- ACRONYMS AND DEFINITIONS
- ADA - American Diabetes Association
- EASD - European Association for the Study of Diabetes
- GI - Glycemic index
- ISPAD - International Society for Pediatric and Adolescent Diabetes
- T1DM - Type 1 diabetes mellitus
- TYPES OF EXERCISE
- Aerobic exercise - exercise that involves continuous, repeated movements of large muscle groups. Examples include walking, cycling, jogging, and swimming. During aerobic exercise, muscles utilize energy pathways that require oxygen. If energy requirements exceed oxygen supply, anaerobic pathways are then utilized.
- Anaerobic exercise - exercise that involves alternating between short bursts of vigorous activity and periods of rest. Examples include weightlifting, sprints, and interval training. Anaerobic exercise utilizes energy pathways that do not require oxygen (e.g. muscle phosphagens, muscle glycogen). These pathways may become depleted quickly. If anaerobic activity is prolonged (e.g. greater 30 seconds), aerobic sources of energy become involved.
- Mixed exercise - exercise that is a combination of aerobic and anaerobic exercise. Examples include team sports like basketball and soccer. [1,2]
- EFFECTS OF EXERCISE ON GLUCOSE AND INSULIN LEVELS
- The effect of exercise on blood glucose and insulin levels is dependent on a number of variables
- Insulin dose, carbohydrate consumption, exercise type, exercise duration, and individual conditioning all have an effect on glucose and insulin regulation during exercise
- The physiologic responses discussed below are given in general terms and may vary by individual
- Aerobic exercise
- During aerobic exercise, muscles increase their uptake of glucose by as much as fifty times. This effect occurs independent of insulin. In order to keep blood glucose levels steady (70 - 110 mg/dl), insulin levels decrease, and counter-regulatory hormones (e.g. glucagon, cortisol, growth hormone, norepinephrine) increase.
- In diabetics who use insulin, insulin levels may not fall appropriately during exercise because exogenous insulin levels are not controlled by counter-regulatory hormones. This may lead to hypoglycemia if carbohydrates are not consumed or if insulin doses are not reduced.
- Anaerobic exercise
- During anaerobic exercise, muscles utilize muscle phosphagens and muscle glycogen for energy. Insulin levels do not decrease as much compared to aerobic exercise and glucose levels tend to rise secondary to counter-regulatory hormones
- In diabetics who use insulin, anaerobic exercise typically causes an increase in blood glucose levels
- Mixed exercise
- During mixed exercise, the effects of anaerobic and aerobic exercise offset each other and blood glucose levels tend to stay steady
- After exercise, insulin-independent glucose uptake by muscles remains elevated for approximately two hours. Insulin sensitivity also increases after exercise and remains elevated for about 24 hours in most individuals.
- Prolonged, strenuous exercise may increase insulin sensitivity for up to 48 hours. Diabetics who use insulin are at increased risk for hypoglycemia after exercise if insulin doses are not adjusted. The greatest risk is during the night that follows afternoon exercise (nocturnal hypoglycemia). [1,2]
- GLUCOSE/CARBOHYDRATE ADJUSTMENTS FOR EXERCISE
- The table below gives recommendations for carbohydrate consumption based on glucose levels checked before exercise. The recommendations are derived from the ADA position statement on exercise and expert opinion. A number of variables affect glucose response to exercise, so it is important to tailor these recommendations to the individual's needs.
|Carbohydrate adjustments for exercise|
Pre-exercise glucose: < 90 mg/dl (< 5 mmol/L)
Pre-exercise glucose: 90 - 150 mg/dl (5 - 8.3 mmol/L)
Pre-exercise glucose: 150 - 250 mg/dl (8.3 - 13.9 mmol/L)
Pre-exercise glucose: 250 - 350 mg/dl (13.9 - 19.4 mmol/L)
Pre-exercise glucose: > 350 mg/dl (> 19.4 mmol/L)
- INSULIN ADJUSTMENTS FOR EXERCISE
- Insulin doses may need to be reduced to avoid hypoglycemia during and around exercise. This is particularly true for aerobic exercise. The amount of reduction will depend upon the type and length of exercise.
