Hi everyone and welcome to this episode of Diabetes Perspectives on decoding how to use AID around physical activity in type 1 diabetes. My name is Dessi Zaharieva. I am an instructor at Stanford University and this is my dear colleague and friend, Prof. Dr. Othmar Moser at University of Bayreuth and University of Graz. Thank you very much for this kind introduction, Dessi. So I think we did set up a very nice position statement for the EASD and ISPAD. But why was it that important writing a specific position statement for AID, type 1 diabetes and exercise? Well, both of us are very passionate about this field and we know that there are a number of consensus and position statements that exist. But many of them are not focusing on one of the greatest challenges of type 1 diabetes management: so exercise and type 1 diabetes, often a challenge for many individuals. And so with other, you know, position statements that exist, one of the things that’s lacking, or at least detailed information and guidance: What do we do around each commercially available system, as there's new systems and new technology available, how do we handle that around exercise? And this was an opportunity for us to highlight all of the different systems available and how we can use those. But let me ask you a stupid question: Is there such a major difference between traditional CSII therapy, so insulin pump therapy, and AID systems or can I use all the recommendations we have written a couple of years ago, also for AID systems? I wish I could say we can use all of them, no problem. I think one of the challenges is: Those guidelines that were used for, you know, open loop insulin pumps and for multiple daily injections, they guide us and they are a starting point for what happens when we use automated insulin delivery. But if we don't have communication between the devices, if there are different types of exercise we do, we need to make different decisions when we use those AID systems. So you did say previously, we did set up a few position statements, consensus reports on exercise and insulin therapy, and there's also a recent consensus report existing on AID systems, but again, the part physical activity and exercise is missing. Do you have the impression, because you are absolutely into the content, that we have the chance to really set something up that is working now for people with type 1 diabetes, when using an AID around exercise? That was the exact goal. You know, by writing this position statement together, you and me, when we came together with the whole group to work on this was how do we focus on each system individually and talk about all of the specifics, because each system is different, and, you know, we should be able to know how to use each of those systems to be able to provide not only guidance for people that live with diabetes, providers that have to manage their patients in the clinic, you know, a lot of the times they don't understand all of the differences. Even for us, there was a lot we had to learn. We don't have every system in the U.S. So for me, this position statement allowed us to learn about each system, even those that we don't have yet in America. So over the couple of last months, I think we had around 20, 30 meetings, each for two hours lasting, and we were absolutely struggling to find the right information for each AID system. So maybe, can you give us a little idea how we did set up, for example, the information about insulin on board, how we can set up our start and exercise mode, how did we do that during the entire process setting this new position statement up? Well, I think some of the challenges were that we were limited on space sometimes. So I think when you think about how much we wrote initially and how much we had to cut back on the content, there's a lot that we had to write and then to fine-tune and make sure that it was just specific to what we wanted to cover. So I think we made sure that each commercially available system was covered, even, you know, newer systems that were just recently released in the U.S., for example, we have all of those systems covered and we talk about not only exercise generally, because we know that different types of exercise can do different things to blood sugars. So we had to talk about, well, also not everybody is planning before exercise what to do. So we had to try to cover topics of planned or unplanned exercise, each system individually. We talked to manufacturers, We have to go back and find out how does insulin on board get reported on each system, make sure that all the information is covering the topics that we need around exercise. May I jump on this? I think it was extremely difficult for us to find the entire information for each AID system. So we had so many conversations with the companies to get the correct information that we are absolutely sure that the patients and the HCPs are receiving the correct information. So this was a whole lot of work, and I think from my point of view, which makes it so extremely interesting, as you were saying, it's not a general overview, what you can do when you're using an AID system, it's absolutely specified for each commercially available system. So the idea of us was you have a sheet of paper in front of you, you find the right insulin pump or AID system the patient is using, this is the problem and this is the solution that you can find within 30 seconds. So I think in the direct comparison to the 2020 CGM position statement, you were also setting this up together with me, we had the issue that it was very complex. So we had so much information included. I think it was like an AI system and algorithm set it up. So but I think this time we were absolutely good in setting something up that it's so easy to understand, it's easy to understand, and it's very fast to understand. You can hand this over to your patient, and I think this makes life for both, for the HCP and for the person living with type 1 diabetes extremely easy. I agree. May