Advances in Exercise, Physical Activity, and Diabetes Mellitus
2017; Mary Ann Liebert, Inc.; Volume: 19; Issue: S1 Linguagem: Inglês
10.1089/dia.2017.2509
ISSN1557-8593
AutoresAoibhe M. Pasieka, Michael C. Riddell,
Tópico(s)Diabetes Treatment and Management
ResumoDiabetes Technology & TherapeuticsVol. 19, No. S1 Original ArticlesFree AccessAdvances in Exercise, Physical Activity, and Diabetes MellitusAoibhe M. Pasieka and Michael C. RiddellAoibhe M. PasiekaSchool of Kinesiology and Health Science, York University, Toronto, ON, Canada.Search for more papers by this author and Michael C. RiddellSchool of Kinesiology and Health Science, York University, Toronto, ON, Canada.Search for more papers by this authorPublished Online:1 Feb 2017https://doi.org/10.1089/dia.2017.2509AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail IntroductionIn 2015/2016, a number of papers were published on the challenges of exercise management for patients living with diabetes. A big focus was on testing how the artificial pancreas might function during exercise, with or without activity announcements and the addition of glucagon. Moreover, several papers revealed barriers to exercise participation for people living with type 1 or type 2 diabetes. A few papers demonstrated that many of the tools for the preservation of glucose control during and after exercise in type 1 diabetes are not being used. This year, we selected 10 papers to highlight the field of exercise and diabetes, with an emphasis on “technology” rather than on the possible mechanisms for exercise action. Our initial search was restricted to human studies and primarily on studies in which patients with diabetes severed as subject participants. We screened over 150 papers on the topic that were found on Pubmed and other common search engines published between July 1, 2015 and June 30, 2016. The following 10 papers, we think, represent some of the highlights.Key Articles Reviewed for the ArticleAlgorithm that delivers an individualized rapid-acting insulin dose after morning resistance exercise counters post-exercise hyperglycaemia in people with type 1 diabetesTurner D, Luzio S, Gray BJ, Bain SC, Hanley S, Richards A, Rhydderch DC, Martin R, Campbell MD, Kilduff LP, West DJ, Bracken RMDiabet Med 2016;33: 506–510Randomized trial of dual-hormone artificial pancreas with dosing adjustment during exercise compared with no adjustment and sense-augmented pump therapyJacobs PG, El Youssef J, Reddy R, Resalat N, Branigan D, Condon J, Preiser N, Katrina Ramsey, Jones M, Edwards C, Kuehl K, Leitschuh J, Rajhbeharrysingh U, Castle JDiabetes Obes Metab 2016;18:1110–1118.Metabolic effects of exercise training among fitness-nonresponsive patients with type 2 diabetes: the HARTD studyPandey A, Swift DL, McGuire DK, Ayers CR, Neeland IJ, Blair SN, Johannsen N, Earnest CP, Berry JD, Church TSDiabetes Care 2015;38: 1494–1501Insulin-based strategies to prevent hypoglycaemia during and after exercise in adult patients with type 1 diabetes on pump therapy: the DIABRASPORT randomized studyFranc S, Daoudi A, Pochat A, Petit MH, Randazzo C, Petit C, Martine Duclos M, Penfornis A, Pussard E, Not D, Heyman E, Koukoui F, Simon S, Charpentier GDiabetes Obes Metab 2015;17: 1150–1157Impact 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 patientsBohn B, Herbst A, Pfeifer M, Krakow D, Zimny S, Kopp F, Melmer A, Steinacker JM, and Holl RW, for the DPV InitiativeDiabetes Care 2015;38: 1536–1543Do youth with type 1 diabetes exercise safely? A focus on patient practices and glycemic outcomesRoberts AJ, Yi-Frazier JP, Aitken KE, Mitrovich CA, Pascual MF, Taplin CEPediatr Diabetes 2016; Jul 6. [Epub ahead of print] DOI 10.1111/pedi.12402General practitioners' barriers to prescribe physical activity: the dark side of the cluster effects on the physical activity of their type 2 diabetes patientsLanhers C, Duclos M, Guttmann A, Coudeyre E, Pereira B, Ouchchane LPLoS One 2015;10: e0140429.