Exercise in children and adolescents with diabetes

In the 1950s, Joslin proposed that exercise is the third essential component in blood glucose regulation for persons with type 1 diabetes, after insulin and dietary management. Although most studies have shown little impact upon HbA1c levels (1–3) [B], a cross-sectional analysis of data on a larger group showed that the frequency of regular physical activity was associated with lower HbA1c without increasing the risk of severe hypoglycaemia (4) [C]. The benefits of exercise go far wider: weight control, reduced cardiovascular risk, and an improved sense of well-being (5) [B]. Post-meal exercise can be a valuable way to minimize postprandial glycemic spikes [E]. For some, participation in physical activity is somewhat sporadic and related to leisure, school or work. For others, daily exercise is a part of an overall training or conditioning program. Children and adolescents with diabetes should derive many of the same health and leisure benefits as adults and should be allowed to participate with equal opportunities and with equal safety. Diabetes should not limit the ability to excel in a chosen sport. Many famous athletes have proved this e.g. Sir Steve Redgrave the five times Olympic Gold Medal winning rower, Gary Hall the US Olympic Gold Medal swimmer at Athens, Wasim Akram is a Pakistani cricketer at the international level, Major League baseball player Jason Johnson, Ironman Triathlete Bill Carlson and female pro golfer Mimmi Hjorth. The topic most commonly discussed with families with regard to exercise is avoidance of hypoglycemia, but prevention of acute hyperglycemia/ketoacidosis may become a concern as well (6) [C]. While this chapter is intended to address the issue of blood glucose regulation during various forms of sports and exercise, it is important for diabetes professionals and parents to appreciate that the demands of day to day physical activity will also have to be considered if a young person is going to participate in any activity, which for them is unusually strenuous or prolonged. Before considering the situation in Type-1 diabetes, it is useful to understand the physiological response to moderate intensity aerobic exercise in the non-diabetic individual. As shown in Figure 1, non diabetic individuals have a reduction in insulin secretion and an increase in glucose counterregulatory hormones that facilitate an increase in liver glucose production which matches skeletal muscle glucose uptake during exercise. As a result of this precise autonomic and endocrine regulation, blood glucose levels remain stable under most exercise conditions (5) [B]. Physiologic responses to exercise in the diabetic and non-diabetic individual. [square brackets denote plasma concentration]. In type 1 diabetes, the pancreas does not regulate insulin levels in response to exercise and there may be impaired glucose counterregulation, making normal fuel regulation nearly impossible. As a result, hypoglycemia commonly occurs during or soon after exercise. In real life, young people with diabetes have variable blood glucose responses to exercise. The blood glucose response to 60 minutes of intermittent exercise is somewhat reproducible within a child if the timing of exercise, the amount of insulin and the pre-exercise meal remain consistent (7) [B]. Glucose production in healthy control subjects increases with exercise intensity and can be entirely attributed to increases in net hepatic glycogenolysis. In contrast, moderately controlled type 1 diabetic subjects exhibit increased rates of glucose production both at rest and during exercise, which can be entirely accounted for by increased gluconeogenesis (8) [B]. Young people with T1D have been found to have decreased aerobic capacity as measured by VO2 max, compared to nondiabetic control subjects (9) [B]. Total-body insulin-mediated glucose metabolism in adolescents correlates with the degree of glycemic control as assessed by the level of glycosylated haemoglobin (10) [B]. However, even in the same individual, it is possible for the blood glucose to be increased, decreased or unchanged by exercise dependent upon circumstances as indicated in Table 1. It is especially important to plan for long duration or intense aerobic exercise, or else hypoglycemia is almost inevitable. Nearly all forms of activity lasting > 30 minutes will be likely to require some adjustment to food and/or insulin. Most team and field sports and also spontaneous play in children are characterized by repeated bouts of intensive activity interrupting longer periods of low to moderate intensity activity or rest. This type of activity has been shown to produce a lesser fall in blood glucose levels compared to continuous moderate intensity exercise, both during and after the physical activity in young adults. (11) [B]. The repeated bouts of high-intensity exercise stimulated higher levels of noradrenaline that increased blood glucose