey, please feel free to contact me toll free at 1-888-000-0000 between 9 am and 8 pm Pacific Time. Once again, thank you for your help with this important research project. Sincerely; Willa Sankey, BHEc. Project Coordinator 145 P O S T C A R D R E M I N D E R #2 Front of Postcard #2 Willa Sankey <Street Address> <City, Province> <Country> <Postal Code> <Subject's Full Name> <Street Address> <City, Province/State> <Canada/U.S.A.> <Postal/Zip Code> Back of Postcard #2 October 11, 1996. About a month ago, you should have received a survey on insulin-dependent diabetes and exercise. The purpose of this study is to obtain information from active diabetics on the diet insulin, and exercise adjustments required to maintain an active and healthy lifestyle. At the time of this mailing, I have not yet received your completed survey. Your participation in this research is very important since only a small number of subjects have been recruited for this study. The contents of the returned survey are strictly confidential. Please take time now to complete the survey. In the event you did not receive a survey or have misplaced it, call me toll free at 1-888-000-0000 between 9 am and 8 pm Pacific Time, for a replacement. Your cooperation is greatly appreciated. If you have returned your survey, kindly disregard this reminder. Thank you for your participation in this important research project. Sincerely; Willa Sankey, BHEc. Project Coordinator 146 APPENDIX C REFERENCES USED FOR QUESTIONNAIRE CONSTRUCTION 147 REFERENCES USED FOR QUESTIONNAIRE CONSTRUCTION Aday, L. (1989). Designing and Conducting Health Surveys: A Comprehensive Guide. Jossey-Bass Publishers, San Francisco, California. American Diabetes Association (1988). Nutrition Guide For Professionals: Diabetes Education and Meal Planning. American Diabetes Association Inc., and The American Dietetic Association. American Diabetes Association (1994). Meal Planning Approaches for Diabetes Management. Diabetes Care and Education Dietetic Practice Group of the American Dietetic Association. Backstrom, C , and Hersh-Cesar, G. (1981). Survey Research. John Wiley and Sons, New York, New York. Bellenir, K., and Dresser, P. (1994). Diabetes Sourcebook. Omnigraphics Inc., Detroit, Michigan. Berdie, D., Anderson, J., and Niebuhr, M. (1986). Questionnaires: Design and Use. The Scarecrow Press, Metuchen, New Jersey. Berg, K. (1986). Diabetic's Guide to Health and Fitness: An Authoritative Approach to Leading an Active Life. Life Enhancement Publications, Champaign, Illinois. Bourque, L., and Fielder, E. (1995). How to Conduct Self-Administered and Mail Surveys. Sage Publications, Thousand Oaks, California. Canadian Diabetes Advisory Board (1992). Clinical practice guidelines for treatment of diabetes mellitus. Canadian Medical Association Journal, 147(5):697-712. Canadian Diabetes Association (1987). Exercise and Diabetes. Canadian Diabetes Association (1994). Good Health Eating Guide Resource. Charach, L. (1975). Using Mail Questionnaires: The Optimal Methodology and an Example. Educational Research Institute of British Columbia Reports, Vancouver, British Columbia. Converse, J., and Presser, S. (1986). Survey Questions: Hand Crafting the Standardized