Exercise management in type 1 diabetes: a consensus statement.

Type 1 diabetes is a challenging condition to manage for various physiological and behavioural reasons. Regular exercise is important, but management of different forms of physical activity is particularly difficult for both the individual with type 1 diabetes and the health-care provider. People with type 1 diabetes tend to be at least as inactive as the general population, with a large percentage of individuals not maintaining a healthy body mass nor achieving the minimum amount of moderate to vigorous aerobic activity per week. Regular exercise can improve health and wellbeing, and can help individuals to achieve their target lipid profile, body composition, and fitness and glycaemic goals. However, several additional barriers to exercise can exist for a person with diabetes, including fear of hypoglycaemia, loss of glycaemic control, and inadequate knowledge around exercise management. This Review provides an up-to-date consensus on exercise management for individuals with type 1 diabetes who exercise regularly, including glucose targets for safe and effective exercise, and nutritional and insulin dose adjustments to protect against exercise-related glucose excursions.

[1]  T. Jones,et al.  Antecedent hypoglycaemia does not diminish the glycaemia-increasing effect and glucoregulatory responses of a 10 s sprint in people with type 1 diabetes , 2014, Diabetologia.

[2]  J. Ulbrecht,et al.  Fluid snacks to help persons with type 1 diabetes avoid late onset postexercise hypoglycemia. , 2000, Medicine and science in sports and exercise.

[3]  G. Charpentier,et al.  Insulin‐based strategies to prevent hypoglycaemia during and after exercise in adult patients with type 1 diabetes on pump therapy: the DIABRASPORT randomized study , 2015, Diabetes, obesity & metabolism.

[4]  S. Anderson,et al.  A Contemporary Estimate of Total Mortality and Cardiovascular Disease Risk in Young Adults With Type 1 Diabetes: The Pittsburgh Epidemiology of Diabetes Complications Study , 2016, Diabetes Care.

[5]  Ronald J Sigal,et al.  Insulin pump therapy is associated with less post-exercise hyperglycemia than multiple daily injections: an observational study of physically active type 1 diabetes patients. , 2013, Diabetes technology & therapeutics.

[6]  M. Riddell,et al.  Effects of acute caffeine supplementation on reducing exercise‐associated hypoglycaemia in individuals with Type 1 diabetes mellitus , 2016, Diabetic medicine : a journal of the British Diabetic Association.

[7]  M. Ladouceur,et al.  Association of aerobic fitness level with exercise‐induced hypoglycaemia in Type 1 diabetes , 2016, Diabetic medicine : a journal of the British Diabetic Association.

[8]  E. Tsalikian,et al.  Aerobic fitness and glycemic variability in adolescents with type 1 diabetes. , 2014, Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists.

[9]  K. Raile,et al.  Associations Between Media Consumption Habits, Physical Activity, Socioeconomic Status, and Glycemic Control in Children, Adolescents, and Young Adults With Type 1 Diabetes , 2011, Diabetes Care.

[10]  Charlene Compher,et al.  Comparison of predictive equations for resting metabolic rate in healthy nonobese and obese adults: a systematic review. , 2005, Journal of the American Dietetic Association.

[11]  B. Frier,et al.  Risks of marathon running and hypoglycaemia in Type 1 diabetes , 2010, Diabetic medicine : a journal of the British Diabetic Association.

[12]  Michael A. Gibney,et al.  Intramuscular risk at insulin injection sites--measurement of the distance from skin to muscle and rationale for shorter-length needles for subcutaneous insulin therapy. , 2014, Diabetes technology & therapeutics.

[13]  M. Riddell,et al.  The Enhancement of Muscle Insulin Sensitivity After Exercise: A Rac1-Independent Handoff to Some Other Player? , 2016, Endocrinology.

[14]  S. Mayor.  Insulin pumps improve glucose control in children with type 1 diabetes, study finds , 2015, BMJ : British Medical Journal.

[15]  Stuart M Phillips.  Dietary protein requirements and adaptive advantages in athletes , 2012, British Journal of Nutrition.