I ask you a further question? So as we know from the title, it's a joint EASD/ISPAD position statement. So do we distinguish between recommendations for children and adolescents with type 1 diabetes and adults? Are they completely the same or are they different? Great point. We went back and forth about this topic for a while because I work in paediatrics, and we know that, unfortunately, a lot of the evidence-based literature that exists, oftentimes many of these studies are done in adults with type 1 diabetes. We wanted to avoid any over-generalised statement. So where we could, we focused on specific studies to clarify that it was done in adults or done in paediatrics, because we want to make sure that people understand what we're talking about, whether that study was only done in adults, we can't just say that's exactly what you would do in paediatrics. If we had the evidence there we made sure we specified, and so we were very clear about that. And I think, if I'm not mistaken, this was something that you had to navigate with the CGM consensus paper, sometimes people ask, was this published in adults, was this done in paediatrics? And so for us, we tried to be as clear as we can in this consensus statement. And then I just wanted to add on that. I think what was really important of this statement was making sure that it covered each system, but we went through each system in a lot of detail, but we kept it practical. That is the key word here, because how do you simplify a complex topic like exercise and diabetes management? You can only simplify so much. So we did our very best to make sure the tables weren't overly busy, but at some point when we started to get into the details and into the specifics, we could have made each table three pages long. So we tried to balance that and make sure, like you said, you can pick and choose a figure that you could print, have it in clinic, have it available for your patients, and easy to understand. And I think this is so important. So we want to make life easy when you have type 1 diabetes. And I think when we look back to all our previous consensus reports and position statements, we were a little bit too scientific, I don't know if this is the right term using this, but we were too much into detail and we were losing the relationship to practical issues. And hopefully I am allowed to say that we have a very close relationship to type 1 diabetes, both of us. So we tried our best to see both sides. So having type 1 diabetes, working with people with type 1 diabetes and doing clinical research in the field of type 1 diabetes and exercise. So I think this group of 26 co-authors, where a whole lot of people have type 1 diabetes in the group, tried the very best that we have a practical position statement, which is supported by EASD and ISPAD, and to bring this to the people living with type 1 diabetes. Let us jump into some details. Give me one sentence how you could summarise the entire position statement with one recommendation in one sentence. That's a lot of pressure because exercise is so challenging. So I think my take-home message would be: If you can pre-plan for exercise, make the adjustments that are necessary in advance. If you can't pre-plan, make those adjustments immediately at the start of exercise, but it's going to take trial and error. I think maybe it's a long sentence, but the reality is, to cover a topic as complex as exercise and diabetes management, you can, like we said, only simplify so much. So I would love to ask if you agree, if you think that there is anything else we could say and summarise this. It's so challenging to summarise this in one sentence, because there are so many specifics that we had to cover in this, but I think we did a great job. So I think one sentence is absolutely difficult to give. So I just wanted to test you. So Dessi, let me ask you now a more detailed question. So we have this general structure, we were discussing spontaneous exercise, planned exercise, exercise under special circumstances. Can you give us a first impression what is within the section for the planned exercise or planned physical activity? I really enjoyed working on this, because the planned section, for me is important, that not everybody is going to be a planner, but for those people that are and again, I work in paediatrics, some kids do not plan in advance, but those that do, usually it's a specific type of personality. They are ready to think about things an hour or two before exercise, and it's important that if we talk about, for example, setting a higher glucose target, we'll say that as a general statement, because each system has its own terminology. So a higher glucose target, we recommend setting one to two hours before exercise if a glucose drop is expected during exercise. Let me interrupt you. Yes. What is better, one hour in advance or, if you can, set it two hours in advance? My goal is always as early as possible. So if we can do it two hours, even better. And I could ask you, why do we think it takes two hours? Because I think for me the big thing was: People often say: I don't remember to do things two hours in advance. And then I say: That's fine, if you can remember one hour it's better than not setting it at all, if glucose levels generally drop. Would you agree that two hours or would you say one hour? So I would agree also on four hours if it’s possible, if the exercise duration following is extremely long. So I think this is the point. So ideally we would be recommending two hours in advance, but also 30 minutes is better than nothing. I agree. It's so important. You said one sentence: These recommendations should only be used when you expect a decrease in glucose concentrations. I think this is a major difference to all the previous recommendations, also the companies were giving. They were saying: Every time when you start exercise start a higher glucose target around two hours in advance. But this is not really true. So what are we recommending