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ADA/JDRF Type 1 Diabetes Sourcebook, Excerpt #23: Physical Activity, Part 5

Mar 23, 2014
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Sheri R. Colberg, PhD, and Michael C. Riddell, PhD

ADA-JDRF-Type-1-Diabetes-Sourcebook-image

Extreme Athletic Events

Despite the challenges presented by participation in long-duration athletic events, many individuals with T1D are currently training for and participating in such events. Research in this area is lacking, but a handful of studies have attempted to investigate the metabolic and hormonal effects of more extreme athletic participation in such individuals.

In an early study on T1D and distance running, researchers examined the metabolic and hormonal effects of a 3-h marathon training run.197 In that study, insulin was withheld for 16–26 h before the start of the run, although participants ate a normal breakfast 2.5 h before. Blood glucose levels decreased during the 3-h run, and post-exercise ketosis was elevated compared to controls without diabetes. Counterregulatory hormone secretion was found to be normal (or even elevated) in response to hypoglycemia during a long-distance run in these reasonably well-controlled, well-trained subjects with T1D but without long-term complications. Similarly, a study of nine males with T1D during a 75-km cross-country skiing race reported that insulin dose reductions of 30–40% before the event resulted in hyperglycemia during the early part of the race, but near normoglycemia during the remainder, likely attributable to several-fold increases in counterregulatory hormone levels.198 In another study, on the day of a marathon, runners with T1D reduced prerace insulin doses by an average of 26% and ingested 130 g of carbohydrate before, 91 g during, and 115 g after the race.199….

More recently, a study involving 14 male amateur athletes with T1D treated with insulin analogs examined responses to participation in two consecutive editions of the same half-marathon.124 For the half-marathon day, athletes reduced total insulin doses by 18.3% the first year, but only by 14.2% the second; basal insulin was reduced by 23.3% and 20.4% and short-acting insulin at breakfast prior to the competition by 31.7% and 15.3% in years 1 and 2, respectively. Athletes also consumed more carbohydrates during the event the second year (49.0 g vs. 59.1 g), with fewer glycemic excursions. Thus, athletes with T1D who are treated using insulin analogs alone may choose to make a lesser insulin reduction compared to traditional guidelines and slightly increase carbohydrate supplementation (amount and timing) to effectively balance blood glucose levels during long-distance competitions.

Others have shown reduced postmarathon insulin needs and increased insulin clearance, resulting in a decreased insulin availability that may allow enhanced muscle lipid utilization and spare glucose after long-duration exercise.200 However, in another study, after successfully managed marathon running, insulin sensitivity was not increased despite low glycogen content and enhanced glycogen synthase activity after marathon, likely due to increased lipid oxidation.199 Also examined were pre-exercise insulin reductions on consequent metabolic and dietary patterns for 24 h after a bout of running in individuals with T1D.141 Participants self-administered 100%, 75%, 50%, or 25% of their full, rapid-acting insulin dose immediately before consuming a meal and 2 h before completing 45 min of moderate running. Initially blood glucose levels were little affected; levels were highest 3 h postexercise with the lowest dose (25%) of rapid-acting insulin, which was maintained over the rest of the 24-h period despite less energy and carbohydrate intake. Based on this study, one can conclude that greater reductions in mealtime insulin may result in greater protection during the activity but may also result in a greater likelihood for post-exercise hyperglycemia.

Researchers have also studied use of continuous glucose monitoring systems (CGMS) during and after marathon participation to determine whether asymptomatic episodes of hypo- and hyperglycemia can be more effectively identified.201 Although such systems are limited in their ability to detect rapid changes in blood glucose levels, use of CGMS may help to identify asymptomatic hypoglycemia or hyperglycemia during and after a long distance run. The system may also be helpful in improving understanding about the individual changes of glucose during and after a marathon and may protect against hypoglycemic or hyperglycemic periods in future races. Of note, individuals with insulin-treated diabetes are advised not to undertake prolonged intensive exercise after severe hypoglycemia due to increased risk of acute damage to skeletal muscle and to organs such as the liver, risk of severe neuroglycopenia, and the induction of seizures.123

Physical Education Classes and After-School and Team Sports

The goals for most physical education classes are to engage children and adolescents in healthy activities so that students can learn about and achieve the health and fitness benefits of exercise and to help develop some basic motor skills (throwing, catching, running, jumping, etc…). Participating in a 30–45 min physical education class also helps achieve at least a portion of their recommended daily physical activities and helps them learn the importance of communication and teamwork with their friends, peers, and teachers. It is also important for young people to be engaged in such activities early in life so that their participation as adults can be fostered. However, for the child or adolescent with T1D and the caregiver participation in physical activity can be challenging because of the possibility for glucose instability (hypoglycemia or hyperglycemia). The International Society for Pediatric and Adolescent Diabetes encourages participation in physical activity classes for students with diabetes and the American Diabetes Association publishes guidelines on diabetes care in school and day care settings.202

Obviously, participation in vigorous exercise during physical education classes can precipitate hypoglycemia, even if the activity is for just 30 min. For students with diabetes, participation in physical education classes and team sports requires communication and collaboration between the student, his or her health care provider, parents, the school nurse, the physical education instructor, and the team coach. A diabetes care plan should be in place for the child or teen and should include specific instructions for physical activity. The Juvenile Diabetes Foundation (https://www.jdrf.org/) has a useful checklist of actions for the physical education instructor or coach:

â–  Encourage exercise and participation in physical activities and sports for students with diabetes as you would for other students.

■ Treat the student with diabetes the same as other students, except in meeting his or her medical needs (remember to respect the student’s right to privacy and confidentiality).

â–  Make sure blood glucose monitoring equipment is available at all activity sites, and encourage the student to keep personal supplies readily accessible.

â–  Always allow the student to check blood glucose levels.

■ Understand and be aware that hypoglycemia can occur during and after physical activity and that a change in the student’s behavior could be a symptom of blood glucose changes.

■ Be prepared to recognize and respond to the signs and symptoms of hypoglycemia and hyperglycemia, and when a blood sugar event occurs, take initial actions in accordance with the student’s school plan.

â–  To treat hypoglycemia, provide the student with immediate access to a fast-acting form of glucose. Consider taping three or four glucose tablets or hard candies to a clipboard or include them in the first aid pack at physical activities, practices, and games.

â–  Communicate with the school nurse or trained diabetes personnel or both regarding any observations or concerns about the student.

Students with diabetes should be responsible for wearing a medic alert ID tag at all times. Students and their teachers should be equipped with fast-acting carbohydrate snacks at all times and instructed on the appropriate treatment of hypoglycemia (15 g of carbohydrate; wait 15 min and retest and retreat if necessary). If reductions in pre-exercise insulin are not performed in anticipation of physical education, then carbohydrate intake at a rate of 1 g carbohydrate/kg body mass/h can be implemented. If blood glucose is already elevated prior to the class (144-198mg/dL.)(>8–11 mmol/l) then additional carbohydrate may not be required. As with other types of activity, vigorous activity during school should be avoided if glucose is markedly elevated (250mg/dL.)(>14 mmol/l) in the presence of moderate or higher levels of ketones.

Parents, teachers, and the patient with T1D should be educated as to the symptoms of hypoglycemia, the individualized action plan for prevention and treatment of hypoglycemia, and for potential emergencies (loss of consciousness).

Camps for Kids

Camping provides young people with diabetes and their families with a unique opportunity to share with and learn from others with diabetes, often in a physically demanding setting. Some studies suggest that a camp experience may improve a child’s psychosocial status and levels of glycemic control, although it should be expected that the experience may increase day-to-day glycemic variability.203–206 Based on retrospective analysis of camp medical records, it is estimated that an empiric 10% reduction in basal insulin appears reasonable upon arrival to camp, as nearly equal numbers of children required dose increases as dose decreases as camp progressed.207In one study of campers, treatment in a camp setting with 0.3 g of fast-acting carbohydrate (glucose tablets, hard candy, or orange juice) was shown to be effective in resolving hypoglycemia within 15 min in most children.208 Guidelines for the staffing and management of diabetes camps can be found through numerous sources including the ADA.209,210

Scuba Diving

Individuals with T1D were once dissuaded from participating in scuba diving, primarily due to concern that hypoglycemia during immersion would be likely to occur and difficult to treat. The National Association of Underwater Instructors (www.naui.org) still prevents individuals with T1D from obtaining certification to dive through their organization, whereas the Professional Association of Diving Instructors (www.padi.com) allows individuals with T1D to be certified. The Divers Alert Network (www.diversalertnetwork.org) reports that many active divers have T1D and that the majority of such divers do not experience dive-related hypoglycemia.211 The United Kingdom is supportive of allowing persons with T1D to scuba dive, as long as certain precautions are taken (https://www.ukdiving.co.uk/information/medicine/diabetes.htm). Indeed, recent evidence suggests that scuba diving can be undertaken safely by well-controlled, experienced, and complication-free individuals with T1D, assuming that appropriate precautionary measures are taken. Important precautions to help prevent hypoglycemia include the use of a rigorous protocol of serial predive blood glucose measurements to determine glucose levels and rates of change before entering the water.212 Some authors recommend a glycemic goal of 200–250 mg/dl (11–13.75 mmol/l) before immersion with a significant reduction of insulin doses (by 30%) and the availability of rapid-acting carbohydrates either on hand or on board.213 These affirmative results resulted in the French diving federation (FESSM) now allowing individuals with T1D to dive with some restrictive qualification requirements: dives must be within the safety curve (no decompression curve), in >14oC water, within depths limited to 6–20 meters, and with mandatory guidance by a diving instructor.