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 insulinMoser O, Tschakert G, Mueller A, Groeschl W, Pieber T, Obermayer-Pietsch B, Koehler G, Hofmann PPLoS One 2015;10: e0136489Classification of physical activity: information to artificial pancreas control systems in real timeTurksoy K, Paulino TM, Zaharieva DP, Yavelberg L, Jamnik V, Riddell MC, Cinar AJ Diabetes Sci Technol 2015;9: 1200–1207One week of bed rest leads to substantial muscle atrophy and induces whole-body insulin resistance in the absence of skeletal muscle lipid accumulationDirks ML, Wall BT, van de Valk B, Holloway TM, Holloway GP, Chabowski A, Goossens GH, van Loon LJCDiabetes 2016;65:2862–2875.Algorithm that delivers an individualized rapid-acting insulin dose after morning resistance exercise counters post-exercise hyperglycaemia in people with type 1 diabetesTurner D1,2, Luzio S2,3, Gray BJ1,2, Bain SC2,3, Hanley S1, Richards A3, Rhydderch DC3, Martin R4, Campbell MD5, Kilduff LP1, West DJ5, Bracken RM1,21Applied Sports, Technology, Exercise and Medicine Research Centre, College of Engineering, Swansea University, Singleton Park, Swansea, UK2Diabetes Research Group, College of Medicine, Swansea University, Singleton Park, Swansea, UK3Abertawe Bro Morgannwg University Health Board, Singleton Hospital, Swansea, UK4Cwm Taf University Health Board, Merthyr Tydfil, UK5Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, Northumbria University, Newcastle-upon-Tyne, UKDiabet Med 2016;33: 506–510BackgroundIn type 1 diabetes, weight training and other forms of anaerobic exercise can acutely increase blood glucose levels. How to manage postexercise hyperglycemia safely and effectively in this patient population is currently unclear. The goal of this study was to test an insulin dose adjustment algorithm that delivers an individualized dose of rapid-acting insulin analog after morning resistance exercise to counter postexercise hyperglycemia in individuals with type 1 diabetes.MethodsEight people with type 1 diabetes (6 men; 2 women, all on multiple daily insulin injections (MDI)), in fair glycemic control (8.7%±1.1%, mean±standard error) attended two morning laboratory sessions in a fasted state, having taken their usual basal insulin the previous evening. They performed a resistance exercise session comprising of six exercises for two sets of 10 repetitions at 60% of the maximum amount of force that was generated in one maximal contraction. In a counterbalanced order, the subjects were administered either an individualized dose of rapid-acting insulin (∼2±1 units, range 0 to 4 units) based on a modification of their own hyperglycemia correction factor (reduced by 50%) or were not administered insulin in recovery. Venous blood glucose concentrations were measured up until 125 min following resistance exercise.ResultsPre-exercise blood glucose averaged 11.2±1.2 in both sessions. Participants had a rise in blood glucose in both sessions (insulin session increased to 13.0±1.6 vs. no-insulin session increasing to 12.7±1.5 mmol/L; P=0.834). The decline in blood glucose concentration between the peak glucose and 125 min mark after exercise was greater in the insulin administered session than in the no-insulin session (3.3±1.0 vs. 1.3±0.4 mmol/L: P=0.015). There were no episodes of hypoglycaemia during that same time frame in either session.ConclusionsThese authors propose that the administration of rapid-acting insulin according to an individualized algorithm reduces hyperglycemia after morning resistance exercise without causing hypoglycaemia in the 2 h postexercise window in people with type 1 diabetes.CommentA large percentage of patients with type 1 diabetes have postexercise hyperglycemia following intense exercise (anaerobic and intense aerobic), likely because of sustained increases in hepatic glucose production that exceeds glucose uptake into muscle that is now finished contracting (1,2). This phenomenon may be more common in patients on MDI than on continuous subcutaneous insulin infusion (CSII) (3), although it can happen in any patient who does intense exercise, particularly if there is heightened competition stress (4). High blood sugars in recovery can be prolonged (5) and can be frustrating since it may promote dehydration and compromise overall A1c levels if it is a frequent occurrence. Some athletes complain that hyperglycemia after exercise makes them feel sluggish and may compromise their capacity