Questionnaire. Sage Publications, Beverly Hills, California. Dillman, D. (1978). Mail and Telephone Surveys: The Total Design Method. John Wiley and Sons, New York, New York. 148 Fink, A., and Kosecoff, J. (1983). How to Conduct Surveys: A Step-by-Step Guide. Sage Publications, Beverly Hills, California. Fink, A. (1995). How to Ask Survey Questions. Sage Publications, Thousand Oaks, California. Fink, A. (1995). How to Design Surveys. Sage Publications, Thousand Oaks, California. Fink, A. (1995). How to Sample in Surveys. Sage Publications, Thousand Oaks, California. Fink, A. (1995). The Survey Handbook. Sage Publications, Thousand Oaks, California. Fowler, F. (1988). Survey Research Methods. Sage Publications, Beverly Hills, California. Gray, G., and Guppy, N. (1993). Successful Surveys: Research Methods and Practice. Harcourt Brace and Company, Toronto, Ontario. Haire-Joshu, D. (1992). Management of Diabetes Mellitus: Perspectives of Care Across the Life Span. Mosby Year Book, St. Louis, Missouri. Health and Welfare Canada (1992). Canada's Food Guide to Healthy Eating. Published Under the Authority of The Minister of National Health and Welfare, Canada. Jenkinson, C. (1994). Measuring Health and Medical Outcomes. University College London Press, London, England. Labow, P. (1980). Advanced Questionnaire Design. Abt Books, Cambridge, Massachusetts. Lewis, A., Cory, G., Hunt, J., and Byres, I. (1989). Exercise and the Curious Diabetic. Canadian Diabetes Association. Lockhart, D. (1984). Making Effective Use of Mailed Questionnaires. Jossey-Bass, San Francisco, California. Marquis, K., Ware, J., and Relies, D. (1979). Measures of Diabetic Patient Knowledge, Attitudes, and Behavior Regarding Self-Care. Appendix C to Summary Report: New Measures of Diabetic Patient Behavior, Knowledge, and Attitudes. RAND, Santa Monica, California. Mood, D., Musker, F., and Rink, J. (1995). Sports and Recreational Activities. Mosby Publishing, St. Louis, Missouri. Mueller, P. (1971). Intermurals: Programming and Administration. The Ronald Press Company, New York, New York. Nadeau, A. (1996). Diabetes and exercise: Working it out. The Canadian Journal of Continuing Medical Education, May 1996:43-56. 149 Oppenheim, A. (1992). Questionnaire Design, Interviewing and Attitude Measurement. Pinter Publishers, New York, New York. Platek, R., Pierre-Pierre, F., and Stevens, P. (1985). Development and Design of Survey Questionnaires. Published Under the Authority of The Minister of Supply and Services, Canada Rifkin, H., and Porte, D. (1990). Ellenberg and Rifkin's Diabetes Mellitus: Theory and Practice. Elsevier Science Publishing, New York, New York. Rossi, P., Wright, J., and Anderson, A. (1983). Handbook of Survey Research. Academic Press, New York, New York. Stephens, T., and Craig, C. (1989). Fitness and activity measurement in the 1981 Canada Fitness Survey. In: Assessing Physical Fitness and Physical Activity in Population Based Surveys. Published by the U.S. Department of Health and Human Services. Stephens, T., and Craig, C. (1990). The well-being of Canadians: Highlights of the 1988 Campbell's Survey. Health and Welfare Canada. Streiner, D., and Norman, G. (1995). Health Measurement Scales: A Practical