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People with type 1 diabetes experience challenges in managing blood glucose around exercise. Previous studies have examined glycaemic responses to different exercise modalities but paid little attention to participants’ prandial state, although this is an important consideration and will enhance our understanding of the effects of exercise in order to improve blood glucose management around activity. This review summarises available data on the glycaemic effects of postprandial exercise (i.e. exercise within 2 h after a meal) in people with type 1 diabetes. Using a search strategy on electronic databases, literature was screened until November 2022 to identify clinical trials evaluating acute (during exercise), subacute (≤2 h after exercise) and late (>2 h to ≤24 h after exercise) effects of postprandial exercise in adults with type 1 diabetes. Studies were systematically organised and assessed by exercise modality: (1) walking exercise (WALK); (2) continuous exercise of moderate intensity (CONT MOD); (3) continuous exercise of high intensity (CONT HIGH); and (4) interval training (intermittent high-intensity exercise [IHE] or high-intensity interval training [HIIT]). Primary outcomes were blood glucose change and hypoglycaemia occurrence during and after exercise. All study details and results per outcome were listed in an evidence table. Twenty eligible articles were included: two included WALK sessions, eight included CONT MOD, seven included CONT HIGH, three included IHE and two included HIIT. All exercise modalities caused consistent acute glycaemic declines, with the largest effect size for CONT HIGH and the smallest for HIIT, depending on the duration and intensity of the exercise bout. Pre-exercise mealtime insulin reductions created higher starting blood glucose levels, thereby protecting against hypoglycaemia, in spite of similar declines in blood glucose during activity between the different insulin reduction strategies. Nocturnal hypoglycaemia occurred after higher intensity postprandial exercise, a risk that could be diminished by a post-exercise snack with concomitant bolus insulin reduction. Research on the optimal timing of postprandial exercise is inconclusive. In summary, individuals with type 1 diabetes exercising postprandially should substantially reduce insulin with the pre-exercise meal to avoid exercise-induced hypoglycaemia, with the magnitude of the reduction depending on the exercise duration and intensity. Importantly, pre-exercise blood glucose and timing of exercise should be considered to avoid hyperglycaemia around exercise. To protect against late-onset hypoglycaemia, a post-exercise meal with insulin adjustments might be advisable, especially for exercise in the evening or with a high-intensity component. Graphical abstract

Introduction The COVID‐19 pandemic has forced rapid reconsideration as to the way in which health care is delivered. One potential means to provide care while avoiding unnecessary person‐to‐person contact is to offer remote services (telemedicine). This study aimed to (1) gather real‐time information on the use and perception of telemedicine in people living with type 1 diabetes and (2) assess the challenges, such as restricted access to health care and/or medical supplies. Methods An anonymous questionnaire was widely distributed between 24 March and 5 May 2020 using an open‐access web‐based platform. Data were analysed descriptively, and results were stratified according to age, sex and HbA1c. Results There were 7477 survey responses from individuals in 89 countries. Globally, 30% reported that the pandemic had affected their healthcare access due to cancelled physical appointments with their healthcare providers. Thirty‐two per cent reported no fundamental change in their medical follow‐up during this period, with 9% stating that no personal contact was established with their doctors over the duration of the study. Twenty‐eight per cent received remote care through telephone (72%) or video‐calls (28%). Of these, 86% found remote appointments useful and 75% plan to have remote appointments in the future. Glucose control, indicated by HbA1c, was positively associated with positive perception of telemedicine. In males, 45% of respondents with an HbA1c > 9% rated telemedicine not useful compared to those with lower HbA1c, while 20% of females with an HbA1c > 9% rated it not useful (χ2 = 14.2, P = .0016). Conclusion Remote appointments have largely been perceived as positive in people with type 1 diabetes with the majority (75%) stating that they would consider remote appointments beyond the pandemic. Age and level of education do not appear to influence perception of telemedicine, whereas poor glucose control, particularly in males, seems to negatively affect perception. This study aimed to gather information on the use and perception of telemedicine in people living with type 1 diabetes during the COVID‐19 pandemic. An anonymous questionnaire was widely distributed. Data were analysed descriptively and the mean population responses were summarised and stratified based on country, age, sex, health status and HbA1c. Age and level of education do not appear to influence perception of telemedicine, whereas poor glucose control, particularly in males, seems to negatively affect perception.