[16]  P Hildebrandt,et al.  Subcutaneous absorption of insulin in insulin-dependent diabetic patients. Influence of species, physico-chemical properties of insulin and physiological factors. , 1991, Danish medical bulletin.

[17]  M. Gibala,et al.  Nutritional strategies to promote postexercise recovery. , 2010, International journal of sport nutrition and exercise metabolism.

[18]  A. Jenkins,et al.  Insulin pump basal adjustment for exercise in type 1 diabetes: a randomised crossover study , 2016, Diabetologia.

[19]  Stuart M Phillips,et al.  Protein "requirements" beyond the RDA: implications for optimizing health. , 2016, Applied physiology, nutrition, and metabolism = Physiologie appliquee, nutrition et metabolisme.

[20]  M. Walker,et al.  Metabolic Implications when Employing Heavy Pre- and Post-Exercise Rapid-Acting Insulin Reductions to Prevent Hypoglycaemia in Type 1 Diabetes Patients: A Randomised Clinical Trial , 2014, PloS one.

[21]  R. Bracken,et al.  A combined insulin reduction and carbohydrate feeding strategy 30 min before running best preserves blood glucose concentration after exercise through improved fuel oxidation in type 1 diabetes mellitus , 2011, Journal of sports sciences.

[22]  David Kerr,et al.  Day after the night before: influence of evening alcohol on risk of hypoglycemia in patients with type 1 diabetes. , 2005, Diabetes care.

[23]  E. Barrett-Connor,et al.  Resistance Versus Aerobic Exercise Acute effects on glycemia in type 1 diabetes , 2012 .

[24]  S. Wild,et al.  Glycaemic control of Type 1 diabetes in clinical practice early in the 21st century: an international comparison , 2015, Diabetic medicine : a journal of the British Diabetic Association.

[25]  P. Aschner,et al.  Effects of Performing Morning Versus Afternoon Exercise on Glycemic Control and Hypoglycemia Frequency in Type 1 Diabetes Patients on Sensor-Augmented Insulin Pump Therapy , 2015, Journal of diabetes science and technology.

[26]  A. Jeukendrup,et al.  Determinants of fat oxidation during exercise in healthy men and women: a cross-sectional study. , 2005, Journal of applied physiology.

[27]  T. Jones,et al.  Effect of Exercise Intensity on Glucose Requirements to Maintain Euglycemia During Exercise in Type 1 Diabetes. , 2016, The Journal of clinical endocrinology and metabolism.

[28]  L. Heinemann,et al.  Changes in Basal Insulin Infusion Rates With Subcutaneous Insulin Infusion , 2009, Diabetes Care.

[29]  E. Blaak.  Sex differences in the control of glucose homeostasis , 2008, Current opinion in clinical nutrition and metabolic care.

[30]  E. Richter,et al.  Increased muscle glucose uptake during contractions: no need for insulin. , 1984, The American journal of physiology.

[31]  R. Bracken,et al.  Blood glucose responses to reductions in pre-exercise rapid-acting insulin for 24 h after running in individuals with type 1 diabetes , 2010, Journal of sports sciences.

[32]  R. Hovorka,et al.  Quantifying the Acute Changes in Glucose with Exercise in Type 1 Diabetes: A Systematic Review and Meta-Analysis , 2015, Sports Medicine.

[33]  A. Jeukendrup,et al.  A Step Towards Personalized Sports Nutrition: Carbohydrate Intake During Exercise , 2014, Sports Medicine.

[34]  Alberto Maran,et al.  Continuous glucose monitoring reveals delayed nocturnal hypoglycemia after intermittent high-intensity exercise in nontrained patients with type 1 diabetes. , 2010, Diabetes technology & therapeutics.

[35]  R. Rabasa-Lhoret,et al.  Guidelines for premeal insulin dose reduction for postprandial exercise of different intensities and durations in type 1 diabetic subjects treated intensively with a basal-bolus insulin regimen (ultralente-lispro). , 2001, Diabetes care.

[36]  O. Bar-or,et al.  Glucose ingestion matched with total carbohydrate utilization attenuates hypoglycemia during exercise in adolescents with IDDM. , 1999, International journal of sport nutrition.

