A lot of disinformation exists concerning how to safely exercise while living with diabetes, particularly Type 1 diabetes. Ginger Vieira, athlete and author of "Exercise with Type 1 Diabetes: How to exercise without scary lows or frustrating highs", joins The Huddle to discuss how to help people with diabetes feel empowered to exercise while managing their potential high and lows. Resources: Learn more about Ginger and her work on her website: https://www.gingervieira.com/ Access Ginger's book on exercise and Type 1 diabetes here: https://www.amazon.com/Exercise-Type-Diabetes-exercise-frustrating/dp/B0BYGNFQ47/
A lot of disinformation exists concerning how to safely exercise while living with diabetes, particularly Type 1 diabetes. Ginger Vieira, athlete and author of "Exercise with Type 1 Diabetes: How to exercise without scary lows or frustrating highs", joins The Huddle to discuss how to help people with diabetes feel empowered to exercise while managing their potential high and lows.
Resources:
Learn more about Ginger and her work on her website: https://www.gingervieira.com/
Access Ginger's book on exercise and Type 1 diabetes here: https://www.amazon.com/Exercise-Type-Diabetes-exercise-frustrating/dp/B0BYGNFQ47/
Dana
Hello and welcome to ADCES’ podcast, The Huddle: Conversations with the diabetes care team. In each episode we speak with guests across the diabetes care space to bring you perspectives, issues and updates that elevate your role and inform your practice.
My name is Dana Moreau. I oversee danatech and digital products here at the Association of Diabetes Care and Education Specialists. I am also a mom to a type 1 son, which makes today's topic especially interesting to me and hopefully it will to you as well. Just so you know, the information in this podcast is for informational purposes only and may not be appropriate or applicable for your individual circumstances. This podcast does not provide medical or professional advice and is not a substitute for consultation with a healthcare professional. Please consult your healthcare professional for any medical questions as always.
So that being said, today we're joined by Ginger Vieira. Ginger is the Associate Director of Communications at T1D Exchange, and also a competitive athlete who was diagnosed with type 1 in 1999. Since then, Ginger has written many, many articles and books, which I love, aimed at those with type 1, including her latest book, "Exercise with Type 1 Diabetes: how to exercise without scary lows or frustrating highs." She's here to talk with us about her book and how diabetes care and education specialists can help empower their patients to find exercise routines that really best work for them while still managing their blood sugars effectively. Ginger, welcome to The Huddle!
Ginger Vieira
Thank you for having me, Dana.
Dana
Ah, I'm so glad to be talking to you in person. Again, I gave a brief intro, but really before we get into the meat of today's discussion, which is such an important one, can you tell us a little bit more about yourself for our audience and really why this topic is important to you?
Ginger Vieira
Sure, I've lived with type 1 for 25 years. I diagnosed myself in the seventh grade while we were all working on our health fair projects and my classmate was doing his project on diabetes. I had all the symptoms on his poster board and my whole family had just had the flu and mine didn't go away and didn't get better. And I eventually said, “mom, I think I have diabetes”. And she said, “no, only old people get that”. And this is in 1999, I'm 37 today.
And sure enough, a few days later, I burst into tears because I felt so terrible. And the diagnosis was pretty obvious once they took me to the doctor. But I really got into the niche of teaching people about exercise because during my, let's say, my freshman and sophomore year of college, I really wasn't taking great care of myself.
My A1C had gone up a little. I wasn't neglecting my diabetes, but I gained a bunch of weight. I was eating gluten all the time. I have celiac, by the way. And I was drinking beer and, not a crazy amount, but just I wasn't taking care of myself. And I joined a gym and started teaching myself the basics of lifting weights. And this is back before CGMs existed. And I had a pump, but didn't really care for it after a DKA issue. It wasn't really the pumps fault, but I was a little turned off by pumps at the time. And so I was on MDI. And I started getting very strong very quickly and working with a powerlifting coach. And I didn't have health insurance at the time. And I didn't have a new adult endocrinology team because I was now in the town where I was going to college. And I went to my doctor's office, this first appointment.