to recover from the activity and may wish to bolus insulin to counter these effects. However, bolusing insulin after exercise is a worry since it may increase risk for late-onset hypoglycaemia, another frustrating side effect of exercise. Our colleagues from the United Kingdom show here that a conservative insulin dose post exercise [i.e., 50% of the typical “correction factor,” based on the total daily insulin dose algorithm calculation, as described by Davidson et al. (6)] is a safe and effective way to gradually bring glucose levels into control after exercise if hyperglycemia develops. The main limitation of this pilot study is that other insulin dose administration protocols were not tested (e.g., 100% correction, bolus before the exercise starts) and the subjects were not followed all that long in recovery (just 120 minutes).Randomized trial of dual-hormone artificial pancreas with dosing adjustment during exercise compared with no adjustment and sense-augmented pump therapyJacobs PG1, El Youssef J2, Reddy R1, Resalat N1, Branigan D2, Condon J1, Preiser N1, Ramsey K3, Jones M2, Edwards C2, Kuehl K4, Leitschuh J1, Rajhbeharrysingh U1, Castle J21Department of Biomedical Engineering, Oregon Health and Science University, Portland, OR2Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, OR3Oregon Clinical and Translational Research Institute Biostatistics & Design Program, Oregon Health & Science University, Portland, ORDepartment of Medicine, Division of Health Promotion and Sports Medicine, Human Performance Laboratory, Oregon Health and Science University, Portland, OR4Department of Medicine, Division of Health Promotion and Sports Medicine, Human Performance Laboratory, Oregon Health and Science University, Portland, ORDiabetes Obes Metab 2016;18:1110–1118.BackgroundIndividuals with type 1 diabetes (T1D) have impaired insulin secretion and dysfunctional glucagon secretion, making them particularly susceptible to hyper- and hypoglycemia. It is generally held that artificial pancreas (AP) systems will help mitigate risk of dysglycaemia. In this system, hormone delivery is determined using an algorithm, however, with exercise, insulin sensitivity is significantly altered and adjustments are likely required. This study aimed to determine the optimal adjustments of insulin and glucagon dosing with exercise to prevent exercise induced hypoglycemia.MethodsThis study was a randomized crossover controlled study comparing dual hormone AP with adjustments (APX), versus dual hormone AP without adjustments (APN) and sensor augmented pump (SAP). Twenty-one T1D patients ages 18 to 45 stayed in a hospital overnight and had standardized meals. Postbreakfast, exercise consisted of running at 60% of HR max for 45 min on a motorized treadmill. The exercising dosing algorithm reduced insulin and increased glucagon during and postexercise for 1.5 h. APN was unadjusted for exercise and SAP manually managed hormone delivery by patients.ResultsDespite similar baseline values, APX promoted significantly less time in hypoglycaemia postexercise compared to APN (0.3% APX vs. 3.1% APN, P=0.001). The APN trial had a reduced percent of time spent in hyperglycemia postexercise than both APX and SAP, although these differences did not reach significance. In the overnight period APN spent significantly less time spent in hyperglycemia than APX (8.7% vs. 17.2%, P=0.04).ConclusionsThis study highlights the importance of adjusting insulin and glucagon doses at the onset of exercise to limit hypoglycaemia. APX performs similarly to SAP when insulin was adjusted prior to exercise.CommentWith T1D, the body's ability to produce insulin is lost and glucagon production becomes dysregulated. As such, maintaining euglycaemia during exercise requires a lot of monitoring, manual adjustments to insulin delivery and carbohydrate snacking. For this reason, the development of the dual hormone AP for the daily monitoring and regulation of blood glucose levels is a novel and exciting branch of research for improving glycemic control in individuals with T1D. In a state of exercise, the rate of change in glycemia occurs more rapidly and in order to counteract this, the dual hormone