Carla Elliot liked to keep busy. A bright and outgoing 14-year-old girl, Carla involved herself in as many activities as she could. Whether it was swimming, cheerleading, softball, 4-H club meetings or simply running around the neighborhood, Carla was there.

These activities came to an abrupt end in January 2000, however, when Carla was diagnosed with Type 1 diabetes.

Like many Type 1s, Carla learned of her disease quite unexpectedly, after being admitted to the hospital in ketoacidosis. Being confined to a hospital bed was a radical departure for a girl who enjoyed perpetual motion, and Carla was certainly anxious to get better and discharged.

She and her family were especially receptive to the education provided during her stay. Once metabolically stable and adequately versed in the basics of diabetes self-care, Carla was discharged from the hospital on a twice-daily split-mix insulin schedule as follows:

A.M. 4R/10NPH

P.M. 3R/7NPH

Being an unseasoned newcomer to the world of insulin injections, finger-stick monitoring and erratic blood sugars, Carla was initially worried about the prospect of continuing her kinetic lifestyle. However, it was not long before she was back in the swing of things, both literally and figuratively.

Taking Control

With the help of her mother Jackie, Carla began incorporating the "consistent carbohydrate diet" as outlined in the book "I'm in Control," by Luther B. Travis, MD, CDE.

This valuable and practical instructional book is provided to pediatric patients diagnosed with Type 1 diabetes at Kaiser-Permanente hospitals. Becoming more consistent with her carbohydrate intake allowed Carla to establish a pattern in her blood sugars that could then be managed by manipulating her insulin and/or carbohydrate intake to better fit her pattern and lifestyle.

Ultimately, improved control and more predictable blood sugars were realized.

Type 1 Diabetes on the GO

Once Carla had gotten the hang of carbohydrate counting, she was ready to resume her activities. Not only did she continue with the cheerleading squad, Carla decided to take on a new activity, becoming a member of her school's dance team. She split her afternoons between the two.

Soon after, Carla began to experience low blood sugars in the afternoon or evening on the days she was dancing or cheerleading. This is a very typical response to increased activity in people with well-controlled Type 1 diabetes. Exercise will increase both insulin sensitivity and glucose utilization and disposal, resulting in lower blood sugars.

When exercise-induced hypoglycemia occurs, there are generally two options. These would include:

• Decreasing the insulin dosages, or
• Increasing the carbohydrate intake

Because Carla was slightly underweight for her height and age, adding carbohydrates was the preferred way of preventing hypoglycemia caused by her activity. Carla began including a snack consisting of about 20 to 30 grams of carbohydrates (i.e., one-half of a PowerBar; one whole Balance bar; one medium (5.5 ounce) apple; 16 ounces of Gatorade; or one granola bar) usually before or during the activity, and the problem was minimized, if not eliminated.

So If Exercise Makes Me Hypoglycemic

After experiencing the effect activity has on lowering blood sugars, Carla began to intuitively put this knowledge to use. On some occasions, when she found her blood sugars to be higher than her target level, Carla would go for a jog around the block or practice her cheerleading moves with her friends, helping to bring her blood glucose levels down.

Again, for Type 1s who are usually in good control, exercise will generally work in this manner, lowering your blood sugars. Good control in this context means having adequate, but not excessive, amounts of insulin in your blood at the time of exercise.

Caution must be used, however, in patients who struggle with their BG control. Contrary to Carla's example, exercise can raise blood sugar to dangerous levels in people who are in poor control. If a patient with Type 1 diabetes is experiencing high blood sugars before exercising, there may not be enough circulating insulin to keep up with the metabolic demands of exercise. This will result in glucose, fat and ketone levels to rise precipitously in the blood during exercise.

"Exercising" Control

Six months after her diagnosis, Carla had achieved a HbA1c of 7.3%, which underscores her success at being able to incorporate physical activity as part of her diabetes management plan. Just recently, Carla has switched to a four-injection-per-day routine to allow for more flexibility, as well as prepare herself for her ultimate goal of managing her diabetes with an insulin pump.

Because of her commitment to frequently monitoring her blood sugars and adjusting her diet and insulin around her lifestyle, Carla has been able to successfully manage her diabetes in spite of her stirring schedule.

Congratulations, Carla, for "exercising" such good control.