During a simulated dive to 27 meters in a hyperbaric chamber, well-controlled adults with T1D who were free of long-term complications were able to effectively self-regulate blood glucose levels to avoid hypoglycemia.214 However, long-term complications of diabetes (such as diabetic proliferative retinopathy) may need to be excluded before a diver with diabetes may be permitted to dive.215 In addition, it may be advantageous for divers to use CGM to help limit hypoglycemia.154 In a CGM-related study, 117 dives were undertaken by 24 adults, half with T1D; hypoglycemia (<70 mg/dl) was detected using CGM in six individuals and on nine occasions, but in none of these cases were hypoglycemic symptoms present during or immediately after diving.154 The number of hypoglycemic episodes, 10 min prediving or immediately postdiving, were related to the duration of diabetes, percentage of SMBG values below target (<72 mg/dl), and total duration below low limit (<70 mg/dl). These results led to the conclusion that well-informed, well-controlled individuals with T1D can dive safely and that the use of CGM and repetitive self-monitoring of blood glucose on a schedule allows identification of individuals who are suitable for diving. Use of CGM under diving conditions has also been reported to be reliable and reasonably accurate.216

Practical diving guidelines include:

â–  Blood glucose levels should be >150 mg/dl before the dive, and the dive should occur following a meal.

â–  If the blood glucose is <150 mg/dl, 5 g of glucose should be consumed for every 25 mg <150 mg/dl. Carbohydrates in the form of simple sugars, such as fruit juice, milk, or glucose tablets or liquid, should be ingested.

â–  The diver should carry liquid sugar in the wet suit during the dive and use as needed.

â–  The diver should measure blood glucose after the dive and ingest glucose as needed.

â–  The diver should always dive with a companion who understands how to recognize and treat a hypoglycemic reaction. When under water, divers should have a prearranged means to communicate the likely incidence of hypoglycemia.

â–  Glycemic control should be stable during the days of planned diving.

â–  Alcohol should not be consumed 24 h before or during the diving activities.217

Treatment of Overweight and Obesity with Physical Activity

Engaging in regular physical activity generally lowers overall insulin requirements and reduces the risk of weight gain associated with excess insulin use.218–222 In rats with alloxan-induced T1D, intensive insulin treatment induces insulin resistance by impairing glucose metabolism–related mechanisms in muscle and liver (i.e., by increasing insulin resistance).223 With the expectation that insulin resistance develops in hyperinsulinized diabetic patients as well, the authors of that study suggested using insulin-sensitizer approaches (like increased physical activity) to effectively treat T1D.

In adults without diabetes, exercise has been shown to have beneficial effects on body fatness in the absence of prescribed dietary change, with a progressive loss of body fat associated with higher exercise energy expenditures in both men and women.224 Even greater free-living activity energy expenditure (such as walking, household chores, and work-related physical activity) can aid in weight loss and weight maintenance.225 Similarly, in individuals with T1D, physical activity can improve insulin action, albeit acutely, and potentially lower insulin requirements and body weight. For example, in one study involving 13 previously sedentary individuals with T1D (ages 13–30 years), engaging in either 12 weeks of aerobic or resistance exercise training lowered their insulin needs, waist circumference, and post-training blood glucose levels, although their A1C levels were not significantly improved.7 Moreover, all adolescents with T1D can benefit from combined aerobic and strength training undertaken twice weekly for 20 weeks, which results in lower daily insulin requirements, improved physical fitness, and an enhanced sense of well-being.226 Similar training has also been shown to reduce cardiovascular risk and insulin resistance risk factors in diabetic adolescent girls.227 Exercise truly is a powerful medicine for anyone with T1D, especially if overweight or obese from insulin use.

AREAS FOR FUTURE RESEARCH

A number of key research areas still need development in the area of exercise and T1D. These include:

â–  What are the health benefits of resistance training for patients with T1D?

â–  What is the impact of exercise in various environments on the pharmacokinetics and pharmacodynamics of rapid-acting and long-acting insulin analogs?

â–  What are the appropriate insulin adjustments for resistance and anaerobic type exercise that results in hyperglycemia?

â–  What are the appropriate postexercise basal rate adjustments to limit postexercise hyperglycemia in the pump-treated patient?

â–  What should be the low-glucose suspend level for sensor-augmented, pump-treated patients engaged in physical activity?

â–  What is the appropriate insulin dose adjustment (correction) for postexercise hyperglycemia in the patient on a multiple daily injection regimen?

â–  What is the optimal feeding strategy to prevent exercise-associated hypoglycemia (type of carbohydrate, timing of ingestion, and dosage)?

â–  What other noninsulin adjustment strategies help to prevent exercise-associated hypoglycemia (e.g., caffeine, protein supplementation, glucagon stimulants or agonists, adrenergic agonists, etc.)?

â–  What are the optimal approaches to prevent severe nocturnal hypoglycemia?

â–  What limitations, if any, should be placed on individuals wishing to per-form extreme or higher risk activities (scuba, skydiving, Ironman, etc.)?

■ What are the optimal insulin-adjustment and nutritional strategies to help facilitate weight (fat) loss via increased physical activity in T1D? 

