What’s your best-kept secret for maximizing time in range with T1D during exercise?
“There are two things I always ask a client with T1D: What’s your insulin on board (IOB), and what’s the direction of your continuous glucose monitor (CGM) arrow? This information supplies the predictive nature of the science behind glucose management,” explained Okemah.
“Understanding how much IOB you have is so important. While you can exercise with IOB, knowing what your glucose is, where your arrow is pointed, and the kind of exercise and duration — will be a road map for managing your workout.”
“If you’re on multiple daily injections with a syringe or smart pen, there’s more work that goes into figuring out IOB than for someone on an insulin pump,” said Okemah. But consistency with exercise and management habits will help to improve your time in range during exercise.”
Is “carbohydrate loading” in or out with T1D? And how often should I be eating?
“Carbohydrate loading is out with T1D,” said Okemah definitively. And here’s why.
“When I work with T1D athletes or people that want to start working out, I talk to them in terms of ‘being a human being,’ not with a ‘diabetes first’ mentality.” That said, “Whatever your individual goals are, eating extra carbs — beyond human capacity — is not beneficial for anyone.”
“With carb loading, you run the risk of hypoglycemia,” explained Okemah. “Having more carbs, beyond the capacity of what your liver and muscles can hold, isn’t helpful for someone with T1D. It’s going to cost more insulin, and it works against the reason you’re exercising in the first place — which is to burn off glucose.”
Here’s the thing. Your liver and muscles store glucose in the form of glycogen. “That’s not a ‘T1D’ thing, it’s a ‘human being’ thing,” said Okemah. “Once these storage facilities are full, it takes insulin to access them. So, if glucose levels are running exceedingly high, that means glucose isn’t in the tissues.”
“That’s why glucose time in range matters. When you’re in range, you have fuel (glycogen) in the storage tanks, which means fuel is available. Having T1D does not allow you to fill your storage tanks even more. With T1D, you can’t carb load without adding excessive insulin and changing the paradigm.”
On the other hand, “It does not benefit anyone to be on a low-carb diet either because it changes the fuel source — similar to a hybrid vehicle when it switches from electricity to gasoline,” said Okemah. “With the human body, the most efficient fuel source for exercise is glucose.”
What role does hydration play in glucose management? Should I be drinking electrolytes?
“Hydration is huge for muscle and electrolyte heart conduction. It also helps with managing glucose levels,” explained Okemah. “Being properly hydrated means you’re urinating regularly, which helps to release glucose when it needs to be.”
“On your CGM, dehydration will be exposed as high glucose. That’s because dehydration concentrates glucose levels. As a T1D athlete, fighting hyperglycemia and dehydration will have a negative impact on your workout.”
“If you need to add something in, I recommend electrolytes, such as Nuun tablets,” said Okemah. “But you won’t always need them.”
“I look at that type and duration of exercise. Meaning, if you’re simply doing a treadmill workout for 30 to 45 minutes, there’s really no need for electrolytes,” said Okemah. “You get plenty of electrolytes from food. But I typically suggest rehydration with electrolytes if you’re exercising beyond 60 minutes.”
How much should I consume during exercise?
“I want to fuel you like a human being — meaning, anyone who is exercising needs to fuel their muscles — T1D or not. You’ll need electrolytes, hydration, and carbohydrates as your ‘clean’ fuel,” said Okemah.
“With T1D, you’ll need to pay attention to IOB, first and foremost. You need to know if you’re feeding the IOB or needing carbs for the actual exercise,” explained Okemah. “That helps with making management adjustments.”
As a general rule, it’s OK to exercise with IOB, explained Okemah. “I won’t ever say ‘don’t exercise if you have insulin on board,’ because it stops people from exercising altogether,” said Okemah. “Instead, I say, ‘If you have IOB, then here’s your exercise plan.’ It’s all about keeping track of IOB and fueling properly for the best exercise experience.”
In other words, “Your fuel plan will be different with IOB, but it should not deter you from exercising,” said Okemah.
Food as Fuel: Why choose processed glucose boosters (bars, gummies, drinks) versus whole foods?
“I have a T1D client who eats KIND bars while exercising. If you’re fueling with complex carbohydrates like that, your access to fuel in the short term won’t be there. That’s because it takes longer to break down protein and fat,” explained Okemah.