And I said, I'm training to compete in powerlifting and I need help. I don't understand really how to keep my blood sugars in, back then in range wasn't even a term, right? Because CGMs didn't exist. But I needed help. And he laughed at me, totally dismissed me. This is the head endocrinologist at this clinic. And I left in tears and never went back and had to really figure out exercise science for myself and I went to school for writing, not science. I got D's in biology. But when I could apply that science with support from my coach who was a very exercise science minded person to type 1 diabetes, I was able to learn things that I wasn't learning anywhere else. And now fast forward like 15 years later, I've written about it so much and coached so many people through it when I was coaching, doing one on one coaching, and written so many articles and gotten so many questions from people that I just knew I need to put this all in one place because you can't teach exercise management in one article with T1D. So that is why this book came about. It's 100 pages. It's really easy to read and it tackles what I know most people need to know and struggle with.
Dana
So I ordered that book a few weeks ago off of Amazon. So if anyone after listening to this is interested, that's where you can find it. And it was great because I did actually highlight quite a few things as people I know have restarted their exercise routines and are struggling with both the highs and lows that you're mentioning. Since we're talking to healthcare education specialists, diabetes care and education specialists, when you're thinking about, I think this is that you have the perspective of having type 1 and also being an athlete. When you're thinking about healthcare providers treating people with diabetes, what are some of the myths or misconceptions about exercise that honestly you still hear being communicated?
Ginger Vieira
Oh my goodness, yeah. I mean, I should add actually that six months after that doctor's appointment, I set a whole bunch of records in my first drug tested power lifting thing, right? And so it would have been really nice to have his support. But what I still hear a lot is things like, I was just diagnosed with type one, this is from a man diagnosed at like 40 years old. My doctor told me I shouldn't kayak anymore. You know, just flat out, stop kayaking.
Another one is just people still being told, eat 15 grams of carbs, then go exercise. That is such old school, overly simplified advice that really doesn't apply anymore because of the technology and the types of insulin that we have. That worked back in the day with, you know, NPH and regular, but we've evolved so much past then. And then I've also had the opportunity to interview and write articles about everyday people doing incredible things like Ironman competitions, right? And these aren't gifted, crazy athletes like Michael Jordan. They are regular people who just set their minds to it and they did it with type one. And they were told when they went to their doctor and asked for support, Oh, I don't know if that's possible. I don't know if you could do that. I don't have any information to help you. Right? And my book certainly doesn't apply to Ironman training, but there are some incredible medically sound resources out there for people. And so no one should be turned away from wanting to pursue intense or even just regular exercise with Type 1. You just need knowledge.
Dana
Exactly. So clearly though, and one of the reasons you bought this or wrote this book is kind of address some of the challenges because it's not as though, you know, most people on some sort of insulin regime don't have challenges that come up as a result of some of these exercises. And that doesn't mean they shouldn't do it. It's just there's things they need to look out for that often make this a little more difficult than it might for someone without diabetes. So can you talk about like what are those primary challenges that people with diabetes, especially, you know, those on insulin you know face when they're exercising.
Ginger Vieira
Sure. And I mean, I don't want to downplay just how complicated it is because I can't tell you how many people, I work with a lot of type ones just as my colleagues, right? I can't tell you how many come to me and say, I'm just terrified of exercising because usually the severe lows and they don't understand why they're dropping so low. And what you need to learn and what I love explaining in regular people language is a few things. It's insulin on board, the timing of your workout in relation to how much insulin you have on board and when you took that insulin, the type of exercise you're doing, which is anaerobic versus aerobic. We just need to know those two types because anaerobic is likely gonna raise your blood sugar and aerobic is definitely gonna lower your blood sugar if you have too much insulin on board.
But there's of course a caveat. If you have too much insulin on board, even anaerobic exercise can cause your blood sugar to plummet, right? And then there's little quirky details within there that you think it's aerobic because your heart is beating the whole time, but it's actually anaerobic and triggering that anaerobic response that your body starts producing glucose without the extra insulin. So I love explaining all those little nitpicky details.
