Outdoor Sports + Hypoglycemia with Amy Hess-Fischl


Amy Hess-Fischl, a certified diabetes care and education specialist (CDCES), joined Beyond Type 2 to discuss today’s topic, we’re going to be talking about hypoglycemia and outdoor activities. These tips from our discussion are going to help you to stay prepared for low blood sugar next time you’re out playing sports or some other kind of physical activity. Watch the video interview below or read the condensed version. To learn more about hypoglycemia awareness, click here.

BT2: Hi Amy, thanks for joining us! Would you mind telling the audience about yourself?

I’m a dietician and certified diabetes care and education specialist. And as you heard T’ara, again, because saying it very slowly because it’s our new title. I have been working with people with diabetes in Chicago for over 20 years.

We focus a lot on high blood sugar when discussing type 2 diabetes, but low blood sugar doesn’t get as much attention. In your opinion, why is hypoglycemia important for people with type 2 diabetes to know about, and how do you can counsel your patients about it?

I’m not saying that high blood sugar and long-term complications aren’t important, they are, but they’re always given top billing, and hypoglycemia is left to the wayside. The lower that you go, the more likely you could pass out. I don’t like throwing around the “d-word”, but we want you to remain in this world. That’s why hypoglycemia is important. Interestingly, it’s one of the most common reasons that people go to the emergency rooms or are hospitalized. The most important thing to keep in mind is that hypoglycemia is caused by many medications that are used for diabetes, especially insulin. Also, if you’re using sulfonylureas or the glinides, those medicines are kicking out insulin from the pancreas. If people don’t know what their medicines are doing, that’s what increases their risk of hypoglycemia. If someone is on insulin, they need a glucagon prescription.

Let’s talk about that glucagon prescription. Is that something that you have brought up with your own patients or do your patients already know about it when they come to see you?

Half and half. I think that because I have worked with children and families of children when I first started as a diabetes educator, 20 something years ago, it was just a protocol. There’s no real conversation you’re getting. Anyone who is on insulin, you’re getting a prescription for glucagon, and the glucagon options have changed so dramatically in the last two years. So again, we have new options that make it so much easier, and that had a lot to do with why people weren’t getting glucagon. Six, seven million people are on insulin, of those, I think it was like less than 10 percent that actually would fill a prescription for glucagon because the original glucagon emergency kits were hard to use. Now with these newer options, more people are interested in learning more about them.

Let’s move into outdoor sports, how do you counsel your patients? How should people with type 2 prepare themselves for low blood sugars?

The first step is understanding which medications that you’re taking that are going to lead to hypoglycemia and coming up with a plan of action. These are just some of these general recommendations, so please have a conversation with your doctor. For example, if you’re going to be out all day, they may want to cut the dose in half or eliminate it altogether. The same with insulin, that again, the general rules that they have out there or some consensus reports that are out there regarding insulin adjustment and exercise is cutting those fast-acting insulin doses in half to reduce your risk. But again, so that’s the first part about medicines.

The second part is having treatment options available because again, remember that when you are using your muscles, your muscles use sugar for energy, the more that your sugar is being pulled into your muscles, the lower your blood sugar is going to go. We know that all best-laid plans may go astray. I’m a worst-case scenario girl, so I always like to have a plan A, B and C. General recommendations call for using the rule of 15: 15 grams of carbohydrate, wait 15 minutes and then recheck your blood glucose levels. So carbohydrate, of course, is the primary thing that’s going to raise your blood sugar, but we’re looking for fast-acting carbohydrates. Glucose tabs are usually the gold standard for treating lows, but they’re expensive. You can use other options like fruit juice, or even Skittles, as long as it’s 15 grams of carbs.

I don’t recommend granola bars. I don’t recommend Snickers, even though it sounds like a wonderful thing. But again, the problem is we want it to raise the blood sugar quickly. If you’re using those types of foods that have protein and fat, it’s going to slow the digestion and not going to bring that blood sugar up fast enough. When that happens, you may overeat and then swing high later on.

Can you talk about the different types of physical activity, such as going for a hike or jog versus high-intensity sports like soccer, and how they impact blood sugar?

We have to think that we term exercise in a couple of different ways: aerobic activity versus anaerobic activity and the intensity levels. When we’re talking about strolling around a park, that’s a pretty low intensity, but if you’re strolling around the park for an hour or two, your muscles are still using that sugar. We may need to throw some carbohydrates throughout that time to just make sure that we keep that the blood glucose level up. Now let’s say, it’s going to be a lovely day and you want to take a bike ride on the path I’d say then, and you’re going to be long-distance, that is going to require some additional glucose right as you start, and then a little more as you go.