[37]  Louise M Burke,et al.  American College of Sports Medicine position stand. Exercise and fluid replacement. , 2007, Medicine and science in sports and exercise.

[38]  Position of the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine: Nutrition and Athletic Performance. , 2016, Canadian journal of dietetic practice and research : a publication of Dietitians of Canada = Revue canadienne de la pratique et de la recherche en dietetique : une publication des Dietetistes du Canada.

[39]  H. Quirk,et al.  Physical activity interventions in children and young people with Type 1 diabetes mellitus: a systematic review with meta-analysis , 2014, Diabetic medicine : a journal of the British Diabetic Association.

[40]  T. Pieber,et al.  Effects of High-Intensity Interval Exercise versus Moderate Continuous Exercise on Glucose Homeostasis and Hormone Response in Patients with Type 1 Diabetes Mellitus Using Novel Ultra-Long-Acting Insulin , 2015, PloS one.

[41]  T. Pang,et al.  What are the health benefits of physical activity in type 1 diabetes mellitus? A literature review , 2012, Diabetologia.

[42]  Thomas Danne,et al.  The PILGRIM study: in silico modeling of a predictive low glucose management system and feasibility in youth with type 1 diabetes during exercise. , 2014, Diabetes technology & therapeutics.

[43]  Gary W. Mack,et al.  Exercise and Fluid Replacement , 1996 .

[44]  W. B. Bakker-van Waarde,et al.  Recurrent nightly ketosis after prolonged exercise in type 1 diabetes – the need for glycogen replacement strategies. Case report and review of literature , 2016, Pediatric diabetes.

[45]  E. Coyle.  Substrate utilization during exercise in active people. , 1995, The American journal of clinical nutrition.

[46]  M. Riddell,et al.  Continuous moderate‐intensity exercise with or without intermittent high‐intensity work: effects on acute and late glycaemia in athletes with Type 1 diabetes mellitus , 2011, Diabetic medicine : a journal of the British Diabetic Association.

[47]  Ronald J Sigal,et al.  Point accuracy of interstitial continuous glucose monitoring during exercise in type 1 diabetes. , 2013, Diabetes technology & therapeutics.

[48]  A. Jeukendrup,et al.  Carbohydrates for training and competition , 2011, Journal of sports sciences.

[49]  C. Cobelli,et al.  Exercise effects on postprandial glucose metabolism in type 1 diabetes: a triple-tracer approach. , 2015, American journal of physiology. Endocrinology and metabolism.

[50]  G. Jabbour,et al.  Barriers to Active Lifestyles in Children with Type 1 Diabetes. , 2016, Canadian journal of diabetes.

[51]  S. Greenfield,et al.  Attitudes and Barriers to Exercise in Adults with Type 1 Diabetes (T1DM) and How Best to Address Them: A Qualitative Study , 2014, PloS one.

[52]  M. Horowitz,et al.  Dysglycaemia in the critically ill – significance and management , 2013, Diabetes, obesity & metabolism.

[53]  M. Phillip,et al.  Exercise With and Without an Insulin Pump Among Children and Adolescents With Type 1 Diabetes Mellitus , 2005, Pediatrics.

[54]  M. Riddell,et al.  Evidence-based risk assessment and recommendations for physical activity clearance: diabetes mellitus and related comorbidities. , 2011, Applied physiology, nutrition, and metabolism = Physiologie appliquee, nutrition et metabolisme.

[55]  R. Bracken,et al.  Impact of pre‐exercise rapid‐acting insulin reductions on ketogenesis following running in Type 1 diabetes , 2011, Diabetic medicine : a journal of the British Diabetic Association.

[56]  H. Chase,et al.  Preventing post-exercise nocturnal hypoglycemia in children with type 1 diabetes. , 2010, The Journal of pediatrics.

[57]  M. Walker,et al.  Insulin therapy and dietary adjustments to normalize glycemia and prevent nocturnal hypoglycemia after evening exercise in type 1 diabetes: a randomized controlled trial , 2015, BMJ Open Diabetes Research and Care.