And then you have to wrap up all of that around when you last ate. So the timing of your food and the old school advice again is to eat before you exercise. But in reality, if you talk to a lot of athletes and avid exercisers with type 1, many will tell you that the easiest time of day to exercise with type 1 is before you eat. And it doesn't have to be before breakfast, it can just be before your next meal when it's been at least three to four hours since your last meal, because you have less insulin on board. Right? So it's learning all those different variables and then creating what I like to call consistent science experiments.
Dana
Okay. And so, thinking about your book, I mean, it really does focus on managing, you know, the inevitable lows or highs. What are some of the top tips that you have that, again, diabetes care and education specialists or other health care professionals can give to their patients to help them avoid or not even necessarily avoid, but manage them as they occur?
Ginger Vieira
Sure. The first tip is that you need to learn how to review your insulin on board and then base the timing of your workout with that. So I'll give you personal examples. I love exercising first thing in the morning before eating breakfast because I'm an MDIer, right? So I only have my long acting insulin in my system and I can wake up at 100, go for a three mile jog and I end at 100 because I don't have a bolus of rapid acting insulin on board. We used to be taught to be afraid of that and this was actually that fasted exercise was taught to me by the bodybuilding world when I was back training in powerlifting because bodybuilders get on a treadmill walk really slowly and they're just trying to burn body fat and they do it fasted because you're going to burn more fat than glucose. And when I was first told this, 15 years ago, I said, no, that's not possible. My blood sugar will drop. But if your long acting or background insulin doses are fine tuned for fasted exercise, you shouldn't drop because you don't have a big bolus on board. Of course, people on an insulin pump definitely need to likely reduce their basal rate starting at least an hour before the exercise. So that's a pretty important difference between MBI and pumps.
But you can create that same fasted environment at any time of day by, you know, when my kids were little, they went to bed at seven. I would put them to bed, make sure that I hadn't eaten since at least before 4pm. So I didn't have a bolus of rapid acting on board. And then I would jump rope for a half hour, 45 minutes at 7pm and then eat dinner. And my blood sugar wouldn't plummet because I didn't have a big bolus on board.
And I mean, I want to add just because so many people are still curious about it, especially clinicians, I also use afrezza as much as possible for my meals. And that also makes exercising even easier because I could eat lunch at noon and walk my dog at 1pm. And a small dose of afrezza is mostly out of your system after about 60 minutes. So my risk of going low during my dog walk is so minimal. And it's as someone who exercises several times a day between intentional cardio and weights and then a couple dog walks, I love the flexibility that afrezza offers me and I have to eat so much less sugar basically, you know, to fuel dog walks than I did before I used afrezza.
Dana
Well, this sounds like a whole other podcast, Ginger.
Ginger Vieira
Yeah, totally. We should definitely hit some inhaled insulin topics.
Dana
So again, not to have cut you off, were there other tips that you had?
Ginger Vieira
Sure. You need to create consistent experiments. The more you can create consistency, at least when you're learning, right, around the timing, insulin on board, what you ate. If you want to eat before you're exercising, just choose the exact same thing every time for at least a week, maybe two weeks, right? And I came from the fitness world where everyone was like hyper methodical about every meal, right?
So this was kind of brainwashed into me during those competition days. But if you could adopt that just for your experiments. So let’s say your goal is to jog for 30 minutes every day at noon and you are having trouble with your blood sugar plummeting. First, look at your basal rates. We'll get to that in a second. That would be my third tip. But then, make sure that you have the exact same variables at play. So the same food if you're going to eat beforehand and then you write down how much insulin you took for that food, how much of a reduction it was for that meal because you knew you were going to go exercise. And if it turns out that you went low anyway, guess what? You need more reduction. If you were high at the end of your jog, guess what? You didn't need as much of a reduction, right?
The other thing that when I talk to groups of people with type 1 about exercise and type 1, the other thing that comes up constantly is they say, well, no matter what I do, I just keep going low. Most people have their basal rate set for that inactive lifestyle if they haven't already incorporated exercise into their lifestyle. So they underestimate the impact of just adding a 30-minute walk to your day.