AP system must be able to measure exercise and possibly make adjustments to both hormones. This study found that when AP was adjusted at the onset of exercise, exercise-associated hypoglycaemia was significantly reduced when compared to nonadjustment AP. SAP also resulted in relatively good glucose control, but a limit to its use is that it requires a lot more manual adjustment, which is a burden and not always feasible, especially with long, sustained exercises. Although this study was beneficial in manipulating the AP to reduce the incidences of hypoglycemia, it did not detect the onset of exercise automatically. Future research from the same group is currently aiming to incorporate an exercise detection component into the AP-algorithm by using accelerometers and heart rate inputs (7) in order to advance the field towards utilizing this technology for day-to-day use.Metabolic effects of exercise training among fitness-nonresponsive patients with type 2 diabetes: the HART-D studyPandey A1, Swift DL2, McGuire DK1,3, Ayers CR3, Neeland IJ1, Blair SN4, Johannsen N5, Earnest CP6, Berry JD1,3, Church TS71Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX2Department of Kinesiology, East Carolina University, Greenville, NC3Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX4Department of Exercise Science, Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC5School of Kinesiology, College of Human Sciences & Education, Louisiana State University, Baton Rouge, LA6Department for Health & Kinesiology, Texas A&M University, College Station, TX7Preventive Medicine Laboratory, Pennington Biomedical Research Center, Baton Rouge, LADiabetes Care 2015;38: 1494–1501BackgroundPhysical activity is closely associated with cardiorespiratory fitness (CRF), yet some individuals are nonresponsive to exercise and do not experience these expected improvements (termed “nonresponders”). This study examined how type 2 diabetes (T2D) patients respond to exercise training, focusing on changes in CRF, hemoglobinA1c (HbA1c) levels and other metabolic parameters.MethodsThis study analyzed data from patients who participated in the Heath Benefits of Aerobic and Resistance Training in Diabetes (HART-D) study. There were 202 participants assigned to supervised training protocols for 9 months. The groups consisted of a nonexercise control group that received stretching and relaxation classes, an aerobic-training group (3 to 5 days/week, 50% to 80% of maximal aerobic capacity [VO2max]), a resistance-training group (3 days/week, 10 to 12 reps of each activity), and a combination-training group receiving both resistance and aerobic training. Greater than 5% increase in peak oxygen uptake was considered a meaningful improvement in CRF, otherwise, they were considered nonresponders.ResultsOnly 36.6% of exercisers were considered CRF responsive (improvements in VO2max <5%). Both responders and nonresponders in the exercise groups had significantly decreased in HbA1c from baseline (−0.26% [95% confidence interval (CI) −0.5 to −0.01], −0.26% [95% CI −0/45 to −0.08]). Additionally, both responders and nonresponders had reduced waist circumference (WC) and percent body fat (−2.6 cm [95% CI −3.7 to −1.5] vs. −1.8cm [95% CI −2.6 to −1.0]), (% body fat −1.07% [95% CI −1.5 to −0.62] vs −0.75% [95% CI −1.09 to −0.41]). Lastly, both responsive and nonresponsive exercisers tended to report a reduced use of diabetes-related oral agents compared to controls (36% vs. 20.5%; P=0.08).ConclusionsExercise is associated with significant improvements in glycemic control, reductions in percent body fat/waist circumference, independent of the cardiorespiratory response to training. Based on this study, it is recommended that exercise be prescribed to T2D patients to decrease their risk of diabetes related comorbidities and improve their glucose control, with little regard to if the exercise makes their cardiorespiratory system more fit or not.CommentMetabolic parameters such as cardiorespiratory fitness and waist circumference are inversely associated with insulin resistance (8,9,10). Regular exercise is known to improve these factors, but for some, termed “nonresponsive” individuals, improvements