levels. Moderate-intensity exercise (40% of VO2 max) followed by an intense cycling sprint at maximal intensity prevented a further decline in blood glucose for at least 2 hours after the exercise (12) [B]. However, typical team games may last up to 90 minutes and the results may not be applicable to this length of physical activity. Furthermore, the authors were unable to explain why the short sprint countered a fall in glucose levels for so long since the rise in catecholamines following the intense exercise was very short-lived. (See also ‘Type of Activity’). Anaerobic efforts last only a short time (sometimes only seconds) but may increase the blood glucose level dramatically due to the release of the hormones adrenaline and glucagon. This rise in blood glucose is usually transient, lasting typically 30–60 minutes, and can be followed by hypoglycaemia in the hours after finishing the exercise. Aerobic activities tend to lower blood glucose both during (usually within 20–60 minutes after the onset) and after the exercise (5) [B]. Where control is poor and pre-exercise blood glucose level is high, circulating insulin levels may be inadequate and the effect of counter-regulatory hormones will be exaggerated, leading to a higher likelihood of ketosis [E]. High blood glucose has been found to reduce the secretion of beta-endorphins during exercise, which has been associated with an increased rating of perceived exertion (RPE) during leg exercise (13) [B]. In fact, even baseline beta-endorphin levels were reduced in the diabetic subjects irrespective of blood glucose, and thus the resultant reduced tolerance of discomfort may compromise exercise performance in individuals with diabetes. Similarly, increases were found in RPE in adolescents with diabetes doing whole-body exercise (14) [B], but the authors indicate that the higher response is thought to be mainly a function of the lower peak mechanical power output often seen in these patients (15). Children with diabetes can have normal aerobic and endurance capacity if good glycemic control is achieved (HbA1c <7.0%), even if they are slightly hyperglycemic at the time of exercise. In one study, physical working capacity in well controlled prepubertal boys was not different from non-diabetic boys matched for age, weight and physical activity patterns, even though the boys with diabetes exercised with considerably higher blood glucose concentrations (mean blood glucose 15 mmol/l at onset of exercise) (16) [B]. In line with this, cycling performances in adult males with type 1 diabetes do not differ between glucose levels clamped at euglycemia vs. In contrast, aerobic capacity is lower and the is higher in with type 1 diabetes glycemic control is HbA1c (9) [B]. performance in sports and a amount of function and is may be during compared with studies have been to address this However, performance has been shown to be in with diabetes blood glucose is or hyperglycemic regular insulin has been to exercise, the most likely time for hypoglycemia will be after and the risk time after insulin is between and 90 minutes [B]. have found studies on the timing of and exercise. or a insulin daily in the can be for one with to reduce the insulin effect the day [E]. meal and should be to to for and for a of This is especially important for longer duration can be with a 1 this also to and for is for a short duration activity, it may be useful to have in a compared with with glucose, as or that and the glucose of as some The amount of should be matched as as possible to the amount of during exercise, if a reduction in insulin is In should be during exercise during peak insulin in young adults with diabetes upon type of activity. Table The will be lower if the for the meal the exercise is or the exercise is hours after the has been with of insulin are especially important the activity is of longer duration 60 [E]. insulin for hours be to lower the risk of hypoglycemia during the hours after the activity duration and intensity activities as weight and may not require to the activity, but may produce a in blood For activities of these after the activity is often the to hypoglycemia [E]. lower intensity aerobic activities as as a between aerobic and and will require during and often after the activity [E]. on the amount and timing of increased to limit However, in or reduced at will usually reduce the [E]. of and at may limit hypoglycemia by exercise [B]. of an or has been with insulin and is exercised the increased blood to the is likely to result in and effect of the insulin may be especially if the is a may consistent response by to in an or the a leg an High will increase insulin and low the [B]. The may be a in long Most studies were with regular insulin. The effect is with [C]. intense of exercise not increase the of in adults with type 1 diabetes [C]. also on the cardiovascular in and for a in blood glucose levels. a in blood glucose and weight activities tend to non that the in blood glucose