within the EASD/ISPAD position statement, if someone is, for example, constantly increasing and it's a planned exercise session? Yeah. Well, I think one, it's important to highlight that this exists, because in prior statements, and not putting any other work down, but the reality is: People's blood sugars do go high with exercise. We think about the difference between competition and practice, for example, and many times with competition settings we see that stress response, blood sugars may rise. At that point, we may not need a higher glucose target. So we often recommend, if the glucose is more likely to go up, and maybe that's through trial and error, you experience that more often, no higher glucose target may be needed, at which point you can leave the system in automated insulin delivery mode. You don't have to turn it necessarily to manual mode, but in some circumstances you may need to do additional things. We often say: Let the system run and go from there. You may need fewer carbs, but these are the things that we like to talk about in more detail that often haven't been focused on: The specifics that blood sugars can actually go high or go low, depending on maybe the type, intensity, you know, situation of exercise. I think one very important information to add for the situation of planned exercise and increase in glucose: If someone is massively, intensively increasing, we have also for some to even set a lower glucose target or different aggressiveness modes, that the basal rate is more intense. So for this recommendation, we would say: At the onset of exercise, lower your glucose target or go up with the aggressiveness of your device. So we have to summarise, there’s three different opportunities: So for someone who is expecting a decrease in glucose, please set a higher glucose target one to two hours in advance to exercise. For someone who is increasing with the glucose, stay on your regular glucose target. Or if someone has the opportunity to lower the glucose target, and this person is massively increasing, then at the onset of exercise please go down with your glucose target. I think this is a nice summary. I think this is a nice summary of the three opportunities we are recommending. However, we are giving much more details for each device. Yeah, I just wanted to add one little piece, because as we talk about this I think about all the other sections that we wrote about, and even in planned exercise, higher glucose target was one section we focussed on, but your area of expertise, a lot of the focus is also around carb feeding. And we had many discussions back and forth around planned exercise, and maybe you can just summarise briefly about carb feeding with the meal before exercise, did we talk about reducing the prandial insulin dose, did we say to leave it? And I think this was also exciting, that we got to focus on this in more detail than other statements have had the chance to. Absolutely. Great question. So we were discussing so much: Should we reduce the prandial insulin dose in advance to exercise if someone is expecting a decrease in glucose? And there is some evidence existing and the recommendation is: If you're consuming carbohydrates very close to the exercise session or around two hours in advance within this window, you should or you can reduce, should is too strong, you can reduce your bolus insulin dose by 25 up to 33 %. But one very important statement: You should always focus achieving exactly the value that you want to fix during exercise. So when you increase the glucose target to, for example, 150 mg/dl, then you should be chasing that you achieve with your prandial ideal insulin dose reduction exactly this value. What is your thought on that, for example, if I do a prandial insulin dose reduction by 50 %, I have fixed the glucose target of 150 mg/dl, and in advance to exercise, I’m running on a 270 mg/dl. Is that an issue and what could happen? Absolutely. Well, each system, like you said, is different, but I think one of the realities is: If glucose starts high, then the challenge is that AID systems have one job: Insulin will be delivered generally if glucose is high. So I think we have to remember that if we cut back on the bolus insulin or the prandial dose aggressively, that glucose may rise, depending on the system, and I have to say this because not every system is the same, there may be additional insulin delivery. So I think that's important as well. And this is so confusing for so many people with type 1. So why should I have a higher risk of hypoglycaemia during exercise if my blood sugars are already extremely high? Because this was something we were recommending for MDI and for traditional CSII, but as you were correctly explaining: Insulin on board, whatever that means, you have written also a statement on that, so it's always different for each system. So we have to keep in mind: Please check maybe also the insulin on board, if glucose is high due to prandial insulin dose reduction, because this could mean that you have a higher risk of hypoglycaemia. Exactly, the more insulin on board, and we think about this just: Insulin’s one job is to bring blood sugars down. So the more insulin, you know, that's in circulation, that's actively, like, in the body at the start of exercise, just means it's going to be an increased risk of hypoglycaemia, generally speaking. Of course, there are some situations maybe with stress hormones and competition stress, having a little bit more insulin on board may not be the worst thing, but it's really important, because we want to avoid hypoglycaemia. In many instances the last thing we want to do is have to tell people they now need to stop, and that was another thing we focused on: How much do we treat with AID? And so I'll actually ask you if you wanted to just summarise really briefly, we went back and forth for many months just discussing this, but what types of tips and tricks that we suggest on if you're using an automated insulin delivery system, do you need 50 g of carbs to treat a low blood sugar? Maybe in some cases, but I'd love your thoughts. Maybe in some cases this might be right. 