- Recommendations for adjusting insulin around exercise from the ADA and other experts are given in the table below. In 2020, the EASD/ISPAD published very detailed recommendations for type 1 diabetics who have continuous or intermittently-scanned glucose monitoring systems. A guide to those recommendations is provided here - EASD/ISPAD recommendations
- When starting or changing an exercise regimen, diabetics who use insulin should closely monitor their blood sugars before, during, and after exercise
|Suggested reduction in bolus (premeal) insulin if given within 90 minutes prior to exercise|
|30 minutes of exercise||Bolus insulin dose reduction|
|Intense aerobic/anaerobic||No dose reduction|
|60 minutes of exercise||Bolus insulin dose reduction|
|Prevention of nocturnal hypoglycemia
(particularly for exercise performed in afternoon or evening)
For first meal after exercise (within 90 minutes)
|Suggested reductions in basal insulin for prolonged exercise (> 30 minutes)|
Patients using multiple injections a day
Patients using insulin pumps
- EASD/ISPAD recommendations for adjusting insulin
- In 2020, the EASD/ISPAD published very detailed recommendations for adjusting insulin before, during, and after exercise in type 1 diabetics who have continuous or intermittently-scanned glucose monitoring systems. Those guidelines are available in pdf format at the link below. A guide to important pages in the publication is also provided.
- EASD and ISPAD T1DM Recommendations for Insulin and Exercise [pdf]
- Risk assessment
- Exercise experience and hypoglycemia risk assessments [page 1381, figure 2]
- Pre-exercise recommendations [page 1379]
- During exercise recommendations [page 1380]
- Post-exercise recommendations [page 1381]
- Children and adolescents
- General recommendations [page 1382]
- Pre-exercise recommendations [page 1383]
- During exercise recommendations [page 1384]
- Post-exercise recommendations [page 1385]
- KETONE TESTING
- In diabetics, a lack of insulin causes the liver to secrete ketone bodies (β-hydroxybutyric acid, acetoacetate). Ketone bodies are used by cells as an alternative fuel source when insulin is deficient. A buildup of ketone bodies can lead to diabetic ketoacidosis.
- Diabetics can test for ketone bodies in the blood or urine. Blood testing can be done with certain glucose meters that provide ketone testing with special strips. Urine testing can be done with widely-available ketone dipsticks.
- Positive ketone levels are found in normal individuals during fasting states and pregnancy
- The table below provides a general estimate of ketone body levels and how they compare in blood and urine. Cutoff values for urine can vary by manufacturer.
- In type one diabetics, ketone levels > 1.5 mmol/L should be addressed immediately by checking glucose levels and administering corrective insulin
|Blood value (mmol/L)||Urine value|
|0.6 - 1.5||Small to moderate|
|1.6 - 3.0||Moderate to large|
- GLYCEMIC INDEX AND EXERCISE
- The glycemic index (GI) is a measure of how much blood sugar levels tend to rise after the ingestion of various carbohydrate-containing foods (see glycemic index for a full discussion)
- Foods with a high GI (≥ 70) tend to cause quick rises in blood glucose levels that are shorter in duration
- Foods with a low GI (≤ 55) tend to cause slower rises in blood glucose levels that are longer in duration
- Foods with a medium GI (56 - 69) fall somewhere between high and low GI foods
- General considerations for consuming carbohydrates based on their GI are given in the table below
|Glycemic index (GI) and exercise|
Low GI foods
High GI foods
- 1 - PMID 27926890 - Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association, Diabetes Care 2016
- 2 - PMID 28126459 - Exercise management in type 1 diabetes: a consensus statement, Lancet Diabetes Endocrinol 2017