REFERENCES
  1. Physical Activity Guidelines Advisory Committee: Physical Activity Guidelines Advisory Committee Report. U.S. Department of Health and Human Services, 2008
  2. Chimen M, Kennedy A, Nirantharakumar K, Pang TT, Andrews R, Narendran P: What are the health benefits of physical activity in type 1 diabetes mellitus? A literature review. Diabetologia 55:542–551, 2012
  3. Aman J, Skinner TC, de Beaufort CE, Swift PG, Aanstoot HJ, Cameron F; Hvidoere Study Group on Childhood Diabetes: Associations between physical activity, sedentary behavior, and glycemic control in a large cohort of adolescents with type 1 diabetes: the Hvidoere Study Group on Child-hood Diabetes. Pediatr Diabetes 10:234–239, 2009
  4. Moy CS, Songer TJ, LaPorte RE, Dorman JS, Kriska AM, Orchard TJ, Becker DJ, Drash AL: Insulin-dependent diabetes mellitus, physical activity, and death. Am J Epidemiol 137:74–81, 1993
  5. Soedamah-Muthu SS, Fuller JH, Mulnier HE, Raleigh VS, Lawrenson RA, Colhoun HM: All-cause mortality rates in patients with type 1 diabetes mel-litus compared with a non-diabetic population from the UK general practice research database, 1992-1999. Diabetologia 49:660–666, 2006
  6. Koivisto VA, Yki-Jarvinen H, DeFronzo RA: Physical training and insulin sensitivity. Diabetes Metab Rev 1:445–481, 1986
  7. Ramalho AC, de Lourdes Lima M, Nunes F, Cambui Z, Barbosa C, Andrade A, Viana A, Martins M, Abrantes V, Aragao C, Temistocles M: The effect of resistance versus aerobic training on metabolic control in patients with type-1 diabetes mellitus. Diabetes Res Clin Pract 72:271–276, 2006
  8. Kriska AM, LaPorte RE, Patrick SL, Kuller LH, Orchard TJ: The association of physical activity and diabetic complications in individuals with insulin-dependent diabetes mellitus: the Epidemiology of Diabetes Complications Study—VII. J Clin Epidemiol 44:1207–1214, 1991
  9. Balducci S, Iacobellis G, Parisi L, Di Biase N, Calandriello E, Leonetti F, Fallucca F: Exercise training can modify the natural history of diabetic peripheral neuropathy. J Diabetes Complicat 20:216–223, 2006
  10. Nielsen PJ, Hafdahl AR, Conn VS, Lemaster JW, Brown SA: Meta-analysis of the effect of exercise interventions on fitness outcomes among adults with type 1 and type 2 diabetes. Diabetes Res Clin Pract 74:111–120, 2006
  11. Waden J, Forsblom C, Thorn LM, Saraheimo M, Rosengard-Barlund M, Heikkila O, Lakka TA, Tikkanen H, Groop PH; FinnDiane Study Group: Physical activity and diabetes complications in patients with type 1 diabe-tes: the Finnish Diabetic Nephropathy (FinnDiane) Study. Diabetes Care 31:230–232, 2008
  12. Bouchard C, Shephard RJ: Physical activity, fitness, and health: the model and key concepts. In Physical Activity, Fitness and Health:International Proceedings and Consensus Statement. Bouchard C, Shephard RJ, Stephens T, Eds. Champaign, IL, Human Kinetics, 1994, p. 77–88
  13. Hart TL, Craig CL, Griffiths JM, Cameron C, Andersen RE, Bauman A, Tudor-Locke C: Markers of sedentarism: the joint Canada/U.S. Survey of health. J Phys Act Health 8:361–371, 2011
  14. Bernardini AL, Vanelli M, Chiari G, Iovane B, Gelmetti C, Vitale R, Errico MK: Adherence to physical activity in young people with type 1 diabetes. Acta Biomed 75:153–157, 2004
  15. Waden J, Tikkanen H, Forsblom C, Fagerudd J, Pettersson-Fernholm K, Lakka T, Riska M, Groop PH; FinnDiane Study Group: Leisure time physical activity is associated with poor glycemic control in type 1 diabetic women: the FinnDiane study. Diabetes Care 28:777–782, 2005
  16. Riddell MC, Perkins BA: Type 1 diabetes and exercise: part I: applications of exercise physiology to patient management during vigorous activity. Can J Diab 30:63–71, 2006
  17. Sigal R, Kenny G, Oh P, Perkins BA, Plotnikoff RC, Prud’homme D, Riddell MC: Physical activity and diabetes. Canadian Diabetes Association Clini-cal Practice Guidelines Expert Committee. Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diab 32:S37–S39, 2008
  18. Evans CH, White RD: Exercise Testing for Primary Care and Sports Medicine Physicians. New York, Springer, 2009
  19. Niranjan V, McBrayer DG, Ramirez LC, Raskin P, and Hsia CC: Glycemic control and cardiopulmonary function in patients with insulin-dependent diabetes mellitus. Am J Med 103:504–513, 1997
  20. Komatsu WR, Gabbay MA, Castro ML, Saraiva GL, Chacra AR, de Barros Neto TL, Dib SA: Aerobic exercise capacity in normal adolescents and those with type 1 diabetes mellitus. Pediatr Diabetes 6:145–149, 2005.
  21. Williams BK, Guelfi KJ, Jones TW, Davis EA: Lower cardiorespiratory fitness in children with type 1 diabetes. Diabet Med 28:1005–1007, 2011
  22. Poortmans JR, Saerens P, Edelman R, Vertongen F, Dorchy H: Influence of the degree of metabolic control on physical fitness in type I diabetic adoles-cents. Int J Sports Med 7:232–235, 1986
  23. Baldi JC, Cassuto NA, Foxx-Lupo WT, Wheatley CM, Snyder EM: Glycemic status affects cardiopulmonary exercise response in athletes with type I diabetes. Med Sci Sports Exerc 42:1454–1459, 2010
  24. Baldi JC, Hofman PL: Does careful glycemic control improve aerobic capacity in subjects with type 1 diabetes? Exerc Sport Sci Rev 38:161–167, 2010
  25. Riddell MC, Burr J: Evidence-based risk assessment and recommendations for physical activity clearance: diabetes mellitus and related comorbidities. Appl Physiol Nutr Metab 36 (Suppl. 1):S154–S189, 2011
  26. Janssen I, Leblanc AG: Systematic review of the health benefits of physical activity and fitness in school-aged children and youth. Int J Behav Nutr Phys Act 7:40, 2010
  27. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents and National Heart, Lung, and Blood Institute: Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pedi- atrics 128 (Suppl. 5):S213–S256, 2011
  28. Rachmiel M, Buccino J, Daneman D: Exercise and type 1 diabetes mellitus in youth; review and recommendations. Pediatr Endocrinol Rev5:656–665, 2007
  29. Kelder SH, Perry CL, Klepp KI, Lytle LL: Longitudinal tracking of adolescent smoking, physical activity, and food choice behaviors. Am J Public Health 84:1121–1126, 1994
  30. Astrup AS: Cardiovascular morbidity and mortality in diabetes mellitus: prediction and prognosis. Dan Med Bull 58:B4152, 2011
  31. Galler A, Lindau M, Ernert A, Thalemann R, Raile K: Associations between media consumption habits, physical activity, socioeconomic status, and glycemic control in children, adolescents, and young adults with type 1 diabe-tes. Diabetes Care 34:2356–2359, 2011
  32. Brazeau AS, Rabasa-Lhoret R, Strychar I, Mircescu H: Barriers to physical activity among patients with type 1 diabetes. Diabetes Care31:2108–2109, 2008
  33. Herbst A, Kordonouri O, Schwab KO, Schmidt F, Holl RW; DPV Initiative of the German Working Group for Pediatric Diabetology Germany: Impact of physical activity on cardiovascular risk factors in children with type 1 diabetes: a multicenter study of 23,251 patients. Diabetes Care30:2098–2100, 2007
  34. Durak EP, Jovanovic-Peterson L, Peterson CM: Randomized crossover study of effect of resistance training on glycemic control, muscular strength, and cholesterol in type I diabetic men. Diabetes Care 13:1039– 1043, 1990
  35. Zoppini G, Carlini M, Muggeo M: Self-reported exercise and quality of life in young type 1 diabetic subjects. Diabetes Nutr Metab 16:77–80, 2003
  36. Salem MA, Aboelasrar MA, Elbarbary NS, Elhilaly RA, Refaat YM: Is exercise a therapeutic tool for improvement of cardiovascular risk factors in adolescents with type 1 diabetes mellitus? A randomised controlled trial. Diabetol Metab Syndr 2:47, 2010