Guide to their Development and Use. Oxford University Press, New York, New York. Sudman, S., and Bradburn, N. (1982). Asking Questions: A Practical Guide to Questionnaire Design. Jossey-Bass Publishers, San Francisco, California. Taunton, J., and M°Cargar, L. (1995). Managing activity in patients who have diabetes. The Physician and Sports Medicine, 23(3):41-52. Taunton, J., and McCargar, L. (1995). Staying active with diabetes: Quick-and-helpful exercise tips. The Physician and Sports Medicine, 23(3):55-56. Warwick, D., and Lininger, C. (1975). The Sample Survey: Theory and Practice. M cGraw-Hill, New York, New York. Weisberg, H., Krosnick, J., and Bowen, B. (1989). Introduction to Survey Research and Data Analysis. Scott, Foresman, and Company, Glenview, Illinois. Woodward, C , and Chalmers, L. (1983). Guide to Questionnaire Construction and Question Writing. The Canadian Public Health Association, Ottawa, Ontario. Zeman, F. (1991). Clinical Nutrition and Dietetics. MacMillan Publishing Company, New York, New York. 150 A P P E N D I X D I D A A N E W S L E T T E R A D V E R T I S E M E N T 151 T H E C H A L L E N G E N E W S L E T T E R A R T I C L E S U M M E R 1996 TNSULTN-DEPENDENT DIABETES AND EXERCISE STUDY The School of Human Kinetics at The University of British Columbia, Vancouver, Canada will be conducting a questionnaire research study that will look at diabetes and exercise. The purpose of this research study is to obtain information from individuals with insulin-dependent diabetes on the diet, insulin, and exercise adjustments that are required to maintain an active and healthy lifestyle. Also, information on the prevention and treatment of insulin reactions, blood glucose monitoring, and person safety while exercising will be collected. The results obtained from the study will be used to increase awareness of the modifications required for exercise in the insulin-dependent diabetic population. Three hundred IDAA members from Canada and The United States will be randomly selected to participate in this research study. The questionnaires will be sent out in late August or early September. If you receive a questionnaire package in the mail, please fill it out and return it within two weeks. Your participation in this important research study would be greatly appreciated. A toll free telephone number will be included with the questionnaire so that I can answer any questions that you may have about the research project. A summary of the research findings will be printed in an IDAA newsletter in 1997. I look forward to receiving your completed questionnaire. Thank you for your assistance! Willa Sankey, BHEc. Project Coordinator 152 A P P E N D I X E T E L E P H O N E L O G 153 T E L E P H O N E L O G Date Time Purpose of Telephone Cal l September 17 1211 Non-diabetic Health Care Professional wanted to know if the questionnaire could be passed on to an associate with IDDM. September 17 1330 Subject wanted clarification on how to answer dietary questions and questions related to insulin adjustments for exercise. September 17 1730 Subject wanted to know if he was NIDDM or IDDM. Diagnosis made later in life, sudden onset, and no history of oral hypoglycemic medications. Subject