in these factors are not seen, even with supervised and regular exercise. This is the first study to compare the effects of chronic moderate-intensity activity on T2D patients in responders versus nonresponders.This was a large study (n=202) with long-term supervised training interventions. It was found that in their population of only T2D adults, a surprising 63% of the subjects were considered fitness nonresponsive, a value that was quite high, especially when compared to the general population. In a recent study, only 17.6% of obese and otherwise healthy subjects were considered nonresponders after undergoing an exercise program with frequent low intensity exercise sessions (11). The reason for the increased prevalence of nonresponders with T2D requires further investigation. The lack of improvement in fitness may be discouraging for individuals and may influence exercise compliance and commitment to an exercise program. However, despite no clinical improvements in CRF, exercise is independently associated with improved glucose control, reduced insulin resistance and less body fat, thus validating that exercise is still a beneficial therapy for diabetes treatment (8).Insulin-based strategies to prevent hypoglycaemia during and after exercise in adult patients with type 1 diabetes on pump therapy: the DIABRASPORT randomized studyFranc S1,2, Daoudi A1, Pochat A1, Petit MH1, Randazzo C1, Petit C1, Martine Duclos M3, Penfornis A2, Pussard E4, Not D5, Heyman E6, Koukoui F7, Simon S8, Charpentier G1,21Centre for Study and Research for Improvement of the Treatment of Diabetes, Evry, France2Department of Diabetes, Sud-Francilien Hospital, Corbeil-Essonnes, France3Department of Sport Medicine and Functional Exploration, Clermont-Ferrand University Hospital, UMR1019 CRNH, Clermont-Ferrand, France4Molecular Genetics, Pharmacogenetics and Hormonology Laboratory, Bicêtre University Hospital, Kremlin-Bicêtre, France5RCTs, Lyon, France6‘Physical Activity, Muscle, Health’ Research Team, URePSSS, University of Lille, Lille, France7Department of Cardiology, Sud-Francilien Hospital, Corbeil-Essonnes, France8Department of Endocrinology, Diabetes and Metabolic Diseases, Lyon Sud University Hospital, Pierre-Bénite, FranceDiabetes Obes Metab 2015;17: 1150–1157BackgroundAerobic exercise is known to cause hypoglycemia in T1D. Previous studies have primarily focused on the optimal doses of bolus and basal insulin for prolonged exercise in athletic patients on CSII, but the guidelines for short, exercise sessions in nonathletic patients have not been determined. This study aimed to define optimal adjustments to insulin dosing for 30 min of exercise performed 3 h (Part 1) or 90 min (Part 2) following a meal (lunch) in patients on CSII.MethodsThis was a randomized control crossover trial with 20 adult TID patients. Subjects attended multiple sessions where they exercised 3 hours postlunch; 1 rest session, 2 moderate exercise sessions (one with a 50% and the other with a 80% basal rate (BR) reduction), and 2 intense exercise sessions (one with an 80% BR reduction and the other with the pump stopped). All BR adjustments were made during exercise and remained for 2 h following exercise (except for the pump stopped session, where the infusion rate was re-established after exercise). Subjects returned for 2 postlunch exercises sessions that occurred 90 min postmeal in order to assess differences between adjusting bolus vs. basal insulin delivery. For all exercises, patients assessed their perceived intensity using the Borg scale.ResultsFor the late exercise sessions, there were no overall differences in the occurrence of hypoglycemia with exercise versus rest. In the afternoon, there were significantly more hypoglycemic events with the milder reductions at both exercise intensities compared to rest (moderate exercise; 50% BR reduction vs. rest, P=0.03; intense exercise, 80% BR reduction vs.