  37. Zinman B, Zuniga-Guajardo S, Kelly D: Comparison of the acute and long- term effects of exercise on glucose control in type I diabetes.Diabetes Care 7:515–519, 1984
  38. Raile K, Kapellen T, Schweiger A, Hunkert F, Nietzschmann U, Dost A, Kiess W: Physical activity and competitive sports in children and adoles-cents with type 1 diabetes. Diabetes Care 22:1904–1905, 1999
  39. Roberts L, Jones TW, Fournier PA: Exercise training and glycemic control in adolescents with poorly controlled type 1 diabetes mellitus. J Pediatr Endocrinol Metab 15:621–627, 2002
  40. Harmer AR, Chisholm DJ, McKenna MJ, Morris NR, Thom JM, Bennett G, Flack JR: High-intensity training improves plasma glucose and acid-base regulation during intermittent maximal exercise in type 1 diabetes. Diabetes Care 30:1269–1271, 2007
  41. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, Nieman DC, Swain DP; American College of Sports Medicine: American College of Sports Medicine position stand. Quantity and quality of exer-cise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc 43:1334–1359, 2011
  42. Warburton DE, Nicol CW, Bredin SS: Prescribing exercise as preventive therapy. CMAJ 174:961–974, 2006
  43. Reddigan JI, Riddell MC, Kuk JL: The joint association of physical activ- activ-ity and glycaemic control in predicting cardiovascular death and all-cause mortality in the US population. Diabetologia 55:632–635, 2012
  44. Physical Activity Guidelines Advisory Committee: Report, 2008. To the secretary of health and human services. Part A: executive summary.Nutr Rev 67:114–120, 2009
  45. Tremblay MS, Warburton DE, Janssen I, Paterson DH, Latimer AE, Rhodes RE, Kho ME, Hicks A, Leblanc AG, Zehr L, Murumets K, Duggan M: New Canadian physical activity guidelines. Appl Physiol Nutr Metab 36:36–46, 47–58, 2011
  46. Chu L, Hamilton J, Riddell MC: Clinical management of the physically active patient with type 1 diabetes. Phys Sportsmed 39:64–77, 2011
  47. Guelfi KJ, Ratnam N, Smythe GA, Jones TW, Fournier PA: Effect of intermittent high-intensity compared with continuous moderate exercise on glucose production and utilization in individuals with type 1 diabetes. Am J Physiol Endocrinol Metab 292:E865–E870, 2007
  48. Yardley JE, Kenny GP, Perkins BA, Riddell MC, Malcolm J, Boulay P, Khandwala F, Sigal RJ: Effects of performing resistance exercise before versus after aerobic exercise on glycemia in type 1 diabetes. Diabetes Care 35:669–675, 2012
  49. Caron D, Poussier P, Marliss EB, Zinman B: The effect of postprandial exercise on meal-related glucose intolerance in insulin-dependent diabetic individuals. Diabetes Care 5:364–369, 1982
  50. Temple MY, Bar-Or O, Riddell MC: The reliability and repeatability of the blood glucose response to prolonged exercise in adolescent boys with IDDM. Diabetes Care 18:326–332, 1995
  51. Riddell MC, Bar-Or O, Ayub BV, Calvert RE, Heigenhauser GJ: Glucose ingestion matched with total carbohydrate utilization attenuates hypoglycemia during exercise in adolescents with IDDM. Int J Sport Nutr 9:24–34, 1999
  52. Kilbride L, Charlton J, Aitken G, Hill GW, Davison RC, McKnight JA: Managing blood glucose during and after exercise in type 1 diabetes: reproducibility of glucose response and a trial of a structured algorithm adjusting insulin and carbohydrate intake. J Clin Nurs 20:3423–3429, 2011
  53. Krause MP, Moradi J, Nissar AA, Riddell MC, Hawke TJ: Inhibition of plasminogen activator inhibitor-1 restores skeletal muscle regeneration in untreated type 1 diabetic mice. Diabetes 60:1964–1972, 2011
  54. Lira FS, Rosa JC, Lima-Silva AE, Souza HA, Caperuto EC, Seelaender MC, Damaso AR, Oyama LM, Santos RV: Sedentary subjects have higher PAI-1 and lipoproteins levels than highly trained athletes. Diabetol Metab Syndr 2:7, 2010
  55. Belalcazar LM, Ballantyne CM, Lang W, Haffner SM, Rushing J, Schwenke DC, Pi-Sunyer FX, Tracy RP; Look Action for Health in Diabetes Research Group: Metabolic factors, adipose tissue, and plasminogen activator inhibitor-1 levels in type 2 diabetes: findings from the look AHEAD study. Arterioscler Thromb Vasc Biol 31:1689–1695, 2011
  56. Wallberg-Henriksson H, Gunnarsson R, Henriksson J, DeFronzo R, Felig P, Ostman J, Wahren J: Increased peripheral insulin sensitivity and muscle mitochondrial enzymes but unchanged blood glucose control in type I diabetics after physical training. Diabetes 31:1044–1050, 1982
  57. Yki-Jarvinen H, DeFronzo RA, Koivisto VA: Normalization of insulin sensitivity in type I diabetic subjects by physical training during insulin pump therapy. Diabetes Care 7:520–527, 1984
  58. Lehmann R, Kaplan V, Bingisser R, Bloch KE, Spinas GA: Impact of physical activity on cardiovascular risk factors in IDDM. Diabetes Care20:1603– 1611, 1997
  59. Mosher PE, Nash MS, Perry AC, LaPerriere AR, Goldberg RB: Aerobic circuit exercise training: effect on adolescents with well-controlled insulin- dependent diabetes mellitus. Arch Phys Med Rehabil 79:652–657, 1998
  60. Laaksonen DE, Atalay M, Niskanen LK, Mustonen J, Sen CK, Lakka TA, Uusitupa MI: Aerobic exercise and the lipid profile in type 1 diabetic men: a randomized controlled trial. Med Sci Sports Exerc 32:1541–1548, 2000
  61. Rigla M, Sanchez-Quesada JL, Ordonez-Llanos J, Prat T, Caixas A, Jorba O, Serra JR, de Leiva A, Perez A: Effect of physical exercise on lipoprotein(a) and low-density lipoprotein modifications in type 1 and type 2 diabetic patients. Metabolism 49:640–647, 2000
  62. Fuchsjager-Mayrl G, Pleiner J, Wiesinger GF, Sieder AE, Quittan M, Nuhr MJ, Francesconi C, Seit HP, Francesconi M, Schmetterer L, Wolzt M: Exercise training improves vascular endothelial function in patients with type 1 diabetes. Diabetes Care 25:1795–1801, 2002
  63. Valerio G, Spagnuolo MI, Lombardi F, Spadaro R, Siano M, Franzese A: Physical activity and sports participation in children and adolescents with type 1 diabetes mellitus. Nutr Metab Cardiovasc Dis 17:376–382, 2007
  64. Coggan AR: Plasma glucose metabolism during exercise in humans. Sports Med 11:102–124, 1991
  65. Wahren J, Felig P, Ahlborg G, Jorfeldt L: Glucose metabolism during leg exercise in man. J Clin Invest 50:2715–2725, 1971
  66. Bergeron R, Kjaer M, Simonsen L, Bulow J, Galbo H: Glucose production during exercise in humans: a-hv balance and isotopic-tracer measurements compared. J Appl Physiol 87:111–115, 1999
  67. Purdon C, Brousson M, Nyveen SL, Miles PD, Halter JB, Vranic M, Marliss EB: The roles of insulin and catecholamines in the glucoregulatory response during intense exercise and early recovery in insulin-dependent diabetic and control subjects. J Clin Endocrinol Metab 76:566–573, 1993
  68. Coggan AR, Coyle EF: Reversal of fatigue during prolonged exercise by carbohydrate infusion or ingestion. J Appl Physiol 63:2388–2395, 1987
  69. Coggan AR, Coyle EF: Effect of carbohydrate feedings during high- intensity exercise. J Appl Physiol 65:1703–1709, 1988
  70. Raguso CA, Coggan AR, Gastaldelli A, Sidossis LS, Bastyr EJ 3rd, Wolfe RR: Lipid and carbohydrate metabolism in IDDM during moderate and intense exercise. Diabetes 44:1066–1074, 1995
  71. Krzentowski G, Pirnay F, Pallikarakis N, Luyckx AS, Lacroix M, Mosora F, Lefebvre PJ: Glucose utilization during exercise in normal and diabetic subjects: the role of insulin. Diabetes 30:983–989, 1981
  72. Riddell MC, Bar-Or O, Schwarcz HP, Heigenhauser GJ: Substrate utilization in boys during exercise with [13C]-glucose ingestion. Eur J Appl Physiol 83:441–448, 2000