qualified for study. September 18 0815 Subject requested information on the purpose of the study and required assistance in answering some of the dietary and insulin adjustment questions. September 20 1505 Non-diabetic Health Care Professional wanted to know if the questionnaire could be passed on to a patient with IDDM. September 23 0945 Subject indicated that they were non-diabetic so would not be participating in the study. Questionnaire not being returned. September 25 Unanswered call September 25 0845 Subject called to get clarification on the dietary questions. September 27 1615 Subject received the first postcard reminder in the mail and indicated that the questionnaire had been sent back. October 01 1525 Subject received a postcard reminder in the mail and called to indicate that she did not qualify for the study. October 01 1830 Subject called to clarify the purpose of the study and to find out when and where the results would be available. October 02 Unanswered call October 02 1245 Subject received a postcard reminder and indicated that the questionnaire had been returned. October 03 Unanswered call October 03 1530 Subject required assistance with the dietary section of the questionnaire. October 04 1100 Subject called for assistance with various parts of the questionnaire. Went through the questionnaire by section. October 07 1350 Subject called and indicated that the questionnaire had just been received in the mail due to a recent move. Wanted to know if the study was still ongoing. October 07 1730 Subject received a postcard reminder and called to see if the questionnaire could be filled out and returned in a weeks time. October 07 1800 Subject received a postcard reminder and indicated that the questionnaire had been returned. October 09 0905 Subject has moved and only received the postcard reminder. Requested another copy of the questionnaire be sent to them. October 11 1420 Subject required assistance in filling out the questionnaire, specifically the dietary section. October 14 1430 Subject received a postcard reminder and indicated that the questionnaire had been returned. 154 Date Time Purpose of Telephone Cal l October 14 1250 Subject received a postcard reminder and did not qualify for the study. The subject will return the questionnaire. October 15 1025 Subject called and wanted to know if study was still ongoing. Subject will complete the questionnaire and return it shortly. October 18 0620 Subject has brittle diabetes and is unable to exercise at this time. Subject will return the questionnaire with an explanation. October 19 0940 Subject called and requested assistance with various part of the questionnaire. Exercise patterns have changed dramatically in the past 6 months and wanted to know which exercise patterns to follow in answering the questions, (requested to use recent changes). October 21 Unanswered call October 21 0915 Subject was out of town for an extended period of time. Subject wanted to know if the questionnaire could still be completed and returned. October 22 0915 Subject had moved and received postcard reminder #2. Subject requested that a second copy of the questionnaire be sent. October 22 0930 Subject received postcard #2 and had sent