Synthesis of Best Practice



In the preceding chapters, we have seen elegant discussions of the hormonal and metabolic responses to exercise and how these responses are altered by type 1 diabetes and insulin therapy. In Chap. 1, we have seen how exercise exerts a great demand on the capacity of the human body to maintain blood glucose homeostasis. The normal physiological counterregulatory hormone response generated by exercise produces coordinated endocrine response which switches the physiological state from the postabsorptive to the exercise state, enabling release of the nutrients required to support increased work. Increased glucose utilization by skeletal muscle proportionate to the duration and intensity of exercise is counteracted by a complex and well-coordinated endocrine response. Hepatic glucose production (through increased glycogenolysis and gluconeogenesis) mediated through increased glucagon and a fall in insulin concentrations in the portal vein are important stimulators of hepatic glucose production during low- and moderate-intensity exercise. Further counterregulatory catecholamine responses during high-intensity exercise are important in intense exercise and with modest hypoglycemia in nondiabetic intervals. It is perhaps surprising that even in nondiabetic individuals, preexercise hypoglycemia is associated with blunted counterregulation during subsequent exercise, and prior exercise blunts the counterregulatory response to subsequent hypoglycemia. There are further age-, gender-, and obesity-related difference in these responses. It is therefore entirely predictable that diabetes and insulin treatment is likely to have very significant effects on the ability to perform exercise though changes in glycemic and counterregulatory responses.