[58]  J. Polańska,et al.  Reasons for the discontinuation of therapy of personal insulin pump in children with type 1 diabetes. , 2016, Pediatric endocrinology, diabetes, and metabolism.

[59]  R. Bracken,et al.  Isomaltulose improves glycemia and maintains run performance in type 1 diabetes. , 2012, Medicine and science in sports and exercise.

[60]  T. Rönnemaa,et al.  Combined Effect of Exercise and Ambient Temperature on Insulin Absorption and Postprandial Glycemia in Type I Patients , 1988, Diabetes Care.

[61]  Bruce A Buckingham,et al.  The effects of aerobic exercise on glucose and counterregulatory hormone concentrations in children with type 1 diabetes. , 2006, Diabetes care.

[62]  Peter G. Jacobs,et al.  Nonadjunctive Use of Continuous Glucose Monitoring for Diabetes Treatment Decisions , 2016, Journal of diabetes science and technology.

[63]  M. Campbell,et al.  Impact of single and multiple sets of resistance exercise in type 1 diabetes , 2015, Scandinavian journal of medicine & science in sports.

[64]  W. Aronow,et al.  Exercise capacity as an independent risk factor for adverse cardiovascular outcomes among nondiabetic and diabetic patients , 2014, Archives of medical science : AMS.

[65]  Ali Cinar,et al.  Exercise and the Development of the Artificial Pancreas , 2015, Journal of diabetes science and technology.

[66]  J. Jendle,et al.  The Benefits of Continuous Glucose Monitoring and a Glucose Monitoring Schedule in Individuals with Type 1 Diabetes during Recreational Diving , 2008, Journal of diabetes science and technology.

[67]  M. Riddell,et al.  Blood Glucose Levels and Performance in a Sports Camp for Adolescents with Type 1 Diabetes Mellitus: A Field Study , 2010, International journal of pediatrics.

[68]  Marc D Breton,et al.  Impact of Blood Glucose Self-Monitoring Errors on Glucose Variability, Risk for Hypoglycemia, and Average Glucose Control in Type 1 Diabetes: An In Silico Study , 2010, Journal of diabetes science and technology.

[69]  T. Jones,et al.  The effect of midday moderate-intensity exercise on postexercise hypoglycemia risk in individuals with type 1 diabetes. , 2013, The Journal of clinical endocrinology and metabolism.

[70]  T. Jones,et al.  The effect of a short sprint on postexercise whole-body glucose production and utilization rates in individuals with type 1 diabetes mellitus. , 2012, The Journal of clinical endocrinology and metabolism.

[71]  R. Porcher,et al.  Glucose response to intense aerobic exercise in type 1 diabetes: maintenance of near euglycemia despite a drastic decrease in insulin dose. , 2003, Diabetes care.

[72]  R. Sigal,et al.  Effects of Performing Resistance Exercise Before Versus After Aerobic Exercise on Glycemia in Type 1 Diabetes , 2012, Diabetes Care.

[73]  J. Hawley,et al.  Adaptations to short-term high-fat diet persist during exercise despite high carbohydrate availability. , 2002, Medicine and science in sports and exercise.

[74]  4. Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care, and Immunization , 2014, Diabetes Care.

[75]  K. Tipton,et al.  Increased protein intake reduces lean body mass loss during weight loss in athletes. , 2010, Medicine and science in sports and exercise.

[76]  M. Walker,et al.  Large Pre- and Postexercise Rapid-Acting Insulin Reductions Preserve Glycemia and Prevent Early- but Not Late-Onset Hypoglycemia in Patients With Type 1 Diabetes , 2013, Diabetes Care.

[77]  B. Frier.  Hypoglycaemia in diabetes mellitus: epidemiology and clinical implications , 2014, Nature Reviews Endocrinology.

[78]  R. Tanenberg,et al.  Confirmation of hypoglycemia in the "dead-in-bed" syndrome, as captured by a retrospective continuous glucose monitoring system. , 2010, Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists.

[79]  M. Riddell,et al.  Preventing exercise-induced hypoglycemia in type 1 diabetes using real-time continuous glucose monitoring and a new carbohydrate intake algorithm: an observational field study. , 2011, Diabetes technology & therapeutics.