50 is extremely high, so let me give it quite structured: So for fast decreasing glucose levels during the exercise session when using an AID system, we recommend 12 up to 20 g fast-acting carbohydrates. If someone is slowly decreasing, we are recommending 6 up to 12 g carbohydrates, and if someone is quite stable, but still not able to hold the target value, then we are recommending 3 up to 6 g fast-acting carbohydrates. So how often is that needed? We did recommend around 20 up to 30 minutes, something like that, but it's more about the situation. So you need to check. You need to consume exactly that amount of carbohydrate that with 20 minutes you are achieving your glucose target, and when you did set your glucose target to 180 mg/dl, for example, so 10 mmol/l, you might need a little bit more carbohydrates, when you are running at the moment on 3.9 mmol/l, but this is exactly the point. We defined a threshold again, when should you consume carbohydrates when using an AID system around exercise? Can you give us this value and can you give us a small explanation at which blood sugar level someone should consume carbohydrates? So we've often said if glucose is dropping during exercise, because we have to remember, well, if you're going up, we may not need to consume carbs. Generally, if it's below 7 mmol/l or below 126 mg/dl and dropping, we start to treat to prevent. I think this is the most important part: Prevent the hypoglycaemia episode before it happens. The reality is ... Let me interrupt you, and this is the most important sentence we had now in this position statement: So we do not treat hypoglycaemia, we do prevent hypoglycaemia, so that people with type 1 diabetes do not have any hypo at all during exercise. So sorry for interrupting, but I need to point your perfect sentence out. Please go on. It was just so important for us because I think the reality is, especially working with kids, I know that the challenge is often we know there are challenges with exercise and CGM lag time and the delay in the CGM, so again, people wonder: Well, why, if the target is 70 to 180, 3.9 to 10, why am I treating at 7? Well, the reality is: There is probably a delay during exercise with the CGM technology that two arrows down or fast dropping glucose probably means the glucose is well below 7 by the time you start to treat. So for us it's important to be proactive when possible rather than waiting until you're two arrows down and already sweating and have hypoglycaemia in the middle of exercise, because now we have to stop exercise, delay the start of exercise, and it just makes it more challenging, when we want people with diabetes to be able to engage in physical activity, be active and not have to stop every hour, every 15 minutes to treat lows. And I think you made a very nice point, because you did the publication, I think, where you did show that for real-time CGM and moderate intensity exercise there is a delay of interstitial glucose to blood glucose of around 12 minutes, as far as I do remember, so you were exactly saying it's important to prevent hypoglycaemia quite early because real blood sugars might be already a little bit lower. So these were the recommendations for planned exercise. So focus on are you a type of person or are you doing a specific type of exercise where you're decreasing or increasing with glucose levels, and secondly, when you're dropping at the threshold of 7 mmol/l treat or prevent hypoglycaemia with 3 to 6, 6 to 12, 12 to 20 g carbs, depending on the drop of glucose levels? What recommendations are we giving in our EASD/ISPAD position statement for unplanned exercise? I think this is the reality of most people. I can tell you that maybe between the two of us, the amount of times we probably plan for exercise is 1 in 10, if that. I do my best obviously to try to plan for exercise, but we know the reality is, and there's been published studies to show this, what we talk about in the consensus guidelines, maybe not what everybody follows, and that's because planning can be difficult, and especially working with kids, you know, they want to be spontaneous. They want to live a life where they don't have to think about their diabetes every minute of every day. And so the reality is: The unplanned exercise is probably more realistic to what people are doing when they live with diabetes. Oh, we're going for a run. Oh, we're going to soccer practice. And so the reality is: If you don't have the time to set a higher glucose target 1 to 2 hours before, what do we recommend? It's still important, if glucose levels drop, to set that higher glucose target when you remember, even if that means five minutes before, at the onset, a couple of minutes into exercise, it's better to set it than to not set it at all. And, you know, I think it's important that we talk about this, because even if somebody forgot to set it all together, well, then we go into the details for unplanned exercise, maybe more carb feeding or more frequent breaks to take small amounts of carb are going to be necessary. And so if you wanted to add anything, I think one of the most important pieces for unplanned exercise is: We're not telling people to change what they're doing, maybe just to implement these strategies when they remember. So it's trying to fit the needs of what people are actually doing for exercise. I think one very important point you were saying is: When you want to start exercise in 20 minutes, set immediately a higher glucose target. When you do see you're still low, we do recommend at the onset of exercise or 10 minutes in advance, consume 20 up to 20 g carbohydrates, that you support the AID system achieving a higher glucose target. Then we have, still during exercise, the recommendations of carbohydrate feeding. However, you know we have this range 3 to 6, 6 to 12, 12 to 20, it might be, for