Insulin Glargine Endurance Exercise Hepatic Glucose Production Insulin Detemir Continuous Subcutaneous Insulin Infusion 
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  1. 1.
    Gallen I. Exercise in type 1 diabetes. Diabet Med. 2003;20:2–5.PubMedCrossRefGoogle Scholar
  2. 2.
    Lumb AN, Gallen IW. Diabetes management for intense exercise [Review, 44 refs]. Curr Opin Endocrinol Diabetes Obes. 2009;16(2):150–5.PubMedCrossRefGoogle Scholar
  3. 3.
    Mitchell TH, Abraham G, Schiffrin A, Leiter LA, Marliss EB. Hyperglycemia after intense exercise in IDDM subjects during continuous subcutaneous insulin infusion. Diabetes Care. 1988;11:311–7.PubMedCrossRefGoogle Scholar
  4. 4.
    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. 2007;292(3):E865–70.PubMedCrossRefGoogle Scholar
  5. 5.
    Bussau VA, Ferreira LD, Jones TW, Fournier PA. The 10-s maximal sprint: a novel approach to counter an exercise-mediated fall in glycemia in individuals with type 1 diabetes. Diabetes Care. 2006;29(3):601–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Bussau VA, Ferreira LD, Jones TW, Fournier PA. A 10-s sprint performed prior to moderate-intensity exercise prevents early post-exercise fall in glycaemia in individuals with type 1 diabetes. Diabetologia. 2007;50(9):1815–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Kennedy JW, Hirshman MF, Gervino EV, Ocel JV, Forse RA, Hoenig SJ, Aronson D, Goodyear LJ, Horton ES. Acute exercise induces GLUT4 translocation in skeletal muscle of normal human subjects and subjects With type 2 diabetes [Miscellaneous article]. Diabetes. 1999;48:1192–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Kraniou GN, Cameron-Smith D, Hargreaves M. Effect of short-term training on GLUT-4 mRNA and protein expression in human skeletal muscle. Exp Physiol. 2004;89:559–63.PubMedCrossRefGoogle Scholar
  9. 9.
    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 Metab. 2007;92(3):963–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Galassetti P. Reciprocity of hypoglycaemia and exercise in blunting respective counterregulatory responses: possible role of cortisol as a mediator [Review, 70 refs]. Diabetes, Nutr Metab Clin Exp. 2002;15(5):341–7; discussion 347–8, 362.Google Scholar
  11. 11.
    Galassetti P, Tate D, Neill RA, Morrey S, Davis SN. Effect of gender on counterregulatory responses to euglycemic exercise in type 1 diabetes. J Clin Endocrinol Metab. 2002;87(11):5144–50.PubMedCrossRefGoogle Scholar
  12. 12.
    Galassetti P, Tate D, Neill RA, Morrey S, Wasserman DH, Davis SN. Effect of antecedent hypoglycemia on counterregulatory responses to subsequent euglycemic exercise in type 1 diabetes. Diabetes. 2003;52(7):1761–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Galassetti P, Tate D, Neill RA, Morrey S, Wasserman DH, Davis SN. Effect of sex on counterregulatory responses to exercise after antecedent hypoglycemia in type 1 diabetes. Am J Physiol Endocrinol Metab. 2004;287(1):E16–24.PubMedCrossRefGoogle Scholar
  14. 14.
    Galassetti P, Tate D, Neill RA, Richardson A, Leu SY, Davis SN. Effect of differing antecedent hypoglycemia on counterregulatory responses to exercise in type 1 diabetes. Am J Physiol Endocrinol Metab. 2006;290(6):E1109–17.PubMedCrossRefGoogle Scholar
  15. 15.
    Sandoval DA, Guy DL, Richardson MA, Ertl AC, Davis SN. Effects of low and moderate antecedent exercise on counterregulatory responses to subsequent hypoglycemia in type 1 diabetes. Diabetes. 2004;53(7):1798–806.PubMedCrossRefGoogle Scholar
  16. 16.
    Sandoval DA, Guy DL, Richardson MA, Ertl AC, Davis SN. Acute, same-day effects of antecedent exercise on counterregulatory responses to subsequent hypoglycemia in type 1 diabetes mellitus. Am J Physiol Endocrinol Metab. 2006;290(6):E1331–8.PubMedCrossRefGoogle Scholar
  17. 17.
    American College of Sports Medicine and American Diabetes Association joint position statement. Diabetes mellitus and exercise. Med Sci Sports Exerc. 1997;29(12):i–vi.Google Scholar
  18. 18.
    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. 2010;12(10):763–8.PubMedCrossRefGoogle Scholar
  19. 19.
    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. 2008;37(2):231–40.PubMedCrossRefGoogle Scholar
  20. 20.
    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. 2010;42(8):1454–9.PubMedCrossRefGoogle Scholar
  21. 21.
    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. 1920;20:349–53.CrossRefGoogle Scholar
  22. 22.
    Tamis-Jortberg B, Downs Jr DA, Colten ME, 5. Effects of a glucose polymer sports drink on blood glucose, insulin, and performance in subjects with diabetes. Diabetes Educ. 1996;22:471–87.PubMedCrossRefGoogle Scholar
  23. 23.
    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. Diabetologia. 2007;50(9):1921–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Chokkalingam K, Tsintzas K, Norton L, Jewell K, Macdonald IA, Mansell PI. Exercise under hyperinsulinaemic conditions increases whole-body glucose disposal without affecting muscle glycogen utilisation in type 1 diabetes. Diabetologia. 2007;50(2):414–21.PubMedCrossRefGoogle Scholar
  25. 25.
    Harmer AR, Chisholm DJ, McKenna MJ, Hunter SK, Ruell PA, Naylor JM, Maxwell LJ, Flack JR, 11. Sprint training increases muscle oxidative metabolism during high-intensity exercise in patients with type 1 diabetes. Diabetes Care. 2008;31:2097–102; Erratum appears in Diabetes Care. 2009;32(3):523.PubMedCrossRefGoogle Scholar
  26. 26.
    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 exercise in euglycaemia and hyperglycaemia in patients with type 1 diabetes mellitus – a prospective single-blinded randomised crossover trial. Diabetologia. 2008;51(8):1457–65.PubMedCrossRefGoogle Scholar
  27. 27.
    Robitaille M, Dube MC, Weisnagel SJ, Prud’homme D, Massicotte D, Peronnet F, Lavoie C, 1. Substrate source utilization during moderate intensity exercise with glucose ingestion in type 1 diabetic patients. J Appl Physiol. 2007;103:119–24.PubMedCrossRefGoogle Scholar