As soon as you do that, your basal rates across the board probably should go down. And if you're going low every time you walk, even if it's a fasted walk and you reduced your basal rate, you probably just have too much basal on board in general. And so people think of their exercise basal rates as the unique basal rate when in fact, if you make this a daily habit, you can bring all your basal rates down so that you have this new kind of, it's the default. You know what I mean? Most people are getting too much basal. And so you could reduce your basil and increase your bolus to get yourself in range and exercise more safely.
Dana
And I think that makes a lot of sense. I'm actually pausing for a minute because I'm applying it to people I know right now. So.
Ginger Vieira
Right, yeah.
Dana
I know that you're MDI, but there is a lot of discussion about diabetes technology and its ability to potentially help people exercise safely or smartly or however we're promoting it. What are your thoughts on this and is tech necessary? Is it helpful from your perspective?
Ginger Vieira
In some ways, technology can make it a little more complicated, right? Because you have to intervene with that algorithm. You have to go in and, you know, depending on what type of closed loop pump you have, you have to go in and tell it to stop doing its job in a way. And they're all a little different in how you can adjust them for exercise, but you need to learn how for that specific system that you're using. In most cases, you're asking it to give less correction insulin and give a significantly reduced basal rate. And most people that I've ever interviewed will tell you they reduce their basal rate by at least 50, sometimes 75% when they're on pumps before cardio exercise.
CGMs are obviously awesome and I would recommend them to anyone with type 1 as I'm sure every clinician listening to this is trying to. I'm sure you guys face resistance all the time. But yeah, I think in some ways that technology can complicate it because you also always have basal insulin dripping. I don't have to worry about that as a person on MDI. I know that if I just get my long acting dose down, I don't have to worry about it suddenly hitting me more strongly an hour later, as long as it's fine-tuned. You know what I mean?
Dana
Yeah that makes a lot of sense. Okay, and so do you have kind of any final thoughts, you know, from the book, any big insights that you want to pull out as our last question or, you know, more details on the book itself and how to get it?
Ginger Vieira
I think the biggest thing that anyone who's going to thrive with type 1 diabetes, and I don't mean set records or do races, I just mean get through their day with joy, right, and minimal low blood sugars, is it comes down to your mindset. So the more you can encourage your patients to have that problem solving mindset and not putting a lot of guilt or emphasis on the high of saying, okay, whatever that approach was didn't quite work out. What can you do differently next time, right?
And it also removes this woe is me self-pity that many patients struggle with where it's like, nothing I do works, this is infuriating and it sucks. And it's like, well, you could go sit in that if you want, but there's no way out of that, right? There's no way to find solutions there. So the more you can just say, okay, what I just did, again, you know, didn't work, brush off, what can I do differently? And people always ask me like, how did you learn all this? I am not some genius. All I did was not sit in the self-pity mode and go find solutions because I wasn't going to let type 1 keep me on the couch.
Dana
Exactly. And it sounds like a lot of trial and error before you kind of got to all this…
Ginger Vieira
Yes, patience and curiosity and just try your best and then try again.
Dana
And I think what's interesting too, and I know we've, I mean, this is primarily looking at type 1, but really a lot of the tips that you're giving are applicable to those, like anyone who's on insulin right now.
Ginger Vieira
Absolutely, yeah.
Dana
Yeah so all of these tips while we do say Type 1 have broader implications across the diabetes spectrum.
Ginger, we're so happy to have you here today. Again, this is such a, it can be a complex topic, but it's nice to see someone who's mastered it and has so much great information to share with others that hopefully everyone can benefit from. I wanna thank you, and thanks to everyone for listening to this episode of The Huddle.
Make sure to download the resources discussed on today's episode. You can find them linked in the show notes at diabeteseducator.org/podcast. Remember, being an ADCES member gets you access to many resources, education, networking opportunities, etc. Learn more about all of the benefits of ADCES membership at diabeteseducator.org/join. Thanks again for joining us. Thanks for the work you do and have an amazing day. Bye bye!