in the questionnaire "a long time ago". Double checked returns table and it had been received. October 23 1005 Subject misplaced questionnaire and requested that I send another copy. October 30 Unanswered call October 30 Unanswered call November 04 1830 Subject received postcard reminder #2. The subject did not qualify for the study and did not send questionnaire back. November 18 1005 Subject just sent the questionnaire package back as they had been out of town for an extended period of time. Total calls = 35 Total answered calls = 29 Total unanswered calls = 6 155 APPENDTX F R E T U R N R A T E T A B L E 156 R E T U R N R A T E T A B L E Date Number Percent Number Number Adjusted % Returned Returned* DNQ Qualified Returned** Sept 17 1 0.3 0 1 0.3 Sept 18 1 0.6 1 0 0.3 Sept 19 0 0.6 0 0 0.3 Sept 20 3 1.5 3 0 0.3 Sept 23 10 4.6 6 4 1.6 Sept 24 28 13.2 13 15 6.6 Sept 25 5 14.8 3 2 7.4 Sept 26 17 20.0 10 7 10.0 Sept 27 7 22.2 5 2 10.9 Sept 30 20 28.3 8 12 15.6 Oct 01 23 35.7 8 15 21.7 Oct 02 7 37.8 2 5 23.8 Oct 03 7 40.0 1 6 26.1 Oct 04 4 40.9 1 3 27.3 Oct 07 9 43.4 1 8 30.3 Oct 08 13 47.4 4 9 34.2 Oct 09 4 48.6 1 3 35.5 Oct 10 3 49.5 3 0 35.9 Oct 11 19 55.4 5 14 42.2 Oct 15 2 56.0 1 1 42.8 Oct 16 8 58.5 1 7 45.8 Oct 17 1 58.8 0 1 46.2 Oct 18 0 58.8 0 0 46.2 Oct 21 8 61.2 2 6 49.0 Oct 22 4 62.5 1 3 50.4 Oct 23 1 62.8 0 1 50.8 Oct 24 0 62.8 0 0 50.8 Oct 25 4 64.0 0 4 52.4 Oct 28 2 64.6 .2 0 52.9 Oct 29 3 65.5 0 3 54.1 Oct 30 0 65.5 0 0 54.1 Oct 31 3 66.5 1 2 55.1 Nov 01 3 67.4 0 3 56.4 Nov 04 1 68.0 1 0 56.8 Nov 05 2 68.6 1 1 57.5 Nov 06 1 68.9 0 1 57.9 Nov 07 1 69.2 0 1 58.3 Nov 08 1 69.5 1 0 58.6 Nov 12 0 69.5 0 0 58.6 Nov 13 2 70.2 0 2 59.4 Nov 14 1 70.5 1 0 59.7 157 Date Number Percent Number Number Adjusted % Returned Returned* DNQ Qualified Returned** Nov 18 3 71.4 0 3 60.9 Nov 21 1 71.7 0 1 61.3 Nov 22 1 72.0 0 1 61.8 Nov 27 1 72.3 0 1 62.2 Dec 05 1 72.6 0 1 62.6 Dec 10 1 72.9 0 1 63.0 Dec 12 1 73.2 0 1 63.4 Total 238 73.2 87 151 63.4 * Percent returned = total questionnaires received / total sent (325) ** Adjusted percent returned = total questionnaires that qualified / [total sent (325) - DNQ] 158 A P P E N D I X G QUESTIONNAIRE R E T U R N T A B L E 159 QUESTIONNAIRE R E T U R N T A B L E N U M S U R V E Y R E C ' D D A T E STATUS C O M M E N T S 1 2700 V Oct 01 Q 2 2701 V Sept 26 Q 3 2702 X 4 2703 V Oct 07 Q 5 2704 • V Oct 21 Q 6 1700 Sept 30 Q 7 2705 V Sept 30 DNQ Moved 8 2706 V Oct 01 Q 9 2707 V Sept 25 DNQ Health Professional 10 2708 X 11 2709 V Sept 23 DNQ NIDDM 12 2710 V Sept 24 Q 13 2711 Oct 10 DNQ Moved 14 2712 v Sept 30 Q 15 2713 X 16 2714 V Oct 22 Q 17 2715 V Oct 08 Q 18 2716 A/ Nov 05 Q 19 2717 V Oct 08 Q 20 2718 Oct 23 Q 21 2719 X 22 1701 V Sept 30 Q 23 2720 V Sept 24 DNQ 24 2721 V Oct 25 Q 25 2722 X 26 2723 V Dec 05 Q 27 2724 X 28 2725 X 29 1702 V Oct 01 Q 30 2726 V Oct 16 DNQ 31 2727 X 32 2728 V Sept 30 Q 33 2729 Nov 13 Q 34 2730 X 35 2731 X 36 2732 X 37 1703 V Oct 11 Q 38 2733 V Sept 26 DNQ 39 2734 X 40 2735 X 41 2736 X 42 2737 Oct 03 Q 160 NUM SURVEY REC'D DATE STATUS COMMENTS 43 2738 X 44 2739 V Oct 01 DNQ 45 2740 X 46 2741 V Oct 03 Q 47 2742 V Oct 11 DNQ Health Professional 48 2743 V Sept 30 DNQ Health Professional 49 2744 V Sept 23 DNQ Health Professional 