  73. Robitaille M, Dube MC, Weisnagel SJ, Prud’homme D, Massicotte D, Peronnet F, Lavoie C: Substrate source utilization during moderate inten-sity exercise with glucose ingestion in Type 1 diabetic patients. J Appl Physiol 103:119–124, 2007
  74. Younk LM, Mikeladze M, Tate D, Davis SN: Exercise-related hypoglycemia in diabetes mellitus. Expert Rev Endocrinol Metab 6:93–108, 2011
  75. Sotsky MJ, Shilo S, Shamoon H: Regulation of counterregulatory hormone secretion in man during exercise and hypoglycemia. J Clin Endocrinol Metab 68:9–16, 1989
  76. Zinker BA, Allison RG, Lacy DB, Wasserman DH: Interaction of exercise, insulin, and hypoglycemia studied using euglycemic and hypoglycemic insu-lin clamps. Am J Physiol 272: E530–E542, 1997
  77. Camacho RC, Galassetti P, Davis SN, Wasserman DH: Glucoregulation during and after exercise in health and insulin-dependent diabetes.Exerc Sport Sci Rev 33:17–23, 2005
  78. Karelis AD, Smith JW, Passe DH, Peronnet F: Carbohydrate administra-tion and exercise performance: what are the potential mechanisms involved? Sports Med 40:747–763, 2010
  79. Chokkalingam K, Tsintzas K, Snaar JE, Norton L, Solanky B, Leverton E, Morris P, Mansell P, Macdonald IA: Hyperinsulinaemia during exercise does not suppress hepatic glycogen concentrations in patients with type 1 diabetes: a magnetic resonance spectroscopy study. Diabetologia50:1921–1929, 2007
  80. Briscoe VJ, Tate DB, Davis SN: Type 1 diabetes: exercise and hypoglycemia. Appl Physiol Nutr Metab 32:576–582, 2007
  81. Berger M, Halban PA, Assal JP, Offord RE, Vranic M, Renold AE: Pharmacokinetics of subcutaneously injected tritiated insulin: effects of exercise. Diabetes 28 (Suppl. 1):53–57, 1979
  82. Edelmann E, Staudner V, Bachmann W, Walter H, Haas W, Mehnert H: Exercise-induced hypoglycaemia and subcutaneous insulin infusion.Diabet Med 3:526–531, 1986
  83. Wasserman DH: Berson award lecture 2008 four grams of glucose. Am J Physiol Endocrinol Metab 296:E11–E21, 2009
  84. Wasserman DH: Regulation of glucose fluxes during exercise in the postabsorptive state. Annu Rev Physiol 57:191–218, 1995
  85. Francescato MP, Carrato S: Management of exercise-induced glycemic imbalances in type 1 diabetes. Curr Diabetes Rev 7:253–263, 2011
  86. Schneider SH, Vitug A, Ananthakrishnan R, Khachadurian AK: Impaired adrenergic response to prolonged exercise in type I diabetes.Metabolism 40:1219–1225, 1991
  87. Cline GW, Rothman DL, Magnusson I, Katz LD, Shulman GI: 13C-nuclear magnetic resonance spectroscopy studies of hepatic glucose metabolism in normal subjects and subjects with insulin-dependent diabetes mellitus. J Clin Invest 94:2369–2376, 1994
  88. McMahon SK, Ferreira LD, Ratnam N, Davey RJ, Youngs LM, Davis EA, Fournier PA, Jones TW: Glucose requirements to maintain euglycemia after moderate-intensity afternoon exercise in adolescents with type 1 diabetes are increased in a biphasic manner. J Clin Endocrinol Metab92:963–968, 2007
  89. Diabetes Research in Children Network (DirecNet) Study Group; Tsalikian E, Kollman C, Tamborlane WB, Beck RW, Fiallo-Scharer R, Fox L, Janz KF, Ruedy KJ, Wilson D, Xing D, Weinzimer SA: Prevention of hypoglycemia during exercise in children with type 1 diabetes by suspending basal insulin. Diabetes Care 29:2200–2204, 2006
  90. Iscoe KE, Campbell JE, Jamnik V, Perkins BA, Riddell MC: Efficacy of continuous real-time blood glucose monitoring during and after prolonged high-intensity cycling exercise: spinning with a continuous glucose moni-toring system. Diabetes Technol Ther 8:627–635, 2006
  91. Diabetes Research in Children Network (DirecNet) Study Group: Impaired overnight counterregulatory hormone responses to spontaneous hypoglyce-mia in children with type 1 diabetes. Pediatr Diabetes 8:199–205, 2007
  92. Iscoe KE, Corcoran M, Riddell MC: High rates of nocturnal hypoglycemia in a unique sports camp for athletes with type 1 diabetes: lessons learned from continuous glucose monitoring. Can J Diab 32:182–189, 2008
  93. Maran A, Pavan P, Bonsembiante B, Brugin E, Ermolao A, Avogaro A, Zaccaria M: Continuous glucose monitoring reveals delayed nocturnal hypoglycemia after intermittent high-intensity exercise in nontrained patients with type 1 diabetes. Diabetes Technol Ther 12:763–768, 2010
  94. Taplin CE, Cobry E, Messer L, McFann K, Chase HP, Fiallo-Scharer R: Preventing post-exercise nocturnal hypoglycemia in children with type 1 diabetes. J Pediatr 157:784–8.e1, 2010
  95. Marliss EB, Vranic M: Intense exercise has unique effects on both insulin release and its roles in glucoregulation: implications for diabetes.Diabetes 51 (Suppl. 1):S271–S283, 2002
  96. Sigal RJ, Purdon C, Fisher SJ, Halter JB, Vranic M, Marliss EB: Hyperinsu- Hyperinsu-linemia prevents prolonged hyperglycemia after intense exercise in insulin-dependent diabetic subjects. J Clin Endocrinol Metab 79:1049–1057, 1994
  97. Delvecchio M, Zecchino C, Salzano G, Faienza MF, Cavallo L, De Luca F, Lombardo F: Effects of moderate-severe exercise on blood glucose in type 1 diabetic adolescents treated with insulin pump or glargine insulin. J Endo-crinol Invest 32:519–524, 2009
  98. Huttunen NP, Kaar ML, Knip M, Mustonen A, Puukka R, Akerblom HK: Physical fitness of children and adolescents with insulin-dependent diabetes mellitus. Ann Clin Res 16:1–5, 1984
  99. Ditzel J, Standl E: The problem of tissue oxygenation in diabetes mellitus. Acta Med Scand Suppl 578:59–68, 1975
  100. Kivela R, Silvennoinen M, Touvra AM, Lehti TM, Kainulainen H, Vihko V: Effects of experimental type 1 diabetes and exercise training on angiogenic gene expression and capillarization in skeletal muscle. FASEB J 20:1570–1572, 2006
  101. Robertson K, Adolfsson P, Scheiner G, Hanas R, Riddell MC: Exercise in children and adolescents with diabetes. Pediatr Diabetes 10 (Suppl. 12):154– 168, 2009
  102. Krause MP, Riddell MC, Hawke TJ: Effects of type 1 diabetes mellitus on skeletal muscle: clinical observations and physiological mechanisms.Pediatr Diabetes 12:345–364, 2011
  103. Surridge DH, Erdahl DL, Lawson JS, Donald MW, Monga TN, Bird CE, Letemendia FJ: Psychiatric aspects of diabetes mellitus. Brit J Psychiat145:269–276, 1984
  104. Van der Does FE, De Neeling JN, Snoek FJ, Kostense PJ, Grootenhuis PA, Bouter LM, Heine RJ: Symptoms and well-being in relation to glycemic control in type II diabetes. Diabetes Care 19:204–210, 1996
  105. Almeida S, Riddell MC, Cafarelli E: Slower conduction velocity and motor unit discharge frequency are associated with muscle fatigue during isometric exercise in type 1 diabetes mellitus. Muscle Nerve 37:231–240, 2008
  106. Andersen H: Muscular endurance in long-term IDDM patients. Diabetes Care 21:604–609, 1998
  107. Riddell MC, Bar-Or O, Gerstein HC, Heigenhauser GJ: Perceived exertion with glucose ingestion in adolescent males with IDDM. Med Sci Sports Exerc 32:167–173, 2000
  108. Crowther GJ, Milstein JM, Jubrias SA, Kushmerick MJ, Gronka RK, Conley KE: Altered energetic properties in skeletal muscle of men with well- controlled insulin-dependent (type 1) diabetes. Am J Physiol Endocrinol Metab 284:E655–E62, 2003
  109. Magee MF, Bhatt BA: Management of decompensated diabetes: diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome. Crit Care Clin 17:75–106, 2001
  110. Jenni S, Oetliker C, Allemann S, Ith M, Tappy L, Wuerth S, Egger A, Boesch C, Schneiter P, Diem P, Christ E, Stettler C: Fuel metabolism during exer-cise in euglycaemia and hyperglycaemia in patients with type 1 diabetes mellitus—a prospective single-blinded randomised crossover trial. Diabetologia 51:1457–1465, 2008