may be with regular conditioning and with the that this The response will blood activity, insulin may not result in hypoglycemia as circulating insulin levels are typically low and glucose counterregulatory hormones may be [C]. severe may with exercise in these even physical activities should be a part of the normal for both health benefits and for in blood glucose management. of and with diabetes have been found to be nondiabetic [C]. and exercise is to it is part of the daily However, may be for sporadic physical activity. level of in exercise and that a child or with diabetes it is good that are of they do and intensity of physical has been and the blood glucose response during and from the diabetes team will be in the but will and [E]. Where exercise is insulin is between glycemic control and aerobic or physical activity in with type 1 diabetes, that increased aerobic capacity may glycemic control or that good control exercise (9) [B]. was between level and the maximal in a in diabetic adolescents [B]. The of on HbA1c with exercise may be related to a to insulin and in an to hypoglycemia [B]. The of diabetes may to the of training so endurance is with long moderate intensity the insulin and may be different from that the is upon power and intensity the and for on the possible effect of intensity on muscle insulin and increased of glucose was and 15 hours after exercise but decreased to levels after in non-diabetic adults and after exercise and from hours in the insulin is in adolescents with type 1 diabetes [B]. In life, exercise for can to increased insulin and an increased risk for hypoglycemia for at least hours This that adolescents only exercise on can have real in [E]. hypoglycemia is it may be to exercise day a in a if a for to with the insulin is children often exercise well day to some which results in in blood glucose [E]. with of should be after the exercise to of the of insulin to and limit However, the insulin will to be reduced to the normal insulin to for the to to the meal increases the glucose uptake and in healthy individuals [C]. will also the exercise. It is well the of this chapter to training but is Diabetes an international that and between health professionals and diabetic a of from and are with For most children and the of insulin will not be by exercise However, for some are it is likely that daily or insulin be considered to for in insulin to and following the activity. daily It may be to very blood glucose control on these especially with different levels of exercise the but the essential of various forms of during and after exercise may be even important for insulin a insulin is a insulin with the meal and a longer insulin at this be by for moderate exercise e.g. or or or at or insulin for training and pre-exercise and rates can be reduced during and after exercise to increase hepatic glucose production and limit hypoglycemia The of insulin is by many different the of various and and in the should be by the of the sport. is that to reduce the training day of hours control of blood glucose with the to periods in the day and to the insulin [C]. In the autonomic and counter-regulatory response to hypoglycemia the following day has been shown to be by repeated of low or moderate intensity exercise [B]. The same is likely to be for Glucose for stable glucose levels in adolescents with diabetes are during and after exercise, as well as from after exercise [B]. In repeated of hypoglycaemia in a results in an counter-regulatory response to exercise and increases the risk for to times glucose may be to euglycemia during exercise following a to hypoglycemia [B]. In studies of diabetic adolescents insulin and minutes on a hypoglycemia if blood glucose was mmol/l In the same study, it was that was to blood glucose to normal In [B], of children with type 1 diabetes blood glucose levels mmol/l during 60 minutes of moderate cycling in the insulin was for the activity. glucose at a that during exercise of the in blood glucose during exercise be prevented [B]. a child with diabetes is during exercise with and of hypoglycemia, glucose or of should be as for of hypoglycemia, even if blood glucose be measured to hypoglycemia [E]. hypoglycemia with a rise in of of glucose is for a 30 child and 15 for a the hypoglycemia chapter for further and or activity all the adults also should be to the of should be that person with diabetes should exercise or go or not to have regular they are is that if young people with diabetes are on they should in of at least so that 2 can if they to adult to the of an or Glucose glucose or some of should be by young people exercise at a within a of the activity. Table for further on to hypoglycemia can hours after exercise, especially this has been and of moderate or intensity [C]. This is due to the effect of increased insulin and in liver and muscle of exercise can increase glucose skeletal muscle for at least hours in non-diabetic and diabetic subjects [B]. In a