Now soccer or another sport, that could cause adrenaline or hormone levels to rise, as well as blood sugar. Our hormones tell our living, which stores sugar, to give us more. Therefore, we may not need to consume as much because our liver is giving it to us. Sporting events may not have the same impact at first but may affect us later. That’s when you may have to make some adjustments like taking insulin or oral medication.

How do you work with patients in terms of when to check your blood sugar, before, during and after physical activity?

I tend to recommend that you’re checking before physical activity, you’re checking even every 30 to 60 minutes during, and then directly after and even two to three hours after you finished. The first time that you start doing any activity, your experiment should be to figure out how it affects you. It’s a lot easier when you’re using a continuous glucose monitor (CGM) because all you have to do is look, but I do strongly encourage that every 30 minutes, take a look if you’re on using a CGM. But if you can, and you’re willing, checking every 30 to 60 minutes with a finger stick while you’re active.

Could you discuss insulin stacking and treating high blood sugar before activity while preventing low blood sugar?

Insulin stacking usually occurs when you are trying to correct a high blood sugar near dosing for a previous meal. So, what’s happening is that insulin has something called insulin action: how the insulin starts to work when it has its strongest activity, and how long it stays in the body. In general, rapid-acting insulin is going to start working in about 15 minutes. So once you inject it, it’s just going to start working. It’s going to start peaking or have the strongest activity about an hour and a half to two hours later. Then it’s usually out of the system within about three to five hours. Now, I’m not talking about the inhaled insulin, I’m just talking about the injectable ones.

Let’s say, “All right, I’m eating my lunch. I’m using a 1:10 carb ratio. I gave myself five units for the 50 grams I took. I want to take a bike ride.” And an hour and a half later, you look and you’re, “Oh my gosh, I’m 236. What on earth happened?” If you try to correct your usual correction at that time, it would have been stacking right on top of that other insulin. It’s going to cause you to go low because you’re basically didn’t give it enough time for it to do it. So the general rule is if you’re going to be correcting within two hours, you want to cut your usual correction dose in half. But then, if we’re talking about exercise, you may want to even cut it down another half, so only take a quarter of it. Those are very general recommendations, but again, we want to minimize the amount of insulin because that previous insulin just hasn’t finished working yet. Another thing is that where you inject your insulin is going to impact how quickly it works too. If you inject it into your legs and then you’re going for a walk, that could work a lot faster. Generally speaking, if you are going to be active, using the abdomen is a nice, consistent, safe place to inject.

How can our community talk to loved ones or others in their support system about helping you prepare for hyperglycemia? How should the loved ones of people with type 2 diabetes prepare for low blood sugars?

This is your diabetes, but again, no man is an island. We want to make sure that all of your loved ones have a good understanding of what to do in the event of an emergency. So that is going to be a conversation that you have with them about your symptoms and treatment plan, including nasal glucagon.

An important thing about glucagon is that it’s the safest thing to get because all glucagon does is dump all the glucose from the liver to raise blood glucose levels. And so again, it’s going to raise the blood glucose level. It only raises the blood glucose level about 120 to 170-ish points, so we’re not talking through to the moon. It usually works within 15 to 30 minutes.

If you have low blood sugar, talk to your health-care provider. Don’t look at this like a failure or like you did something wrong because, again, everything when we think of diabetes self-management, it’s a journey. If somebody does have low blood sugar, it’s telling us that we need to create a better plan so it’s necessary to have that dialogue.

Get to know Amy and her work, here.

This content was made possible with support from Baqsimi, a Founding Partner of Beyond Type 2.

WRITTEN BY T'ara Smith, MS, Nutrition Education, POSTED 06/14/21, UPDATED 10/04/22

T’ara was diagnosed with type 2 diabetes in July 2017 at the age of 25. Since her diagnosis, she focused her academic studies and career on diabetes awareness and living a full life with it. She’s excited to have joined the Beyond Type 1 team to continue her work as the project manager for Beyond Type 2. Outside the office, T’ara enjoys going to the movies, visiting parks with her dog, listening to BTS and cooking awesome healthy meals. T’ara holds an MS in Nutrition Education from American University.