  111. McKewen MW, Rehrer NJ, Cox C, Mann J: Glycaemic control, muscle glycogen and exercise performance in IDDM athletes on diets of varying carbohydrate content. Int J Sports Med 20:349–353, 1999
  112. Andersen H, Schmitz O, Nielsen S: Decreased isometric muscle strength after acute hyperglycaemia in type 1 diabetic patients. Diabet Med22:1401– 1407, 2005
  113. Boehncke S, Poettgen K, Maser-Gluth C, Reusch J, Boehncke WH, Baden-hoop K: Endurance capabilities of triathlon competitors with type 1 diabetes mellitus. Dtsch Med Wochenschr 134:677–682, 2009
  114. Heyman E, Briard D, Dekerdanet M, Gratas-Delamarche A, Delamarche P: Accuracy of physical working capacity 170 to estimate aerobic fitness in prepubertal diabetic boys and in 2 insulin dose conditions. J Sports Med Phys Fitness 46:315–321, 2006
  115. Stettler C, Jenni S, Allemann S, Steiner R, Hoppeler H, Trepp R, Christ ER, Zwahlen M, Diem P: Exercise capacity in subjects with type 1 diabetes mel-litus in eu- and hyperglycaemia. Diabetes Metab Res Rev 22:300–306, 2006
  116. Kelly D, Hamilton JK, Riddell MC: Blood glucose levels and performance in a sports camp for adolescents with type 1 diabetes mellitus: a field study. Int J Pediatr 2010: 216167. E-pub Aug 2, 2010
  117. Ramires PR, Forjaz CL, Strunz CM, Silva ME, Diament J, Nicolau W, Liberman B, Negrao CE: Oral glucose ingestion increases endurance capacity in normal and diabetic (type I) humans. J Appl Physiol 83:608–614, 1997
  118. Riddell MC, Bar-Or O, Hollidge-Horvat M, Schwarcz HP, Heigenhauser GJ: Glucose ingestion and substrate utilization during exercise in boys with IDDM. J Appl Physiol 88:1239–1246, 2000
  119. Gonder-Frederick LA, Zrebiec JF, Bauchowitz AU, Ritterband LM, Magee JC, Cox DJ, Clarke WL: Cognitive function is disrupted by both hypo- and hyperglycemia in school-aged children with type 1 diabetes: a field study. Diabetes Care 32:1001–1006, 2009
  120. Jimenez CC, Corcoran MH, Crawley JT, Guyton Hornsby W, Peer KS, Philbin RD, Riddell MC: National athletic trainers’ association position statement: management of the athlete with type 1 diabetes mellitus. J Athl Train 42:536–545, 2007
  121. Tansey MJ, Tsalikian E, Beck RW, Mauras N, Buckingham BA, Weinzimer SA, Janz KF, Kollman C, Xing D, Ruedy KJ, Steffes MW, Borland TM, Singh RJ, Tamborlane WV; Diabetes Research in Children Network (DirecNet) Study Group: The effects of aerobic exercise on glucose and counterregula-tory hormone concentrations in children with type 1 diabetes. Diabetes Care 29:20–25, 2006
  122. Mendez-Villanueva A, Fernandez-Fernandez J, Bishop D: Exercise-induced homeostatic perturbations provoked by singles tennis match play with reference to development of fatigue. Br J Sports Med 41:717–722, discussion 722, 2007
  123. Graveling AJ, Frier BM: Risks of marathon running and hypoglycaemia in type 1 diabetes. Diabet Med 27:585–588, 2010
  124. Murillo S, Brugnara L, Novials A: One year follow-up in a group of half- marathon runners with type-1 diabetes treated with insulin analogues.J Sports Med Phys Fitness 50:506–510, 2010
  125. Tuominen JA, Karonen SL, Melamies L, Bolli G, Koivisto VA: Exercise- induced hypoglycaemia in IDDM patients treated with a short-acting insu-lin analogue. Diabetologia 38:106–111, 1995
  126. Gerich JE, Langlois M, Noacco C, Karam JH, Forsham PH: Lack of glucagon response to hypoglycemia in diabetes: evidence for an intrinsic pancreatic alpha cell defect. Science 182:171–173, 1973
  127. Zander E, Schulz B, Chlup R, Woltansky P, Lubs D: Muscular exercise in type I-diabetics. II. Hormonal and metabolic responses to moderate exercise. Exp Clin Endocrinol 85:95–104, 1985
  128. American Diabetes Association: Standards of medical care in diabetes: 2012. Diabetes Care 35 (Suppl. 1):S11–S63, 2012
  129. Guelfi KJ, Jones TW, Fournier PA: New insights into managing the risk of hypoglycaemia associated with intermittent high-intensity exercise in indi-viduals with type 1 diabetes mellitus: implications for existing guidelines. Sports Med 37:937–946, 2007
  130. Wasserman DH, Zinman B: Exercise in individuals with IDDM. Diabetes Care 17:924–937, 1994
  131. Dube MC, Weisnagel SJ, Prud’homme D, Lavoie C: Exercise and newer insulins: how much glucose supplement to avoid hypoglycemia? Med Sci Sports Exerc 37:1276–1282, 2005
  132. Riddell MC, Iscoe KE: Physical activity, sport, and pediatric diabetes. Pedi- atr Diabetes 7:60–70, 2006
  133. Francescato MP, Geat M, Fusi S, Stupar G, Noacco C, Cattin L: Carbohy-drate requirement and insulin concentration during moderate exercise in type 1 diabetic patients. Metabolism 53:1126–1130, 2004
  134. Bracken RM, Page R, Gray B, Kilduff LP, West DJ, Stephens JW, Bain SC: Isomaltulose improves glycaemia and maintains run performance in type 1 diabetes. Med Sci Sports Exerc 2011
  135. American College of Sports Medicine and American Diabetes Association joint position statement: Diabetes mellitus and exercise. Med Sci Sports Exerc 29:i–vi, 1997
  136. Gallen I: Exercise in type 1 diabetes. Diabet Med 20 (Suppl. 1):2–5, 2003
  137. Steppel JH, Horton ES: Exercise in the management of type 1 diabetes mellitus. Rev Endocr Metab Disord 4:355–360, 2003
  138. De Feo P, Di Loreto C, Ranchelli A, Fatone C, Gambelunghe G, Lucidi P, Santeusanio F: Exercise and diabetes. Acta Biomed 77 (Suppl. 1):14–17, 2006
  139. Rabasa-Lhoret R, Bourque J, Ducros F, Chiasson JL: 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). Diabetes Care24:625–630, 2001
  140. Mauvais-Jarvis F, Sobngwi E, Porcher R, Garnier JP, Vexiau P, Duvallet A, Gautier JF: Glucose response to intense aerobic exercise in type 1 diabetes: maintenance of near euglycemia despite a drastic decrease in insulin dose. Diabetes Care 26:1316–1317, 2003
  141. West DJ, Morton RD, Bain SC, Stephens JW, Bracken RM: Blood glucose responses to reductions in pre-exercise rapid-acting insulin for 24 h after running in individuals with type 1 diabetes. J Sports Sci 28:781–788, 2010
  142. West DJ, Stephens JW, Bain SC, Kilduff LP, Luzio S, Still R, Bracken RM: 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. J Sports Sci 29:279–289, 2011
  143. Sane T, Helve E, Pelkonen R, Koivisto VA: The adjustment of diet and insu-lin dose during long-term endurance exercise in type 1 (insulin-dependent) diabetic men. Diabetologia 31:35–40, 1988
  144. Berger M, Berchtold P, Cuppers HJ, Drost H, Kley HK, Muller WA, Wiegelmann W, Zimmerman-Telschow H, Gries FA, Kruskemper HL, Zimmermann H: Metabolic and hormonal effects of muscular exercise in juvenile type diabetics. Diabetologia 13:355–365, 1977
  145. Klip A, Marette A, Dimitrakoudis D, Ramlal T, Giacca A, Shi ZQ, Vranic M: Effect of diabetes on glucoregulation. From glucose transporters to glucose metabolism in vivo. Diabetes Care 15:1747–1766, 1992
  146. Perkins BA, Riddell MC: Type 1 diabetes and exercise: part II: using the insulin pump to maximum advantage. Can J Diab 30:72–80, 2006
  147. Riddell MC, Perkins BA: Exercise and glucose metabolism in persons with diabetes mellitus: perspectives on the role for continuous glucose monitoring. J Diabetes Sci Technol 3:914–923, 2009
  148. Zisser H, Robinson L, Bevier W, Dassau E, Ellingsen C, Doyle FJ, Jovanovic L: Bolus calculator: a review of four "smart" insulin pumps. Diabetes Technol Ther 10:441–444, 2008
  149. Wilson DM, Beck RW, Tamborlane WV, Dontchev MJ, Kollman C, Chase P, Fox LA, Ruedy KJ, Tsalikian E, Weinzimer SA; DirecNet Study Group: The accuracy of the FreeStyle Navigator continuous glucose monitoring system in children with type 1 diabetes. Diabetes Care 30:59–64, 2007