controlled study, as many a on the after an exercise day compared to the after a day the insulin was not glucose may be a valuable for the blood glucose response and hypoglycemia risk during and after exercise athletes may be to reduce insulin to hypoglycemia and control may as a result [B]. and are In a group of young people a of at least hours of a lower HbA1c [C]. In one study, with type 1 diabetes were to on for hours without hypoglycemia the by compared to only 90 minutes if the was reduced by [C]. people that insulin may an rise in blood glucose which performance [E]. In a it is to on reduction for for on of pre-exercise in to is a for reduction of insulin the is within 1 of the exercise, the of reduction is for exercise hours regular insulin. [B]. For exercise, it may be to reduce the the meal by to as well as of the activity. insulin a reduction in insulin or in or in and/or low glycemic following the activity is or activities as sports a reduction of insulin the and on the day of the activity, or a reduction in the insulin the day and the following the activity. High and may be likely to of For of exercise it may be to to the of the activity and remain for up to during an In these patients may require a of the insulin if to reduce any a of the insulin effect during the exercise, the to be at least 90 minutes the exercise but many that the should not be for The may be to a 90 minutes the activity, lasting the of exercise. if the is during exercise, hypoglycemia can for hours after the of the activity [C]. a short of intense exercise VO2 responses to which for 2 hours in adults with type 1 [B]. pre-exercise plasma glucose was there a which for 2 hours in patients [C]. This may be if the has been during exercise. The rise in blood glucose may be prevented by a of insulin at or after the exercise is [E]. In of poor control or any exercise is likely to be of the effect of of the counter-regulatory In one in patients with a blood glucose of > mmol/l and a rise in blood glucose minutes [B]. The production of with impaired muscle glucose uptake will not only to but may and it is important for families to be not in exercise if blood glucose is and or are in the or the level of in blood is > It is a that insulin is exercise is to be This be a insulin is by a long and under to [E]. This is for and of levels and is [E]. of blood > mmol/l is in children with diabetes insulin is not reduced to for exercise, it is usually to in to This is dependent upon type and duration of activity. The amount of on the of the child and the activity as well as the level of circulating insulin [B]. to of of strenuous exercise may be for on duration of activity and are found in a by Gary by and and for in a by and It is adolescents and young adults the effect of upon the ability to to exercise and blood glucose on and the glucose in subjects with diabetes by gluconeogenesis not hypoglycemia likely and is in exercise, especially as may also While not to people with diabetes, the risk of should be in be upon glucose a in due to may performance [C]. In both can often be by but if is a risk, should also be should and that there is in weight may to be as as in adolescents in and [B]. glucose is the for the child with diabetes so that in glycemic responses can be should of blood glucose, the duration and intensity of exercise, as well as the to glucose concentrations in the normal of glucose should be during and after the of exercise with to the of in hours after exercise and is on strenuous activities as hypoglycemia is It levels hypoglycemia and are after exercise. In one study, a blood glucose of mmol/l risk for hypoglycemia found for hypoglycemia risk after exercise in the glucose has to be a valuable to blood glucose in both the prevention and of hypoglycemia should be in [B]. glucose may at In circumstances control is to the e.g. on a long further with the only between 15 In as a and of to the will usually should be at the of hypoglycemia may be with of While this chapter is at the of intense and/or physical activity, it is that the can be for moderate exercise. In the normal school most young people will have at least one of physical and they with hypoglycemia will be dependent upon all of the For all that will be is a of for a or a or or sports This may also be a to a as or a which will the to be This can it for activity, for or long However, the will not a child with weight Where a or a is a reduction in the pre-exercise or a may be For a short of may be to activity. For longer periods of physical activity a reduction in insulin by should be with are a part of the school and many young people with diabetes also have the to diabetes differ mainly in the with the usually and by diabetes professionals with of insulin and food professionals can the of diabetes by in diabetes and in some this is a training The benefits of a in the are but is often and the activity is with with diabetes, there are real opportunities to of for children with