=rest, P=0.028). For the early exercise sessions, there was a trend towards fewer hypoglycemia events with bolus versus BR reduction, but this did not reach significance (P=0.07). When asked about perceived intensity, 90% of subjects accurately rated the 50%VO2max exercise as moderate, while the 75%VO2max exercise was only accurately perceived as intense 60% of the time.ConclusionsIn adults with T1D, it is possible to exercise for 30 min, 3 h postlunch without increasing the risk of hypoglycemia by reducing the BR by 80% for moderate exercise and by stopping the pump altogether for intense exercise. If exercising shortly after a meal, reducing the bolus insulin dose by 50% appears to be sufficiently effective in preventing hypoglycemia.CommentThe benefits of exercise are well known, but with fear of hypoglycemia being one of the major barriers to exercise in type 1 diabetes, there is an increased requirement to develop specific strategies to limit its likelihood of occurring. Most studies use well trained athletes, but with a significant percent of the general population being physical inactive (∼36.1%) (12), a percentage that only increases in the T1D population (∼63%) (13), specific guidelines for a nonathletic population are required. This study used insulin pumps as opposed to multiple daily injections and one of the major benefits to this with exercise is that adjustments can be made at the onset of exercise, making an employable strategy if activity cannot be foreseen in advance. This study successfully determined optimal dose adjustments of nonathletic individuals performing short bouts of exercise (30 min) that would be representative of daily leisure or work activity. Based on this study, an aggressive reduction of basal insulin delivery (i.e., 80%–100%) might be most effective, as the 50% BR reduction did not fully prevent hypoglycemia. This adjustment was found to be in agreement with a study by McAuley and colleagues, where a 50% BR reduction was not sufficient to reduce circulating insulin levels even when it was performed an hour before the start of the activity (14).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 patientsBohn B1, Herbst A2, Pfeifer M3, Krakow D4, Zimny S5, Kopp F6, Melmer A7, Steinacker JM8, and Holl RW1, for the DPV Initiative1Institute of Epidemiology and Medical Biometry, ZIBMT, German Center for Diabetes Research, University of Ulm, Ulm, Germany2Centre for Paediatrics, Medical Clinic Leverkusen, Leverkusen, Germany3Diabetes Center, Clinic Tettnang, Tettnang, Germany4DZFO, Diabetes Centre Forchheim, Forchheim, Germany5Center for Internal Medicine, Endocrinology and Diabetology, Schwerin Hospital, Schwerin, Germany6Diabetes Center, Augsburg Clinical Center, Augsburg, Germany7Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria8Division of Sports and Rehabilitation Medicine, Department of Internal Medicine II, University of Ulm, Ulm, GermanyDiabetes Care 2015;38: 1536–1543BackgroundVarious studies have demonstrated the positive effects of physical activity on a multitude of diseases including cardiovascular disease, T2D and some cancers, yet studies on T1D tend to be smaller and meta-analyses have shown conflicting results for exercise recommendations. For this reason, this study aims to examine the influence of exercise on glycemic control and cardiovascular risk factors in 18,028 patients with T1D.MethodsSubject information was provided by the Diabetes Patienten-Verlaufsdokumentation (DPV) database in Germany and Austria, which documented diabetes care strategies and their outcomes from 18,028 patients aged 18 to 80 years. Data reported included self-reported physical activity (PA), measured as frequency per week (PA2; 2 or more times per week, PA1;1 time a week, and PA0; inactive), HbA1c values, body mass index (BMI), hypertension and the use of anti-hypertensive drugs, dyslipidemia, diabetic ketoacidosis (DKA), and events of severe hypoglycemia and hypoglycemia resulting in a loss of consciousness. Data were stratified by group size and further stratified by age and gender.ResultsFrequency of PA ranged between 0 and 9 times per week. The number of subjects who reported exercising more than two times per week (PA2) was 3212 (17.8%), 3459 subjects (19.9%) reported to be physically active one to two times (PA1), and 11,357 (63.0%) were inactive (PA0). Women were more often inactive compared with men (PA0: 66.0% vs. 60.5%, respectively) and the percentage of inactive