[80]  R. Rabasa-Lhoret,et al.  Comparison of Two Continuous Glucose Monitoring Systems, Dexcom G4 Platinum and Medtronic Paradigm Veo Enlite System, at Rest and During Exercise. , 2016, Diabetes technology & therapeutics.

[81]  Hirofumi Tanaka,et al.  Continuous vs interval training on glycemic control and macro‐ and microvascular reactivity in type 2 diabetic patients , 2014, Scandinavian journal of medicine & science in sports.

[82]  M. McKenna,et al.  Sprint Training Increases Muscle Oxidative Metabolism During High-Intensity Exercise in Patients With Type 1 Diabetes , 2008, Diabetes Care.

[83]  S. Weisnagel,et al.  Is early and late post-meal exercise so different in type 1 diabetic lispro users? , 2006, Diabetes research and clinical practice.

[84]  D. Klonoff,et al.  Hypoglycemia begets hypoglycemia: the order effect in the ASPIRE in-clinic study. , 2014, Diabetes technology & therapeutics.

[85]  A. Kriska,et al.  The association of physical activity and diabetic complications in individuals with insulin-dependent diabetes mellitus: the Epidemiology of Diabetes Complications Study--VII. , 1991, Journal of clinical epidemiology.

[86]  S. Bain,et al.  Algorithm that delivers an individualized rapid‐acting insulin dose after morning resistance exercise counters post‐exercise hyperglycaemia in people with Type 1 diabetes , 2016, Diabetic medicine : a journal of the British Diabetic Association.

[87]  W. Saris,et al.  The effects of increasing exercise intensity on muscle fuel utilisation in humans , 2001, The Journal of physiology.

[88]  Matthew D. Campbell,et al.  A Low–Glycemic Index Meal and Bedtime Snack Prevents Postprandial Hyperglycemia and Associated Rises in Inflammatory Markers, Providing Protection From Early but Not Late Nocturnal Hypoglycemia Following Evening Exercise in Type 1 Diabetes , 2014, Diabetes Care.

[89]  G. Steil,et al.  Impact of Fat, Protein, and Glycemic Index on Postprandial Glucose Control in Type 1 Diabetes: Implications for Intensive Diabetes Management in the Continuous Glucose Monitoring Era , 2015, Diabetes Care.

[90]  D. Wasserman,et al.  Glucoregulation During and After Exercise in Health and Insulin-Dependent Diabetes , 2005, Exercise and sport sciences reviews.

[91]  M. Riddell,et al.  Exercise in children and adolescents with diabetes , 2008, Pediatric diabetes.

[92]  K. Hemming,et al.  Does Exercise Improve Glycaemic Control in Type 1 Diabetes? A Systematic Review and Meta-Analysis , 2013, PloS one.

[93]  O. Laitano,et al.  Effect of carbohydrate ingestion on the glycemic response of type 1 diabetic adolescents during exercise. , 2005, Diabetes care.

[94]  B. Kiens,et al.  Energy availability in athletes , 2011, Journal of sports sciences.

[95]  F. Karpe,et al.  Regulation of human subcutaneous adipose tissue blood flow , 2014, International Journal of Obesity.

[96]  J. Jendle,et al.  Education and individualized support regarding exercise and diabetes improves glucose control and level of physical activity in type 1 diabetes individuals , 2015 .

[97]  L. Laffel,et al.  Challenges and Opportunities in the Management of Cardiovascular Risk Factors in Youth With Type 1 Diabetes: Lifestyle and Beyond , 2015, Current Diabetes Reports.

[98]  L. Burke.  Re-Examining High-Fat Diets for Sports Performance: Did We Call the ‘Nail in the Coffin’ Too Soon? , 2015, Sports Medicine.

[99]  T. Graham.  Caffeine and Exercise , 2001, Sports medicine.

[100]  M. Riddell,et al.  Clinical Management of the Physically Active Patient with Type 1 Diabetes , 2011, The Physician and sportsmedicine.