50 2745 V Sept 24 DNQ Health Professional 51 2746 Sept 26 DNQ Health Professional 52 2747 V Oct 07 Q 53 2748 V Sept 30 DNQ 54 2749 Nov 18 Q 55 2750 V Sept 24 Q 56 2751 V Oct 16 Q 57 1704 V Sept 26 DNQ 58 2752 V Sept 26 Q 59 1705 V Sept 26 Q 60 1706 V Oct 03 Q 61 2753 V Sept 24 Q 62 2754 V Sept 24 Q 63 2755 X 64 2756 V Oct 08 Q 65 2757 V Oct 09 Q Subject 9 yrs - parent completed 66 2758 X 67 2759 V Oct 01 Q 68 2760 X 69 2761 V Oct 09 Q 70 2762 X 71 2763 Sept 24 DNQ Health Professional 72 2764 V Oct 11 Q 73 2765 Oct 01 DNQ Health Professional 74 2766 X 75 1707 Sept 24 Q 76 2767 V Sept 30 DNQ 77 2768 X 78 1708 Sept 30 DNQ Health Professional 79 2769 V Oct 07 Q 80 2770 V Oct 01 Q 81 2771 V Sept 20 DNQ 82 2772 V Oct 01 Q 83 2773 V Oct 22 Q 84 2774 X 85 2775 X 86 2776 V Sept 24 DNQ Health Professional 161 NUM SURVEY REC'D DATE STATUS COMMENTS 87 2777 V Sept 24 DNQ Health Professional 88 2778 X 89 2779 V Oct 25 Q 90 2780 V Sept 25 Q 91 2781 V Oct 02 DNQ Moved 92 2782 V Oct 21 Q 93 2783 V Nov 22 Q Quest sent Oct 31 #2838 - lost orig. 94 1709 V Sept 25 DNQ 95 1710 Dec 12 Q Quest sent Oct 07 #1731 - lost orig. 96 2784 v Sept 30 DNQ ND, mother of adult with IDDM 97 1711 X 98 2785 v Oct 07 Q 99 2786 V Oct 02 Q 100 2787 V Sept 30 Q 101 1712 V Sept 24 DNQ 102 2788 X 103 1713 V1 Oct 02 Q 104 2789 V Oct 01 Q 105 2790 V Oct 03 Q 106 2791 V Sept 27 Q 107 1714 V Sept 24 Q 108 2792 V Oct 10 DNQ Moved 109 1715 V Oct 04 Q 110 2793 V Oct 01 DNQ Undeliverable as addressed 111 2794 V Oct 10 DNQ Moved - postcard #1 returned also 112 2795 v Sept 26 DNQ Moved - postcard #1 returned also 113 2796 V Oct 08 Q 114 2797 X 115 2798 V Sept 30 Q 116 2799 V Sept 24 DNQ Health Professional 117 2800 X 118 2801 X 119 2802 Sept 27 DNQ 120 2803 V Oct 01 DNQ Health Professional 121 2804 V Sept 26 Q 122 2805 X 123 1716 Sept 17 Q 124 2806 Oct 01 Q 125 2807 Oct 08 DNQ ND 126 2808 V1 Oct 01 Q 127 1717 Oct 29 Q 128 2809 Oct 04 DNQ Moved 129 2810 X 130 2811 V Oct 21 DNQ ND 162 NUM SURVEY REC'D DATE STATUS COMMENTS 131 2812 V Oct 11 Q 132 2813 V Nov 13 Q 133 2814 V Oct 31 Q 134 2815 V Sept 30 Q 135 2816 X 136 2817 X 137 2818 V Sept 20 DNQ Moved - postcard #1 returned also 138 1718 X 139 2819 V Oct 01 INC Questionnaire only partly filled out 140 2820 V Oct 21 Q 141 2821 X 142 2822 A/ Nov 27 Q 143 2823 V Oct 07 Q 144 2824 V Oct 31 DNQ Moved - postcard #2 returned also 145 2825 X 146 2826 V Oct 16 Q 147 2827 V Sept 26 Q 148 2828 V Oct 11 Q 149 2829 V Oct 22 Q 150 2830 Sept 23 Q 151 2831 %/ Sept 24 Q 152 2832 X 153 2833 X 154 2834 X 155 2835 Sept 23 Q 156 2836 Sept 23 DNQ Health Professional 157 2837 X 158 2838 V Sept 26 DNQ Moved 159 2839 X 160 2840 Oct 11 DNQ 161 2841 V Sept 24 Q 162 1719 Oct 16 Q 163 2842 Oct 02 Q 164 2843 Oct 07 DNQ Moved 165 2844 V Oct 11 Q 166 2845 Oct 11 Q 167 2846 V Sept 26 DNQ Moved 168 2847 Sept 27 DNQ Health Professional 169 2848 Oct 11 Q 170 2849 Oct 21 Q 171 2850 V Oct 17 Q 172 1720 X 173 2851 X 174 2852 V Nov 07 Q 163 NUM SURVEY REC'D DATE STATUS COMMENTS 175 1721 V Oct 01 Q 176 2853 X 177 2854 V Nov 01 Q 178 1722 V Oct 28 DNQ 179 2855 V Sept 30 Q 180 2856 V Oct 29 Q 181 2857 X 182 1723 V Sept 18 DNQ 183 1724 V Sept 30 Q 184 2858 X 185 2859 X 186 2860 X 187 2861 Oct 01 DNQ ND 188 2862 V Oct 16 Q 189 2863 