diabetes that on and insulin for exercise can result in improved glycemic control may have to be reduced to hypoglycemia, especially in children not to physical activity, and it is to with a reduction in daily [C]. for a on a or an for insulin will increase after which will for insulin by or even especially if not to physical The increased insulin will for at least a of after Where young people will be for by professionals it is that both the adults and the are with and as well as should be of the to plan often last longer so and hypoglycemia should be While very it may be for a diabetes team to to a school that a young person should not go on a school activity For be if the person with diabetes has as of insulin or of The from a child and the impact upon the in the group the for children with diabetes. possible should be to a young person with diabetes has or to understand to control However, diabetes have a of and there are is participation is and It be to without of the overall control and of the as well as the possible impact of any health as diabetes It may be possible to a little to the young person that it is in to with the team to management. in almost any or exercise is likely to be in but for the person with diabetes this is even very one should diabetes and to and in a sports team should be of a person with diabetes and to the hypoglycemia It is good to have on the in the of a or of diabetes in may be e.g. the and of and be with It is to that the is making some and to blood glucose or to or may to an increased risk of in a person with diabetes [C]. However, in of the with diabetes without [C]. in the as well as in many have allowed individuals with diabetes to under controlled circumstances in and only people with diabetes are allowed to The limit in the is if part in a training [E]. In the the same and are only allowed to after by a and with they understand to for diabetes during a This is usually only to with parents and after In all is allowed with type 1 diabetes, the has to be as to by a and this should also be [E]. of by individuals with diabetes has been of or hypoglycemia even in adolescents [C]. In were in very with [C]. found of diabetes in a group of in [C]. In this of diabetes which indicate that individuals with diabetes are to a higher risk healthy of hypoglycaemia should be during since this the response during exercise or hypoglycaemia [B]. The of data 2 of glucose it possible to are for In to of hypoglycaemia during the a is with of glucose levels 30 and and The same result was found data from a continuous glucose during and after individuals with type 1 diabetes that are to should be to for hypoglycaemia with the For they should also be to a for the if of hypoglycaemia are during As to the situation in type 1 diabetes, there is that exercise has a and important part in the of type 2 diabetes. results in in the amount of and increasing the amount of and This increases the blood and and increases the risk of cardiovascular and The of studies on type 2 diabetes and exercise have been in but there is to that the results are applicable to adolescents as well [E]. and of adolescents in type 2 diabetes has been have characterized by physical activity training increased insulin in adolescents of in in adults with impaired glucose tolerance that exercise can reduce the of type 2 diabetes In a it was found that exercise training reduced HbA1c by an amount that should the risk of diabetic This effect was not by weight The of hypoglycaemia in type 2 diabetes is lower in type 1 diabetes, counter-regulatory are but patients insulin or long may require reduction in sports are for with type 1 diabetes is in good control and without [E]. However, patients that have or should exercise conditions that can result in blood as any in which a is or high-intensity [E]. with should be with blood during exercise. with should be to and and should and sports that of and for on diabetes and exercise, and for a of insulin to activity the in insulin exercise type and amount of for activities exercise is and should be if pre-exercise blood glucose levels are with or of daily all meal and in and exercise have up of of of strenuous or longer duration exercise circulating insulin levels are high, if pre-exercise insulin are not decreased gluconeogenesis so hypoglycemia is likely if is a risk also are of of activity, food and glucose results is important for good diabetes control during exercise may be during or after exercise, but is also possible up to due to increased insulin of hypoglycemia is high, and should be if blood glucose level is have or should exercise likely to result in blood should be that the and chosen are for the they will be and hypoglycemia should be at school on and of exercise and is essential should be for should to for children with diabetes and in and The 1 Diabetes in adolescents and young of and Diabetes and The to Diabetes and Diabetes

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.