  150. Iscoe KE, Riddell MC: Continuous moderate-intensity exercise with or without intermittent high-intensity work: effects on acute and late glycae-mia in athletes with type 1 diabetes mellitus. Diabet Med 2011
  151. Diabetes Research In Children Network (Direcnet) Study Group; Buckingham BA, Kollman C, Beck R, Kalajian A, Fiallo-Scharer R, Tansey MJ, Fox LA, Wilson DM, Weinzimer SA, Ruedy KJ, Tamborlane WV: Evaluation of factors affecting CGMS calibration. Diabetes Technol Ther 8:318–325, 2006
  152. Davey RJ, Ferreira LD, Jones TW, Fournier PA: Effect of exercise-mediated acidosis on determination of glycemia using CGMS. Diabetes Technol Ther 8:516–518, 2006
  153. Davey RJ, Stevens K, Jones TW, Fournier PA: The effect of short-term use of the Guardian RT continuous glucose monitoring system on fear of hypoglycaemia in patients with type 1 diabetes mellitus. Prim Care Diabetes 6:35–39, 2012
  154. Adolfsson P, Ornhagen H and Jendle J: The benefits of continuous glucose monitoring and a glucose monitoring schedule in individuals with type 1 diabetes during recreational diving. J Diabetes Sci Technol 2:778–784, 2008
  155. Riddell MC, Milliken J: Preventing exercise-induced hypoglycemia in type 1 diabetes using real-time continuous glucose monitoring and a new carbohydrate intake algorithm: an observational field study. Diabetes Technol Ther 13:819–825, 2011
  156. Iscoe KE, Davey RJ, Fournier PA: Increasing the low-glucose alarm of a continuous glucose monitoring system prevents exercise-induced hypoglycemia without triggering any false alarms. Diabetes Care 34:e109, 2011
  157. Bernbaum M, Albert SG, Cohen JD: Exercise training in individuals with diabetic retinopathy and blindness. Arch Phys Med Rehabil 70:605–611, 1989
  158. Graham C, Lasko-McCarthey P: Exercise options for persons with diabetic complications. Diabetes Educ 16:212–220, 1990
  159. Albert SG, Bernbaum M: Exercise for patients with diabetic retinopathy. Diabetes Care 18:130–132, 1995
  160. Draznin MB: Type 1 diabetes and sports participation: strategies for training and competing safely. Phys Sportsmed 28:49–56, 2000
  161. Chipkin SR, Klugh SA, Chasan-Taber L: Exercise and diabetes. Cardiol Clin 19:489–505, 2001
  162. Flood L, Constance A: Diabetes and exercise safety. Am J Nurs 102:47–55, quiz 56, 2002
  163. Kanade RV, van Deursen RW, Harding K, Price P: Walking performance in people with diabetic neuropathy: benefits and threats. Diabetologia49:1747– 1754, 2006
  164. Colberg SR, Sigal RJ, Fernhall B, Regensteiner JG, Blissmer BJ, Rubin RR, Chasan-Taber L, Albright AL, Braun B; American College of Sports Medicine; American Diabetes Association: Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement executive summary. Diabetes Care 33:2692– 2696, 2010
  165. Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin JM, Orchard TJ, Raskin P, Zinman B; Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group: Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 353:2643–2653, 2005
  166. Hughes BC, White RD: Testing in special populations. In Exercise Testing for Primary Care and Sports Medicine. New York, Springer-Verlag, 2005, p. 55–77
  167. Gill JM, Malkova D: Physical activity, fitness and cardiovascular disease risk in adults: interactions with insulin resistance and obesity. Clin Sci(Lond) 110:409–425, 2006
  168. Konduracka E, Gackowski A, Rostoff P, Galicka-Latala D, Frasik W, Piwowarska W: Diabetes-specific cardiomyopathy in type 1 diabetes mellitus: no evidence for its occurrence in the era of intensive insulin therapy. Eur Heart J 28:2465–2471, 2007
  169. Aiello LP, Cahill MT and Wong JS: Systemic considerations in the manage-ment of diabetic retinopathy. Am J Ophthalmol 132:760–776, 2001
  170. Schneider SH, Khachadurian AK, Amorosa LF, Clemow L, Ruderman NB: Ten-year experience with an exercise-based outpatient life-style modification program in the treatment of diabetes mellitus. Diabetes Care 15:1800– 1810, 1992
  171. Cruickshanks KJ, Moss SE, Klein R, Klein BE: Physical activity and pro-liferative retinopathy in people diagnosed with diabetes before age 30 yr.Diabetes Care 15:1267–1272, 1992
  172. Cruickshanks KJ, Moss SE, Klein R, Klein BE: Physical activity and the risk of progression of retinopathy or the development of proliferative retinopathy. Ophthalmology 102:1177–1182, 1995
  173. Samanta A, Burden AC, Jagger C: A comparison of the clinical features and vascular complications of diabetes between migrant Asians and Caucasians in Leicester, U.K. Diabetes Res Clin Pract 14:205–213, 1991
  174. LaPorte RE, Dorman JS, Tajima N, Cruickshanks KJ, Orchard TJ, Cav-ender DE, Becker DJ, Drash AL: Pittsburgh Insulin-Dependent Diabetes Mellitus Morbidity and Mortality Study: physical activity and diabetic com-plications. Pediatrics 78:1027–1033, 1986
  175. Orchard TJ, Dorman JS, Maser RE, Becker DJ, Ellis D, LaPorte RE, Kuller LH, Wolfson SK Jr, Drash AL: Factors associated with avoidance of severe complications after 25 yr of IDDM. Pittsburgh Epidemiology of Diabetes Complications Study I. Diabetes Care 13:741–747, 1990
  176. Aiello LP, Wong J, Cavallerano JD, Bursel SE, Aiken LM: Retinopathy. In Handbook of Exercise in Diabetes. Ruderman NB, Devlin JT, Schneider SH, Kriska AM, Eds. Alexandria, VA, American Diabetes Association, 2002, p. 401–413
  177. Jawa A, Kcomt J, Fonseca VA: Diabetic nephropathy and retinopathy. Med Clin North Am 88:1001–1036, xi, 2004
  178. National Institutes of Health: Consensus Development Conference on Diet and Exercise in Non-Insulin-Dependent Diabetes Mellitus. National Insti-tutes of Health. Diabetes Care 10:639–644, 1987
  179. Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C: Physical activity/exercise and type 2 diabetes. Diabetes Care 27:2518–2539, 2004
  180. Lemaster JW, Reiber GE, Smith DG, Heagerty PJ, Wallace C: Daily weight-bearing activity does not increase the risk of diabetic foot ulcers.Med Sci Sports Exerc 35:1093–1099, 2003
  181. Armstrong DG, Lavery LA, Holtz-Neiderer K, Mohler MJ, Wendel CS, Nixon BP, Boulton AJ. Variability in activity may precede diabetic foot ulceration. Diabetes Care 27:1980–1984, 2004
  182. Headley SA, Germain MJ, Braden GL: Nephropathy: advanced. In Hand-book of Exercise in Diabetes. Ruderman NB, Devlin JT, Schneider SH, Kriska AM, Eds. Alexandria, VA, American Diabetes Association, 2002, p. 451–462
  183. Mogensen CE: Nephropathy: early. In Handbook of Exercise in Diabetes. Ruderman NB, Devlin JT, Schneider SH, Kriska AM, Eds. Alexandria, VA, American Diabetes Association, 2002, p. 433–449
  184. Evans N, Forsyth E: End-stage renal disease in people with type 2 diabetes: systemic manifestations and exercise implications. Phys Ther84:454–463, 2004
  185. Oh-Park M, Fast A, Gopal S, Lynn R, Frei G, Drenth R, Zohman L: Exercise for the dialyzed: aerobic and strength training during hemodialysis.Am J Phys Med Rehabil 81:814–821, 2002
  186. Painter PL: Exercise in end-stage renal disease. Exerc Sport Sci Rev 16:305– 339, 1988
  187. Moore GE, Painter PL, Brinker KR, Stray-Gundersen J, Mitchell JH: Cardiovascular response to submaximal stationary cycling during hemodialysis. Am J Kidney Dis 31:631–637, 1998
  188. Painter PL, Hector L, Ray K, Lynes L, Dibble S, Paul SM, Tomlanovich SL, Ascher NL: A randomized trial of exercise training after renal transplanta-tion. Transplantation 74:42–48, 2002
  189. Painter PL, Hector L, Ray K, Lynes L, Paul SM, Dodd M, Tomlanovich SL, Ascher NL: Effects of exercise training on coronary heart disease risk factors in renal transplant recipients. Am J Kidney Dis 42:362–369, 2003
