Physical Activity Checklist DO a minimum of 150 minutes of moderate-to vigorous-intensity aerobic exercise per week INCLUDE resistance exercise ≥ 2 times a week SET physical activity goals and INVOLVE a multi-disciplinary team ASSESS patient’s health before prescribing an exercise regimen Type 1 Diabetes – Risk of Hypos

Know your Community Resources and Advertise Them Speak to your patients about community resources: Community pools, gyms, safe walking trails, weight loss smart phone apps etc.

Pre-exercise Assessment Assess for conditions that can predispose to injury before prescribing an exercise regimen: Neuropathy (autonomic and peripheral) Retinopathy Coronary artery disease – resting ECG +/- exercise stress test (see CPG Chapter 23) Peripheral arterial disease

Recommendation 1 People with diabetes should accumulate a minimum of 150 minutes of moderate to vigorous intensity aerobic exercise each week, spread over at least 3 days of the week, with no more than 2 consecutive days without exercise [Grade B, Level 2, for T2DM; Grade C, Level 3 for T1DM]

Recommendation 2 People with diabetes (including elderly people) should perform resistance exercise at least twice a week, and preferably 3 times per week [Grade B, Level 2] in addition to aerobic exercise [Grade B, Level 2]. Initial instruction and periodic supervision by an exercise specialist are recommended [Grade C, level 3]

Recommendations 3 and 4 People with diabetes should set specific physical activity goals, anticipate likely barriers to physical activity (e.g. weather, competing commitments), develop strategies to overcome these barriers [Grade B, Level 2], and keep records of their physical activity [Grade B, Level 2] Structured exercise programs supervised by qualified trainers should be implemented when feasible for people with type 2 diabetes to improve glycemic control, CVD risk factors, and physical fitness [Grade B, Level 2]

Recommendation 5 People with diabetes with possible cardiovascular disease or microvascular complications of diabetes, who wish to undertake exercise that is substantially more vigorous than brisk walking, should have medical evaluation for conditions that might increase exercise-associated risk. The evaluation would include history, physical examination (including fundoscopic exam, foot exam, and neuropathy screening), resting ECG, and, possibly, exercise ECG stress testing [Grade D, consensus]

Exercise Fails to Prevent Fast-Food-Related Body Weight Increase In Healthy Adults: A 10-Year Follow-Up Study

Learning from qualitative work BG Targets drifted and were ‘forgotten’ Few graduates sustained effective self management Key self management behaviours were not maintained Record keeping Reflection and insulin adjustment rarely undertaken Graduates required structured professional support

Perhaps we can learn from Germany PRIMAS 12 90 min group sessions, x2 per week Home work between visits Integration of treatment and education CHO counting – basal/bolus separation correction doses

REPOSE - Conclusion Structured training and pumps offer few benefits (overall) to structured training alone in adults with high A1c levels who wish to undertake flexible intensive insulin therapy Structured training (or trial participation?) reduces rates of severe hypoglycaemia and leads to modest but long lasting falls in Hba1c These results support current NICE guidance in T1DM starting with initial structured training using MDI and pumps reserved where MDI limits effective self management Further work is needed (in the UK) to develop more effective approaches to support people to achieve glucose targets

Summary Severe hypoglycaemia in the last 24 hrs an absolute contraindication to exercise Hyperglycaemia with ketones an absolute contra- indication to exercise Hypoglycaemia can occur during and immediately after exercise, as well as the night that follows Different exercises effect blood glucose in different ways

Hypoglycaemia Don’t exercise within 24 hours of severe hypoglycaemia Take extra precautions when there has been a self treated hypoglycaemia within the previous 24 hours Insulin Sensitivity Increases During exercise and for the hour after exercise At 6-8 hours post exercise Glucose thus needs to be watched at two timepoints

Endurance Anaerobic Intermittent Hiking Weight Lifting Childs play Road cycling Body Building Soccer Cycle Tour Dressage Team Sports Mountain Biking Fencing Distance running Track and Field Swimming Sprinting Marathon Archery Wrestling ?

Bolus Dose Reduction for planned exercise Exercise Intensity 30 min of exercise 60 min of exercise Low (< 50% MHR of RPE <10) 25 50 Med (51-74% MHR of RPE of 10-15) 75 Moderate (>75% MHR of RPE of >15) - Quick acting insulin dose reduction for exercise for low, medium or moderate intense activity (adapted from Rabasa-Lharet) Intensity of activity is calculated by percentage of maximum heart rate (MHR) or rating of perceived exertion (RPE) on Borg scale

The Impact of Exercise on Sleep in Adults with Type 1 Diabetes Fear of hypoglycemia (FoH) in type 1 diabetes (T1D) is inversely associated with glycemic control and quality of life and is a major barrier to physical activity. However, little is known regarding the impact of FoH on behaviors around exercise, especially related to insulin adjustments. It has been recently reported that youth are not making insulin adjustments around exercise (Roberts et al, 2016). The goal of this pilot study was, therefore, to examine the association between FoH and key behaviors around exercise in youth with T1D. We studied 30 youth with T1D, 43% female, mean age 15.0 ±2.4, on insulin pump therapy. Parent and child hypoglycemia fear surveys (HFS) were collected, with 3 subscales: behavior, worry, and total hypoglycemia fear scores, along with the “Type 1 Diabetes Report of Exercise Practices Survey (T1D-REPS)”, and 3-day physical activity (PA) recall. Ninety-three percent of participants met daily PA recommendations (≥60 min PA daily). From T1D-REPS responses, an exercise hypoglycemia avoidance score was generated based on key behaviors before, during, and after exercise. Higher exercise hypoglycemia avoidance scores were associated with child HFS behavior scores (r= 0.38, p=0.04). Those who reported a target glucose of over 180 mg/dL prior to exercise had higher child HFS worry and total scores compared to those with a target glucose of 120- 180 mg/dL (t=-1.71, p<.10). Higher child HFS behavior scores were associated with higher physical activity levels (r= 0.40, p=0.04), and higher child HFS worry and total scores were associated with higher A1c (r’s=.48, .46, p’s<.05 respectively). Parent HFS scores were not associated with exercise behaviors or glycemic control. In summary, this pilot study demonstrates an association between FoH in youth and exercise behaviors to avoid hypoglycemia, which may also explain some of the detrimental impact of FoH on glycemic control.

The aim of this pilot study was to investigate the impact of exercise on sleep and nocturnal hypoglycemia in adults with type 1 diabetes. In a 3-week crossover trial, 10 adults with type 1 diabetes were randomized to perform aerobic, resistance or no exercise. During each exercise week, participants completed two separate 45-minute exercise sessions at an academic medical center. Participants returned home and wore a wrist based activity monitor to estimate sleep duration and physical activity along with a continuous glucose monitor. On average, participants lost 70 (±49) minutes of sleep (p = 0.0015) on nights following aerobic exercise and 27 (±78) minutes (p=0.3) following resistance exercise, as compared with nights with no exercise (Figure). The total number of hypoglycemia treatments during the night across all participants was 11, 8 and 3 for aerobic, resistance, and control weeks, respectively. Aerobic exercise can lead to sleep loss in people with type 1 diabetes and this may be due to increased risk of nocturnal hypoglycemia.