  28. 28.
    Yamakita T, Ishii T, Yamagami K, Yamamoto T, Miyamoto M, Hosoi M, Yoshioka K, Sato T, Onishi S, Tanaka S, Fujii S. Glycemic response during exercise after administration of insulin lispro compared with that after administration of regular human insulin. Diabetes Res Clin Pract. 2002;57(1):17–22.PubMedCrossRefGoogle Scholar
  29. 29.
    Arutchelvam V, Heise T, Dellweg S, Elbroend B, Minns I, Home PD. Plasma glucose and hypoglycaemia following exercise in people with Type 1 diabetes: a comparison of three basal insulins. Diabet Med. 2009;26(10):1027–32.PubMedCrossRefGoogle Scholar
  30. 30.
    Tsalikian E, Mauras N, Beck RW, Tamborlane WV, Janz KF, Chase HP, Wysocki T, Weinzimer SA, Buckingham BA, Kollman C, Xing D, Ruedy KJ. Diabetes research in children network DirecNet Study Group: Impact of exercise on overnight glycemic control in children with type 1 diabetes mellitus. J Pediatr. 2005;147(4):528–34.PubMedCrossRefGoogle Scholar
  31. 31.
    Bracken RM, West DJ, Stephens JW, Kilduff LP, Luzio S, Bain SC. Impact of pre-exercise rapid-acting insulin reductions on ketogenesis following running in Type 1 diabetes. Diabet Med. 2011;28:218–22.PubMedCrossRefGoogle Scholar
  32. 32.
    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. 2003;26(4):1316–7.PubMedCrossRefGoogle Scholar
  33. 33.
    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 Care. 2001;24(4):625–30.PubMedCrossRefGoogle Scholar
  34. 34.
    Francescato MP, Geat M, Fusi S, Stupar G, Noacco C, Cattin L. Carbohydrate requirement and insulin concentration during moderate exercise in type 1 diabetic patients. Metabolism. 2004;53(9):1126–30.PubMedCrossRefGoogle Scholar
  35. 35.
    Francescato MP, Zanier M, Gaggioli F. Prediction of glucose oxidation rate during exercise. Int J Sports Med. 2008;29(9):706–12.PubMedCrossRefGoogle Scholar
  36. 36.
    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. 1997;83(2):608–14.PubMedGoogle Scholar
  37. 37.
    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. 2000;88(4):1239–46.PubMedGoogle Scholar
  38. 38.
    Jeukendrup AE, Jentjens R. Oxidation of carbohydrate feedings during prolonged exercise: Current thoughts, guidelines and directions for future research. Sports Med. 2000;29(6): 407–24.PubMedCrossRefGoogle Scholar
  39. 39.
    Perrone CA, Rodrigues CA, Petkowicz RO, Meyer F. The effect of 8 and 10% carbohydrate drinks on blood glucose level of type 1 diabetic adolescents during and after exercise. Med Sci Sports Exerc [Abstract]. 2004;36:S272.Google Scholar
  40. 40.
    West DJ, Morton RD, Stephens JW, Bain SC, Kilduff LP, Luzio S, Still R, Bracken RM. Isomaltulose improves postexercise glycemia by reducing CHO oxidation in T1DM. Med Sci Sports Exerc. 2011;43(2):204–10.PubMedCrossRefGoogle Scholar
  41. 41.
    Gallen IW, Ballav C, Lumb A, Carr J. Caffeine supplementation reduces exercise induced decline in blood glucose and subsequent hypoglycaemia in adults with type 1 diabetes (T1DM) treated with multiple daily insulin injection (MDI). Diabetes Care. 2010;59:184-P.Google Scholar
  42. 42.
    Davison R, Aitken G, Charlton J, McKnight J, Kilbride L. Comparison of patient blood glucose monitoring with continuous blood glucose monitoring during exercise. Diabetic Medicine Conference: Diabetes UK Annual Professional Conference; 2010 Mar 3–5; Liverpool, UKGoogle Scholar
  43. 43.
    Aitken G, Charlton J, Davison R, Hill G, Kilbride L, McKnight J. Reproducibility of the glucose response to moderate intensity exercise in people with type 1 diabetes exercise. Diabetologia Conference: 45th EASD Annual Meeting of the European Association for the Study of Diabetes Vienna Austria Conference; 2009 Sep 29–Oct 2; Vienna, AustriaGoogle Scholar
  44. 44.
    Cauza E, Hanusch-Enserer U, Strasser B, Kostner K, Dunky A, Haber P, 12. Strength and endurance training lead to different post exercise glucose profiles in diabetic participants using a continuous subcutaneous glucose monitoring system. Eur J Clin Invest. 2005;35:745–51.PubMedCrossRefGoogle Scholar
  45. 45.
    Cauza E, Hanusch-Enserer U, Strasser B, Ludvik B, Kostner K, Dunky A, Haber P, 9. Continuous glucose monitoring in diabetic long distance runners. Int J Sports Med. 2005;26:774–80.PubMedCrossRefGoogle Scholar
  46. 46.
    Kapitza C, Hovelmann U, Nosek L, Kurth HJ, Essenpreis M, Heinemann L. Continuous glucose monitoring during exercise in patients with type 1 diabetes on continuous subcutaneous insulin infusion. J Diabetes Sci Technol. 2010;4(1):123–31.PubMedGoogle Scholar
  47. 47.
    Iscoe KE, Corcoran M, Riddell MC, 3. High rates of nocturnal hypoglycemia in a unique sports camp for athletes with type 1 diabetes: Lessons learned from continuous glucose monitoring systems. Can J Diabetes. 2008;32:182–9.Google Scholar
  48. 48.
    Svarstad E, Gerdts E, Omvik P, Ofstad J, Iversen BM. Renal hemodynamic effects of captopril and doxazosin during slight physical activity in hypertensive patients with type-1 diabetes mellitus. Kidney Blood Press Res. 2001;24(1):64–70.PubMedCrossRefGoogle Scholar
  49. 49.
    Tuominen JA, Ebeling P, Koivisto VA. Long-term lisinopril therapy reduces exercise-induced albuminuria in normoalbuminuric normotensive IDDM patients. Diabetes Care. 1998;21(8):1345–8.PubMedCrossRefGoogle Scholar
  50. 50.
    Viberti G, Pickup JC, Bilous RW, Keen H, Mackintosh D. Correction of exercise-induced microalbuminuria in insulin-dependent diabetics after 3 weeks of subcutaneous insulin infusion. Diabetes. 1981;30:818–23.PubMedCrossRefGoogle Scholar
  51. 51.
    Kruger M, Gordjani N, Burghard R. Postexercise albuminuria in children with different duration of type-1 diabetes mellitus. Pediatr Nephrol. 1996;10(5):594–7.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2012

Authors and Affiliations

  1. 1.Diabetes CentreWycombe HospitalHigh WycombeUK

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