“Nutrition recommendations are 10 to 20 grams of carbs per hour while exercising. But I don’t put that on people with T1D who are constantly watching their CGM data,” said Okemah. “I just want people to be aware they need to fuel beyond what their glucose indicates.”
“There’s a huge benefit to gummies and sugary electrolyte drinks such as Gatorade and Cytomax because they’re fast-acting,” said Okemah. “During exercise, it’s the one time that I want you to think about food differently. These products have their place, and their functionality makes sense. While they aren’t meals, they do the trick during an event — as do potato chips and pickles.”
“I want you to like your fuel, and a mixture of savory and sweet is enjoyable,” said Okemah. “Afterwards, whole foods will have their place in your recovery meal.”
While the focus seems to be on carbs, where do fats and proteins fit in?
“I look at nutrition and athletes in three categories: pre-event, during, and post-event,” explained Okemah.
“The human body is so efficient — we create glucose out of everything, and we’ve been doing it for 10,000 years,” said Okemah. “But during an event, proteins and fat are going to confuse the fuel system. That’s why we use carbs as fuel during exercise. They are the most efficient fuel source.”
“During long exercise sessions, your calorie level will go down, as will your insulin needs — and the benefits of exercise increase.”
Why is glucose management during exercise different for each person?
I don’t want people with T1D to overthink exercise. You don’t need to be fasting or exercise at specific times of the day — you should just exercise,” explained Okemah.
“One thing is certain, I don’t want people to take the usual amount of insulin during an event,” emphasized Okemah. “During this time, you can burn through glucose without bolusing insulin — muscle tissue will suck it up like a dry kitchen sponge.”
Moreover, the benefit of exercise is that you’ll be using less insulin. “So, should you take insulin (as usual) for a peanut butter and jelly sandwich?” Okemah says, “No, no, no!”
“Everyone is a little different, and I enjoy helping people find niche foods that work for them. And I’m going to tell you, hands down, bananas are always involved,” said Okemah with a chuckle.
Can I still exercise if my glucose is high?
“That depends,” said Okemah. “There are so many factors to work through with high glucose levels, so you’ll need to troubleshoot first. Is there a problem with your pump, insulin, or site? What do your CGM arrows have to say? Do you have ketones in your urine?”
“Perhaps you like to have your glucose in a certain range before exercise, and it’s higher than that, but it’s not terrible. Hydration is something you can do. I want to make sure you’re hydrated so you can be safe during exercise. It’ll also help you to pee out extra glucose,” explained Okemah.
How do you keep a happy gut during exercise (when eating throughout)?
“There are two categories of foods that can irritate the gut: those with high fiber and those with an intense glucose source,” explained Okemah.
“High-fiber foods are more difficult to digest. And if you eat a gel or a GU, these products require dilution. If you don’t drink water, they’ll pull water from elsewhere in your body. This results in a disturbing ‘slew’ of fluid in your stomach — and an unhappy digestive tract.”
“Although Shot BLOCKS, gels, and protein bars are good, they’re designed to be chased with water. This way, your stomach contents are not so concentrated that it requires gastrointestinal fluid for dilution.”
How do you coach someone who avoids exercise because they have to eat so much (during and after physical activities) — so they feel it’s not beneficial?
“One of the main concepts I talk to people about is ‘feeding insulin’ — if that’s what’s going on, there’s something wrong with management calculations,” explained Okemah.
“I want you to fuel like a human being as much as possible. And yes, this means when you eat, sometimes you’ll need to take insulin for it, because even without diabetes, a functioning pancreas is always at work in the background,” said Okemah. “But you shouldn’t have to feel like you’re robbing a candy store. If you’re doing that, something needs adjusting.”
Let’s talk about 10-second sprints to raise glucose — is this a real thing?
“Yes, it works for a little bit — if you have glycogen stores in your liver and muscles. Even jumping jacks will potentially raise your glucose if you have fuel stores, but it’s very temporary,” said Okemah.
“Keep in mind, you’re depleting glycogen storage (your fuel tank) by doing this, so you’ll still want a carbohydrate source to prevent your glucose from crashing even further.”
