We searched PubMed and other relevant biomedical databases for articles containing the terms “type 1 diabetes” or “insulin-dependent diabetes” and “exercise” or “physical activity”, published between January, 1990, and July, 2016, filtered for studies done in human beings, and restricted to English language publications. Additional searches were done with the following terms for various subtopics within this Review: “nutrition”, “dietary carbohydrate”, “dietary protein”, “glycaemic index”,
ReviewExercise management in type 1 diabetes: a consensus statement
Introduction
Despite tremendous advances since the discovery of insulin almost 100 years ago, management of type 1 diabetes remains challenging.1, 2 The majority of patients living with type 1 diabetes do not have a healthy bodyweight (about 60% are overweight or obese), about 40% have hypertension, about 60% have dyslipidaemia,3 and most do not engage in enough regular physical activity.4 Regular exercise can help patients achieve several goals: it improves the cardiovascular disease risk profile in paediatric patients5 and reduces HbA1c by about 0·3% in the paediatric population.6 Body composition, cardiorespiratory fitness, endothelial function, and blood lipid profile (ie, triglycerides and total cholesterol) all improve with regular physical activity in children and young people with type 1 diabetes.6 These cardiometabolic improvements are all important, given that cardiovascular disease is the leading cause of morbidity and mortality in young people with type 1 diabetes.7, 8 In adults with type 1 diabetes, both retinopathy and microalbuminuria are less common in those who are physically active than in those who are not.9 Active adults with type 1 diabetes tend to have better chance of achieving their HbA1c and blood pressure targets, and a healthier BMI, than do inactive patients.3 Regular exercise also decreases total daily insulin needs.10 Having a high exercise capacity in adulthood is associated with a reduced risk of coronary artery disease, myocardial ischaemia, and stroke, regardless of whether a person has diabetes or not.11 In a large cross-sectional study of 18 028 adults with type 1 diabetes,3 patients who were categorised as being most physically active (exercising two or more times per week) had better HbA1c concentrations, a more favourable BMI, less dyslipidaemia and hypertension, and fewer diabetes-related complications (retinopathy and microalbuminuria) than those who were less habitually active. The study also showed that patients with type 1 diabetes who are more active tend to have less diabetic ketoacidosis and a reduced risk of developing severe hypoglycaemia with coma.3 However, older women who are physically active have higher rates of severe hypoglycaemia (with coma) than those who are inactive.3 Several barriers to exercise might exist, including a fear of hypoglycaemia, loss of glycaemic control, insufficient time, access to facilities, an absence of motivation, issues around body image, and a general scarcity of knowledge around exercise management.12, 13, 14
For all adults living with diabetes, including those living with type 1 diabetes, 150 min of accumulated physical activity is recommended each week, with no more than two consecutive days of no physical activity.15 Resistance exercise is also recommended two to three times a week.15 Getting this much exercise is difficult for many patients; results from a large cross-sectional study showed that less than 20% of patients manage to do aerobic exercise more than two times per week, and about 60% of patients do no structured exercise at all.3 For children and young people with diabetes, at least 60 min of physical activity should be done per day.16 Physical inactivity and prolonged sitting times increase gradually with age and are linked to high HbA1c concentrations in young people with type 1 diabetes.17 Physical inactivity appears to be more common in women than in men with type 1 diabetes.3
Regular exercise should be encouraged and supported by health-care professionals for many reasons, but primarily because the overall cardiometabolic benefits outweigh the immediate risks if certain precautions are taken. In this Review, the basic categories of exercise are described from a physiological perspective, as are the starting points for nutritional and insulin dose adjustments to keep patients in a targeted glycaemic range. This Review summarises our consensus on the available strategies that help incorporate exercise safely into the daily management plan for those adults with type 1 diabetes who are regularly engaging in exercise, sports, or competitive events. We hope these new recommendations for exercise management will improve glycaemic control and encourage more individuals with type 1 diabetes to increase their physical activity.
Section snippets
Modalities of exercise
An understanding of the metabolic and neuroendocrine responses to the various types of exercise done by people with type 1 diabetes is essential for determination of appropriate nutritional and insulin management strategies. Exercise is generally classified as aerobic or anaerobic, depending on the predominant energy systems used to support the activity, although most exercise activities include a combination of energy systems. Aerobic exercise (eg, walking, cycling, jogging, and swimming)
Exercise goals and glycaemic targets
Individuals with type 1 diabetes should engage in exercise for various health reasons. The evidence on whether regular exercise improves metabolic control in adults with type 1 diabetes is somewhat scarce,20, 54 although exercise appears to be helpful in young people with type 1 diabetes.6 Exercise readiness questionnaires, such as Physical Activity Readiness Medical Examination (ePARmed-X+) and Physical Activity Readiness Questionnaire for Everyone (PAR-Q+), are available online for adults
Contraindications and cautions for exercise
Although few exercise restrictions should be placed on patients, some considerations are important and are highlighted below.
Goals for nutritional management
Nutritional management for people with type 1 diabetes should incorporate strategies that optimise glycaemic control while promoting long-term health.66 The main strategies around nutrition for exercise and sport discussed in this section primarily aim to maximise athletic performance and are based largely on studies done in highly trained healthy individuals without diabetes,59 with few studies done in people with type 1 diabetes. Application of these strategies to people with type 1 diabetes
Recommendations for management of glycaemia
Blood glucose responses to the various forms and intensities of exercise show high variability between and within individuals (figure 1). Glycaemic management is therefore based on frequent glucose monitoring, adjustments to both basal and bolus insulin dosing, and consumption of carbohydrates during and after exercise. These recommendations are intended to serve as a starting point for insulin adjustments and carbohydrate intake that can then be individualised (figure 2).
Clinical management
Emerging tools for exercise management
Several treatment regimens exist for people with type 1 diabetes. Continuous subcutaneous insulin infusion offers better flexibility in basal insulin adjustments and management of exercise-associated hyperglycaemia than other methods of insulin delivery.117 Continuous subcutaneous insulin infusion is associated with reduced hyperglycaemia after exercise compared with multiple daily insulin injections,112 but can create frustrating challenges for sports that might require disconnection of the
Conclusion
Regular physical activity should be a routine objective for patients with type 1 diabetes, for various health and fitness reasons. Considerable challenges remain for people with type 1 diabetes, and their health-care team, in management of exercise and sports. Several small observational studies and a few clinical trials have been published to date that help to inform the consensus recommendations presented here. More studies are needed to determine how to best prevent exercise-associated
Search strategy and selection criteria
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