1.4.0.0 Phys­i­cal Ac­tiv­i­ty and Ex­er­cise

Rec­om­men­da­tions

13.5 Ex­er­cise is rec­om­mend­ed for all youth with type 1 di­a­betes with the goal of 60 min of mod­er­ate-‍to vig­or­ous-‍in­ten­si­ty aer­o­bic ac­tiv­i­ty daily, with vig­or­ous mus­cle-‍strength­en­ing and bone-‍strength­en­ing ac­tiv­i­ties at least 3 days per week. C

13.6 Ed­u­ca­tion about fre­quent pat­terns of glycemia dur­ing and after ex­er­cise, which may in­clude ini­tial tran­sient hy­per­glycemia fol­lowed by hy­po­glycemia, is es­sen­tial. Fam­i­lies should also re­ceive ed­u­ca­tion on pre­ven­tion and man­age­ment of hy­po­glycemia dur­ing and after ex­er­cise, in­clud­ing en­sur­ing pa­tients have a preex­er­cise glu­cose level of 90–250 mg/dL (5–13 mmol/‍L) and ac­cessible car­bo­hy­drates be­fore en­gag­ing in ac­tiv­i­ty, in­di­vid­u­al­ized ac­cord­ing to the type/‍in­ten­si­ty of the planned phys­i­cal ac­tiv­i­ty. E

13.7 Pa­tients should be ed­u­cat­ed on strate­gies to pre­vent hy­po­glycemia dur­ing ex­er­cise, after ex­er­cise, and overnight fol­low­ing ex­er­cise, which may in­clude re­duc­ing pran­di­al in­sulin dos­ing for the meal/‍snack pre­ced­ing (and, if need­ed, fol­low­ing) ex­er­cise, in­creas­ing car­bo­hy­drate in­take, eat­ing bed­time snacks, using con­tin­u­ous glu­cose mon­i­tor­ing, and/‍or re­duc­ing basal in­sulin doses. C

13.8 Fre­quent glu­cose mon­i­tor­ing be­fore, dur­ing, and after ex­er­cise, with or with­out use of con­tin­u­ous glu­cose mon­i­tor­ing, is im­por­tant to pre­vent, de­tect, and treat hy­po­glycemia and hy­per­glycemia with ex­er­cise. C

Ex­er­cise pos­i­tive­ly af­fects in­sulin sen­si­tiv­i­ty, phys­i­cal fitness, strength build­ing, weight man­age­ment, so­cial in­ter­ac­tion, mood, self-‍es­teem build­ing, and cre­ation of health­ful habits for adult­hood, but it also has the po­ten­tial to cause both hy­po­glycemia and hy­per­glycemia.

See below for strate­gies to mit­i­gate hy­po­glycemia risk and min­i­mize hy­per­glycemia with ex­er­cise. For an in-‍depth dis­cus­sion, see re­cently pub­lished re­views and guide­lines (11-13).

Over­all, it is rec­om­mend­ed that youth with type 1 di­a­betes par­tic­i­pate in 60 min of mod­er­ate-‍ (e.g., brisk walk­ing, danc­ing) to vig­or­ous-‍ (e.g., run­ning, jump­ing rope in­ten­si­ty aer­o­bic ac­tiv­i­ty daily, in­clud­ing re­sis­tance and flex­i­bil­i­ty train­ing (14). Al­though un­com­mon in the pe­di­atric pop­u­la­tion, pa­tients should be med­i­cally eval­u­ated for co­mor­bid con­di­tions or di­a­betes com­pli­ca­tions that­ may re­strict­ par­tic­i­pa­tion in an ex­er­cise pro­gram. As hy­per­glycemia can occur be­fore, dur­ing, and after phys­i­cal ac­tiv­i­ty, it is im­por­tant to en­sure that the el­e­vat­ed glu­cose level is not re­lat­ed to in­sulin deficien­cy that would lead to wors­en­ing hy­per­glycemia with ex­er­cise and ke­to­sis risk. In­tense ac­tiv­i­ty should be post­poned with marked hy­per­glycemia (glu­cose ≥350 mg/dL [19.4 mmol/‍L]), mod­er­ate to large urine ke­tones, and/‍or b-‍hydroxybutyrate (B-OHB) >1.5 mmol/‍L. Cau­tion may be need­ed when B-OHB lev­els are ≥0.6 mmol/‍L (10,11).

The pre­ven­tion and treat­ment of hy­po­glycemia as­so­ci­at­ed with phys­i­cal ac­tiv­i­ty in­clude de­creas­ing the pran­di­al in­sulin for the meal/‍snack be­fore ex­er­cise and/‍or in­creas­ing food in­take. Pa­tients on in­sulin pumps can lower basal rates by ~10–50% or more or sus­pend for 1–2 h dur­ing ex­er­cise (15). De­creas­ing basal rates or long act­ing in­sulin doses by ~20% after ex­er­cise may re­duce de­layed ex­er­cise-induced hy­po­glycemia (16). Ac­ces­si­ble rapid-‍act­ing car­bo­hy­drates and fre­quent blood glu­cose mon­i­tor­ing be­fore, dur­ing, and after ex­er­cise, with or with­out con­tin­u­ous glu­cose mon­i­tor­ing, max­i­mize safe­ty with ex­er­cise.

Blood glu­cose tar­gets prior to ex­er­cise should be 90–250 mg/dL (5.0–13.9 mmol/‍L). Con­sid­er ad­di­tional car­bo­hy­drate in­take dur­ing and/‍or after ex­er­cise, de­pend­ing on the du­ra­tion and in­ten­si­ty of phys­i­cal ac­tiv­i­ty, to pre­vent hy­po­glycemia. For low- to mod­er­ate-‍in­ten­si­ty aer­o­bic ac­tiv­i­ties (30-60 min), and if the pa­tient is fast­ing, 10-15 g of car­bo­hy­drate may pre­vent hy­po­glycemia (17). After in­sulin bo­lus­es (rel­a­tive hyperin­sulinemia), con­sid­er 0.5–1.0 g of car­bo­hy­drates/kg per hour of ex­er­cise (~30–60 g), which is sim­i­lar to car­bo­hy­drate re­quire­ments to op­ti­mize per­for­mance in ath­letes with­out type 1 di­a­betes (18-20).

In ad­di­tion, obe­si­ty is as com­mon in chil­dren and ado­les­cents with type 1 di­a­betes as in those with­out di­a­betes. It is as­so­ci­at­ed with high­er fre­quen­cy of car­dio­vas­cu­lar risk fac­tors, and it dis­pro­por­tion­ate­ly af­fects racial/‍eth­nic mi­nori­ties in the U.S. (21-25). There­fore, di­a­betes care pro­viders should mon­i­tor weight sta­tus and en­cour­age a healthy diet, ex­er­cise, and healthy weight as key com­po­nents of pe­di­atric type 1 di­a­betes care.