  190. Burge MR, Garcia N, Qualls CR, Schade DS: Differential effects of fasting and dehydration in the pathogenesis of diabetic ketoacidosis.Metabolism 50:171–177, 2001
  191. American College of Sports Medicine; Sawka MN, Burke LM, Eichner ER, Maughan RJ, Montain SJ, Stachenfeld NS: American College of Sports Medicine position stand: exercise and fluid replacement. Med Sci Sports Exerc 39:377–390, 2007
  192. Tamis-Jortberg B, Downs DA Jr, Colten ME: Effects of a glucose polymer sports drink on blood glucose, insulin, and performance in subjects with diabetes. Diabetes Educ 22:471–487, 1996
  193. Hubing KA, Bassett JT, Quigg LR, Phillips MD, Barbee JJ, Mitchell JB: Exercise-associated hyponatremia: the influence of pre-exercise carbohy-drate status combined with high volume fluid intake on sodium concentra-tions and fluid balance. Eur J Appl Physiol 111:797–807, 2011
  194. Peacock OJ, Thompson D, Stokes KA: Voluntary drinking behaviour, fluid balance and psychological affect when ingesting water or a carbohydrate-electrolyte solution during exercise. Appetite 58:56–63, 2012
  195. Hernandez JM, Moccia T, Fluckey JD, Ulbrecht JS, Farrell PA: Fluid snacks to help persons with type 1 diabetes avoid late onset postexercise hypogly-cemia. Med Sci Sports Exerc 32:904–910, 2000
  196. Perrone C, Laitano O, Meyer F: Effect of carbohydrate ingestion on the glycemic response of type 1 diabetic adolescents during exercise.Diabetes Care 28:2537–2538, 2005
  197. Meinders AE, Willekens FL, Heere LP: Metabolic and hormonal changes in IDDM during long-distance run. Diabetes Care 11:1–7, 1988
  198. Koivisto VA, Sane T, Fyhrquist F, Pelkonen R: Fuel and fluid homeostasis during long-term exercise in healthy subjects and type I diabetic patients. Diabetes Care 15:1736–1741, 1992
  199. Tuominen JA, Ebeling P, Vuorinen-Markkola H, Koivisto VA: Post-marathon paradox in IDDM: unchanged insulin sensitivity in spite of glycogen depletion. Diabet Med 14:301–308, 1997
  200. Tuominen JA, Ebeling P, Koivisto VA: Exercise increases insulin clearance in healthy man and insulin-dependent diabetes mellitus patients. Clin Physiol 17:19–30, 1997
  201. Cauza E, Hanusch-Enserer U, Strasser B, Ludvik B, Kostner K, Dunky A, Haber P: Continuous glucose monitoring in diabetic long distance runners. Int J Sports Med 26:774–780, 2005
  202. American Diabetes Association; Clarke W, Deeb LC, Jameson P, Kaufman F, Klingensmith G, Schatz D, Silverstein JH, Siminerio LM: Diabetes care in the school and day care setting. Diabetes Care 35 (Suppl. 1):S76–S80, 2012
  203. Choleau C, Aubert C, Cahane M, Reach G: High day-to-day glucose vari-ability: a frequent phenomenon in children and adolescents with type 1 diabetes attending summer camp. Diabetes Metab 34:46–51, 2008
  204. Ruzic L, Sporis G, Matkovic BR: High volume-low intensity exercise camp and glycemic control in diabetic children. J Paediatr Child Health44:122– 128, 2008
  205. Santiprabhob J, Likitmaskul S, Kiattisakthavee P, Weerakulwattana P, Chai-chanwattanakul K, Nakavachara P, Peerapatdit T, Nitiyanant W: Glycemic control and the psychosocial benefits gained by patients with type 1 diabetes mellitus attending the diabetes camp. Patient Educ Couns 73:60–66, 2008
  206. Wang YC, Stewart S, Tuli E, White P: Improved glycemic control in ado-lescents with type 1 diabetes mellitus who attend diabetes camp.Pediatr Diabetes 9:29–34, 2008
  207. Miller AR, Nebesio TD and Dimeglio LA: Insulin dose changes in children attending a residential diabetes camp. Diabet Med 28:480–486, 2011
  208. McTavish L, Wiltshire E: Effective treatment of hypoglycemia in children with type 1 diabetes: a randomized controlled clinical trial. Pediatr Diabetes 12:381–387, 2011
  209. American Diabetes Association: Management of diabetes at diabetes camps. Diabetes Care 22:167–169, 1999
  210. Ciambra R, Locatelli C, Suprani T, Pocecco M: Management of diabetes at summer camps. Acta Biomed 76 (Suppl. 3):81–84, 2005 211
  211. Dear Gde L, Pollock NW, Uguccioni DM, Dovenbarger J, Feinglos MN, Moon RE: Plasma glucose responses in recreational divers with insulin-requiring diabetes. Undersea Hyperb Med 31:291–301, 2004
  212. Bonomo M, Cairoli R, Verde G, Morelli L, Moreo A, Grottaglie MD, Bram-billa MC, Meneghini E, Aghemo P, Corigliano G, Marroni A: Safety of recreational scuba diving in type 1 diabetic patients: the Deep Monitoring programme. Diabetes Metab 35:101–107, 2009
  213. Lormeau B, Sola A, Tabah A, Chiheb S, Dufaitre L, Thurninger O, Bresson R, Lormeau C, Attali JR, Valensi P: Blood glucose changes and adjustments of diet and insulin doses in type 1 diabetic patients during scuba diving (for a change in French regulations). Diabetes Metab31:144–151, 2005
  214. Edge CJ, Grieve AP, Gibbons N, O’Sullivan F, Bryson P: Control of blood glucose in a group of diabetic scuba divers. Undersea Hyperb Med24:201– 207, 1997
  215. Edge CJ, St Leger Dowse M, Bryson P: Scuba diving with diabetes mellitus: the UK experience 1991-2001. Undersea Hyperb Med 32:27–37, 2005
  216. Adolfsson P, Ornhagen H and Jendle J: Accuracy and reliability of continu-ous glucose monitoring in individuals with type 1 diabetes during recre-ational diving. Diabetes Technol Ther 11:493–497, 2009
  217. Kruger DF, Owen SK,Whitehouse FW: Scuba diving and diabetes. Practical guidelines. Diabetes Care 18:1074, 1995
  218. Influence of intensive diabetes treatment on body weight and composition of adults with type 1 diabetes in the Diabetes Control and Complications Trial. Diabetes Care 24:1711–1721, 2001
  219. Ferriss JB, Webb D, Chaturvedi N, Fuller JH, Idzior-Walus B; EURODIAB Prospective Complications Group: Weight gain is associated with improved glycaemic control but with adverse changes in plasma lipids and blood pres-sure in type 1 diabetes. Diabet Med 23:557–564
  220. Jacob AN, Salinas K, Adams-Huet B, Raskin P: Potential causes of weight gain in type 1 diabetes mellitus. Diabetes Obes Metab 8:404–411, 2006
  221. Conway B, Miller RG, Costacou T, Fried L, Kelsey S, Evans RW, Orchard TJ: Temporal patterns in overweight and obesity in Type 1 diabetes.Diabet Med 27:398–404, 2010
  222. Brown RJ, Wijewickrama RC, Harlan DM, Rother KI: Uncoupling intensive insulin therapy from weight gain and hypoglycemia in type 1 diabetes. Diabetes Technol Ther 13:457–460, 2011
  223. Okamoto MM, Anhe GF, Sabino-Silva R, Marques MF, Freitas HS, Mori RC, Melo KF, Machado UF: Intensive insulin treatment induces insulin resistance in diabetic rats by impairing glucose metabolism-related mecha-nisms in muscle and liver. J Endocrinol 211:55–64, 2011
  224. Elder SJ, Roberts SB: The effects of exercise on food intake and body fat-ness: a summary of published studies. Nutr Rev 65:1–19, 2007
  225. Weinsier RL, Hunter GR, Desmond RA, Byrne NM, Zuckerman PA, Dar-nell BE: Free-living activity energy expenditure in women successful and unsuccessful at maintaining a normal body weight. Am J Clin Nutr 75:499– 504, 2002
  226. D’hooge R, Hellinckx T, Van Laethem C, Stegen S, De Schepper J, Van Aken S, Dewolf D, Calders P: Influence of combined aerobic and resistance training on metabolic control, cardiovascular fitness and quality of life in adolescents with type 1 diabetes: a randomized controlled trial. Clin Rehabil 25:349–359, 2011
  227. Heyman E, Toutain C, Delamarche P, Berthon P, Briard D, Youssef H, Dekerdanet M, Gratas-Delamarche A: Exercise training and cardiovascular risk factors in type 1 diabetic adolescent girls. Pediatr Exerc Sci 19:408–419, 2007

Anne Peters, MD, and Lori Laffel, MD, MPH, Editors
Jane Lee Chiang, MD, Managing Editor

 

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