individuals increased with age in both genders. PA had an inverse association with total daily insulin levels and HbA1c levels, independent of age and gender (P<0.0001). Additionally, physical activity was inversely associated with DKA, BMI, and dyslipidemia (P<0.0001 for all). Rates of severe hypoglycemia were lowest in the moderately active group. In addition to having the highest rates of hypoglycemia, the least active group had the highest incidence of retinopathy and microalbuminuria.ConclusionsPhysical activity has a beneficial effect on T1D patients in terms of improving HbA1c levels and associated comorbidities. Despite this, an increased percentage of subjects were reported to be inactive (63% versus approximately 34% in the general population) and more research should focus on encouraging participation in physical activity in this patient population.CommentThis multicenter cross-sectional study from Germany and Austria is the largest to date to demonstrate the beneficial impact of exercise on T1D. Overall, high levels of PA were associated with a lower daily insulin dose, a lower HbA1c and reduced diabetes-related complications. However, with T1D, the potential for developing exercise-induced hypoglycemia is one of the greatest barriers to participating in exercise (15). In this large study, it was found that in women and in the oldest age-group (45 to 80 years), the rate of severe hypoglycemia increased with PA, whereas in other subgroups, there was an inverse association. This finding should caution health-care providers about prescribing exercise for older women living with type 1 diabetes, whose rates of hypoglycemia are already elevated when compared to younger women (16).Do youth with type 1 diabetes exercise safely? A focus on patient practices and glycemic outcomesRoberts AJ1,2, Yi-Frazier JP3, Aitken KE1, Mitrovich CA3, Pascual MF3, Taplin CE1,21Seattle Children's Hospital Division of Endocrinology and Diabetes, Seattle, WA2University of Washington, Seattle, WA3Seattle Children's Research Institute, Seattle, WAPediatr Diabetes 2016; Jul 6. [Epub ahead of print] DOI 10.1111/pedi.12402BackgroundVarious insulin adjustment strategies have been tested to help reduce glycemic excursions during and after exercise, but little is known about their use in youth with type 1 diabetes. These authors aimed to assess the typical exercise management practices in youth with type 1 diabetes and examine the associations between key behaviors and glycemic control.MethodsThe “Type 1 Diabetes Report of Exercise Practices Survey (T1D-REPS)” was developed and piloted in 100 youth with type 1 diabetes on CSII. Participants completed a 3 day physical activity recall and 30 days of pump/glucose data were collected and analysed.ResultsEighty-four percent of participants modified their insulin regimen around exercise; only 40% reported adjusting prandial insulin immediately before exercise, while 68% reported some modification (suspension or decrease) of basal insulin during exercise. Following exercise, only 10% reported reducing basal insulin overnight. Those who performed ≥5 glucose checks/day adjusted basal insulin during exercise more frequently than those with fewer daily glucose checks (33% vs. 13%, P=0.05, χ(2)=3.7), and were more likely to report decreasing insulin dose for the bedtime snack following exercise (50% vs. 17%, P=0.004, χ(2)=8.2).ConclusionsBasal insulin reduction at the time of exercise appears to be the most common approach to reduce the risk of exercise-associated hypoglycemia. Despite research demonstrating that hypoglycemia after exercise is a frequent occurrence in youth, a majority (∼90%) are not adjusting insulin overnight after exercise. A tool designed to capture patient practices and provide clinicians with a framework for patient education may lead to improved safety around exercise in this active patient population.CommentOver the last several years, a good number of clinical studies have been conducted to help inform insulin dose reductions and/or carbohydrate snacks for aerobic exercise in adolescents with type 1 diabetes (17,18,19,20). Guidelines for exerci
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