v Oct 08 Q 190 2864 V Sept 24 DNQ Moved - postcard #1 returned also 191 2865 V Nov 08 DNQ NIDDM 192 2866 X 193 2867 V Sept 26 Q 194 2868 V Sept 20 DNQ Moved 195 2869 V Sept 27 DNQ Subject under age - quest, returned 196 2870 Oct 01 Q 197 2871 V Sept 24 Q 198 2872 V Sept 30 DNQ 199 2873 V Oct 01 Q 200 1725 V Sept 25 DNQ Moved 201 2874 X 202 2875 Oct 28 DNQ ND 203 2876 v Oct 08 Q 204 2877 X 205 2878 X 206 2879 Sept 24 Q 207 2880 V Sept 26 DNQ 208 2881 V Sept 24 DNQ ND 209 2882 Nov 18 Q 210 2883 X 211 2884 V1 Sept 24 DNQ Health Professional 212 2885 Oct 01 DNQ Health Professional 213 2886 V Oct 21 Q 214 2887 v Oct 08 DNQ 215 2888 V Oct 25 Q 216 2889 V Nov 06 Q 217 2890 V Sept 25 Q 218 2891 X 164 NUM SURVEY REC'D DATE STATUS COMMENTS 219 2892 X 220 2893 X 221 2894 X 222 2895 X 223 2896 V Oct 08 DNQ Health Professional 224 1726 V Sept 30 DNQ 225 1727 V Oct 01 Q 226 2897 Sept 24 Q 227 2898 X 228 2899 V Sept 26 DNQ 229 2900 V Oct 21 DNQ Health Professional 230 2901 X 231 2902 V Oct 15 Q 232 2903 X 233 2904 X 234 2905 V Oct 07 Q 235 2906 Oct 11 Q 236 2907 V Sept 26 DNQ 237 2908 V Oct 15 DNQ ND 238 2909 < Dec 10 Q 239 2910 V Sept 23 Q 240 1728 V Oct 11 Q 241 2911 V Nov 05 DNQ Moved 242 2912 V Oct 01 Q 243 2913 X 244 2914 Sept 26 Q 245 2915 V Sept 26 DNQ Moved 246 2916 Sept 24 Q 247 2917 V Sept 23 DNQ ND - phoned in response 248 2918 X 249 2919 X 250 2920 V Oct 09 DNQ Undeliverable as addressed 251 2921 V Oct 11 DNQ Moved 252 2922 X 253 2923 V Sept 30 Q 254 2924 V Sept 23 DNQ NIDDM 255 2925 Sept 24 Q 256 1729 Oct 02 Q 257 2926 Oct 11 DNQ ND 258 2927 X 259 2928 X 260 2929 Oct 07 Q 261 2930 V Sept 24 Q 262 2931 Oct 08 Q 165 N U M S U R V E Y R E C ' D D A T E STATUS C O M M E N T S 263 2932 Oct 31 Q 264 2933 X 265 2934 V Oct 11 Q 266 2935 A/ Oct 11 Q 267 2936 V Oct 11 Q 268 2937 V Sept 24 DNQ 269 2938 X 270 2939 X 271 2940 V Sept 24 DNQ Moved - postcard #1 returned also 272 2941 V Sept 24 DNQ NIDDM 273 2942 V Oct 09 Q 274 2943 V Oct 03 Q 275 2944 V Oct 04 Q 276 2945 V Oct 08 DNQ 277 2946 Sept 30 Q 278 2947 X 279 1730 V Sept 23 DNQ Health Professional 280 2948 X 281 2949 V Oct 01 DNQ Moved 282 2950 V Sept 27 Q 283 2951 X 284 1731 V Oct 02 DNQ ND 285 2952 V Sept 23 Q 286 2953 V Sept 24 Q 287 2954 V Sept 30 Q 288 2955 V Oct 03 Q 289 2956 V Oct 11 Q 290 2957 V Nov 18 Q 291 1732 X 292 1733 V Oct 07 Q 293 2958 X 294 2959 V Oct 11 DNQ Moved - postcard #1 returned also 295 2960 V Nov 14 DNQ Moved 296 1734 V Oct 08 Q 297 2961 X 298 2962 V Oct 29 Q 299 2963 X 300 2964 v Oct 04 Q 301 1735 V Oct 21 Q 302 2965 V Oct 16 Q 303 2966 V Nov 01 Q 304 2967 Oct 16 Q 305 2968 X 306 2969 V Oct 16 Q 166 N U M S U R V E Y R E C ' D D A T E S T A T U S C O M M E N T S 307 2970 A/ Oct 02 Q 308 2971 X 309 2972 Oct 08 Q 310 2973 V Oct 25 Q 311 1736 X 312 2974 X 313 1737 Oct 22 DNQ Moved 314 1738 X 315 2975 Oct 01 DNQ Moved 316 2976 V Nov 01 Q 317 2977 Oct 01 Q 318 1739 X 319 2978 Nov 04 DNQ 320 2979 V Oct 03 DNQ Moved 321 1740 V Oct 11 Q 322 1741 V Nov 21 Q 323 1742 Sept 27 DNQ 324 1743 V Sept 27 DNQ 325 2980 X Key: Num = Number Rec'd = Received V = Questionnaire returned x = Questionnaire not returned Status: Q = Qualified DNQ = Did Not Qualify INC = Incomplete 167 

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