spontaneous exercise, as you were saying, it might be needed more often. Yes. But secondly, always use the upper limit. So it might be this 6 g recommendation, this 12 g recommendation, and the 20 g are needed for unplanned exercise. But why do we need more carbohydrates for unplanned exercise during the exercise session? I think it goes back to a topic we were already discussing. Yes. Well, the key thing in all of this is: If you don't plan in advance, and nothing against not planning, but an AID system is trying to deliver insulin to keep glucose levels in range, and so the reality is: When you don't have the chance to plan in advance, usually, that means there's going to be more insulin or more active insulin in the circulation by the time exercise starts. Of course, insulin's main job to cause low is basically bring blood sugars down during exercise. So the reality is: Without planning in advance, we may need more carbohydrates to cover just the amount of insulin in circulation. So I think that's kind of the main reason. I wanted to touch on one thing again about both planned and unplanned exercise. When we talk about setting a higher glucose target, and maybe you can address this, what did we say about stopping the higher glucose target? Because I think there's been a lot of discussion on do we keep it on, do you turn it off? When do you turn it off? And a lot of times people say, they don't understand when they should stop it. So that was something we focussed on as well. So I think the correct answer would be personalised medicine, individualised solution. So it's an individualised situation and we need to focus on that. If someone is going low in post-exercise condition, this person might still go on a higher glucose target. So I think it's a nice recommendation to check that, when you are at home, do a few exercise sessions, assess the post-exercise period, and when you need to eat carbohydrates 20 times within two hours, then you are this type of person when you keep the glucose target a little bit higher. Yes. So Dessi, let me ask you one question: AID, type 1 diabetes and spontaneous exercise, go or no go? Go. Always go. The reality is: We want to encourage people to exercise. That's more important than any other focus in this position statement. It is encouraging physical activity and exercise for anybody that has type 1 diabetes. Can you give us a quick impression of a very important section within this position paper, about exercise, AID under special circumstances, so what is this about? Is this needed within such a position statement? What is your take on that? Well, with 26 co-authors, all of us discussing this back and forth, this was probably the one section that was told to us we cannot remove. And the reality is, again: Other position statements cover special circumstances. We've talked about this in the paediatric guidelines and the adult guidelines. But the focus on AID systems in special circumstances are, again: What happens when your patient comes to the clinic and says: I am going for an Ironman race and I'm going to be exercising for 12 hours. And now we think, oh my gosh, how are we going to support somebody doing activity for six hours or more? And the reality is: These are sometimes special circumstances. We're not encouraging everybody to be elite athletes and doing very difficult things with their bodies when they're exercising. But some people with type 1 diabetes do that. And so the reality is with special circumstances we cover: What are the situations people in real life have to live through prolonged pump disconnect, if they're in the water for a long time and their device is not waterproof, they have to disconnect their system if they're not wearing a patch pump, and what do they do in those situations? They now don't have insulin delivery and if they're in the water for a long time, what happens? How do devices communicate in water or out of water? All of these kind of special circumstances we talk about, and the reality is: People are going to find unique circumstances with exercise. Maybe we didn't cover all of them, but we tried to keep it to the most general and common scenarios that we see with type 1 diabetes. Let me ask you one further last question on that specific topic. As you were saying, pump disconnection is a thing, is an issue. What about ketone levels? Do we give a specific recommendation about ketones within this position statement? It's a great point. I think one of the concerns for us any time we talk about prolonged pump disconnect, in this case we talk about over 120 minutes of no pump connection, of course, the pump being suspended, if it is disconnected from the body. But regardless if it's on body or not on body, if it's suspended, no insulin delivery, we start to worry about ketones developing, with long duration exercise, very little insulin delivery, and so one of the realities we like to talk about is: Sometimes you may be encouraged to reconnect the pump, give a little bit of insulin delivery during exercise, maybe to cover like we talk about around 50 % of the usual basal that was missed, but we do talk about the specifics, because the one thing we do want to avoid with long exercise is a rise in ketones. Thank you very much for this answer. Dessi, thank you very much for this conversation and thank you very much for this great position statement. I think we want to thank also all our 26 people who were involved in this position statement from the EASD and ISPAD, and that we tried our best to give practical recommendations. Our recommendation is: Please hand this over to your patients living with type 1 diabetes. Try to read through the paper and I think it's quite easy to understand, and we will make it quite accessible for all people living with type 1 diabetes. So it was our sincere pleasure doing this conversation together and give you some details about this novel EASD/ISPAD position statement. Thank you so much. Thank you so much for being here with us. And goodbye.