[101]  B. Linde,et al.  Hypoglycemia Risk During Exercise After Intramuscular Injection of Insulin in Thigh in IDDM , 1990, Diabetes Care.

[102]  D. Dunstan,et al.  Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association , 2016, Diabetes Care.

[103]  C. Stettler,et al.  Accuracy of continuous glucose monitoring during differing exercise conditions. , 2016, Diabetes research and clinical practice.

[104]  J. Hawley,et al.  Carbohydrate availability and exercise training adaptation: Too much of a good thing? , 2015, European journal of sport science.

[105]  D. Owens,et al.  Effects of exercise on the absorption of insulin glargine in patients with type 1 diabetes. , 2005, Diabetes care.

[106]  A. Fenning,et al.  Effects of high-intensity interval training on cardiometabolic health: a systematic review and meta-analysis of intervention studies , 2016, British Journal of Sports Medicine.

[107]  Ksenia Tonyushkina,et al.  Glucose Meters: A Review of Technical Challenges to Obtaining Accurate Results , 2009, Journal of diabetes science and technology.

[108]  M. Funk,et al.  Cardiovascular health in adults with type 1 diabetes. , 2016, Preventive medicine.

[109]  Stuart M Phillips,et al.  Considerations for protein intake in managing weight loss in athletes , 2015, European journal of sport science.

[110]  J. Jendle,et al.  Evaluation of glucose control when a new strategy of increased carbohydrate supply is implemented during prolonged physical exercise in type 1 diabetes , 2015, European Journal of Applied Physiology.

[111]  A. Brazeau,et al.  Barriers to Physical Activity Among Patients With Type 1 Diabetes , 2008, Diabetes Care.

[112]  T. Jones,et al.  Effect of intermittent high-intensity compared with continuous moderate exercise on glucose production and utilization in individuals with type 1 diabetes. , 2007, American journal of physiology. Endocrinology and metabolism.

[113]  J. McGavock,et al.  A systematic review and meta-analysis of exercise interventions in adults with type 1 diabetes. , 2014, Diabetes research and clinical practice.

[114]  J. Steinacker,et al.  Impact of Physical Activity on Glycemic Control and Prevalence of Cardiovascular Risk Factors in Adults With Type 1 Diabetes: A Cross-sectional Multicenter Study of 18,028 Patients , 2015, Diabetes Care.

[115]  O. Kordonouri,et al.  Impact of Physical Activity on Cardiovascular Risk Factors in Children With Type 1 Diabetes , 2007, Diabetes Care.

[116]  T. Heise,et al.  Similar risk of exercise‐related hypoglycaemia for insulin degludec to that for insulin glargine in patients with type 1 diabetes: a randomized cross‐over trial , 2015, Diabetes, obesity & metabolism.

[117]  S. Davis,et al.  Effect of differing antecedent hypoglycemia on counterregulatory responses to exercise in type 1 diabetes. , 2006, American journal of physiology. Endocrinology and metabolism.

[118]  M. Albada,et al.  Recurrent nightly ketosis after prolonged exercise in type 1 diabetes – the need for glycogen replacement strategies. Case report and review of literature , 2016 .

[119]  T. Jones,et al.  Contribution of an Intrinsic Lag of Continuous Glucose Monitoring Systems to Differences in Measured and Actual Glucose Concentrations Changing at Variable Rates in Vitro , 2010, Journal of diabetes science and technology.

[120]  W. A. Müller,et al.  Metabolic and hormonal effects of muscular exercise in juvenile type diabetics , 1977, Diabetologia.

[121]  T. Heise,et al.  Plasma glucose and hypoglycaemia following exercise in people with Type 1 diabetes: a comparison of three basal insulins , 2009, Diabetic medicine : a journal of the British Diabetic Association.

[122]  Chris Boesch,et al.  Metabolic and hormonal response to intermittent high-intensity and continuous moderate intensity exercise in individuals with type 1 diabetes: a randomised crossover study , 2016, Diabetologia.

[123]  C. Stettler,et al.  Exercise-associated glucose metabolism in individuals with type 1 diabetes mellitus , 2015, Current opinion in clinical nutrition and metabolic care.