With more than 1.4 billion adults worldwide classified as physically inactive, physical inactivity is a public health crisis leading to an increased risk of cardiometabolic diseases. Motivating and engaging training strategies are needed to tackle this public health crisis. Studies have shown that exergames, games controlled by active body movements, are potentially usable, attractive, and effective tools for home-based training. The ExerCube (by Sphery Ltd) has been developed as a physically immersive and adaptive functional fitness game. The development of a home-based version of the ExerCube could increase accessibility, reduce barriers to exercise, and provide an attractive solution to improve physical and cognitive health. The aim was threefold: (1) to develop a usable home-based exergame system, (2) to evaluate the usability and training experience of the home-based exergame and its early-stage on-body feedback system, and (3) to identify avenues for further user-centered design iterations of the system. A total of 15 healthy participants (mean age 25, SD 3 years) completed 2 laboratory visits consisting of four 5-minute exergame sessions. In each session, the on-body feedback system provided a different feedback modality (auditory, haptic, and visual feedback) to the participant. Following the second visit, participants completed a range of assessments, including the System Usability Scale (SUS), the Physical Activity Enjoyment Scale (PACES), the Flow Short Scale (FSS), the Immersive Experience Questionnaire (IEQ), and a rating of perceived exertions (RPEs) both physically and cognitively. Participants answered questions regarding the on-body feedback system and completed a semistructured interview. Usability was rated as acceptable, with a SUS score of 70.5 (SD 12). The questionnaires revealed medium-to-high values for the training experience (FSS: 5.3, SD 1; PACES: 5.3, SD 1.1; IEQ: 4.7, SD 0.9. Physical (mean 4.8, SD 1.6) and cognitive (mean 3.9, SD 1.4) RPEs were moderate. Interviews about the on-body feedback system revealed that the majority of participants liked the haptic feedback and the combination of haptic and auditory feedback the best. Participants enjoyed the distinct perceptibility, processing, and integration of the exergame and its supportive and motivating effect. The visual feedback was perceived less positively by participants but was still classified as \"potentially\" helpful. The auditory feedback was rated well but highlighted an area for further improvement. Participants enjoyed the training experience and described it as motivating, interactive, immersive, something new, interesting, self-explanatory, as well as physically and cognitively challenging. Moreover, 67% (n=10) of the participants could imagine exercising at home and continuing to play the exergame in the future. The home-based exergame and its early-stage on-body feedback system were rated as usable and an enjoyable training experience by a young healthy population. Promising avenues emerged for future design iterations.

Sedentary behaviour is associated with an increased risk of cardiovascular disease and all-cause mortality in individuals with type 1 diabetes (T1D). Recent laboratory-based research suggests that breaking up prolonged sedentary periods improves glycaemic markers in people with T1D. However, the effects of breaking up sedentary behaviour for prolonged periods in real-world settings remain unknown. This study aims to assess the effect of 4 weeks of active breaks on time spent within the target glycaemic range (time in range (TIR), 3.9–10.0 mmol/L) in adults with T1DAdults with T1D (n=118) who are sedentary for ≥8 hours per day will first complete a 7-day baseline assessment. Participants will then be randomised into either a control group (maintenance of habitual lifestyle) or an intervention group, where active breaks (3 min of self-paced walking every 30 min between 09:00 and 17:00, Monday through Friday) will be prescribed for 4 weeks. Activity levels (activPAL), TIR (via continuous glucose monitor), insulin dose and carbohydrate intake will be monitored throughout. The effect of active breaks on TIR will be compared between baseline and week 4, with data analysed using analysis of covariance (ANCOVA).The trial has been approved in the UK by the West Midlands-Solihull Ethics Committee (22/WM/0221). The findings from the study will be disseminated through peer-reviewed journals and presentations at national and international scientific conferences.Trial registration numberNCT05706298.

IntroductionThis prospective observational study sought to establish the glycemic, physiological and dietary demands of strenuous exercise training as part of a 9-day performance camp in a professional cycling team with type 1 diabetes (T1D).Research design and methodsSixteen male professional cyclists with T1D on multiple daily injections (age: 27±4 years; duration of T1D: 11±5 years; body mass index: 22±2 kg/m2; glycated hemoglobin: 7%±1% (50±6 mmol/mol); maximum rate of oxygen consumption: 73±4 mL/kg/min) performed road cycle sessions (50%–90% of the anaerobic threshold, duration 1–6 hours) over 9 consecutive days. Glycemic (Dexcom G6), nutrition and physiological data were collected throughout. Glycemic data were stratified into predefined glycemic ranges and mapped alongside exercise physiology and nutritional parameters, as well as split into daytime and night-time phases for comparative analysis. Data were assessed by means of analysis of variance and paired t-tests. A p value of ≤0.05 (two-tailed) was statistically significant.ResultsHigher levels of antecedent hypoglycemia in the nocturnal hours were associated with greater time spent in next-day hypoglycemia overall (p=0.003) and during exercise (p=0.019). Occurrence of nocturnal hypoglycemia was associated with over three times the risk of next-day hypoglycemia (p<0.001) and a twofold risk of low glucose during cycling (p<0.001). Moreover, there was trend for a greater amount of time spent in mild hypoglycemia during the night compared with daytime hours (p=0.080).ConclusionThe higher prevalence of nocturnal hypoglycemia was associated with an increased risk of next-day hypoglycemia, which extended to cycle training sessions. These data highlight the potential need for additional prebed carbohydrates and/or insulin dose reduction strategies around exercise training in professional cyclists with T1D.Trial registration numberDRKS00019923.

Regular exercise is important for health, fitness and longevity in people living with type 1 diabetes, and many individuals seek to train and compete while living with the condition. Muscle, liver and glycogen metabolism can be normal in athletes with diabetes with good overall glucose management, and exercise performance can be facilitated by modifications to insulin dose and nutrition. However, maintaining normal glucose levels during training, travel and competition can be a major challenge for athletes living with type 1 diabetes. Some athletes have low-to-moderate levels of carbohydrate intake during training and rest days but tend to benefit, from both a glucose and performance perspective, from high rates of carbohydrate feeding during long-distance events. This review highlights the unique metabolic responses to various types of exercise in athletes living with type 1 diabetes.

Abstract Context We investigated whether 6 weeks of high-intensity interval training (HIT) induced improvements in cardiometabolic health markers similar to moderate-intensity continuous training (MICT) in people with type 1 diabetes (T1D), and whether HIT abolished acute reductions in plasma glucose levels observed after MICT sessions. Methods Two groups of sedentary individuals with T1D (n = 7 per group) completed 6 weeks of thrice weekly HIT or MICT. Pre- and post-training measurements were made of 24-hour interstitial glucose profiles, using continuous glucose monitors, and cardiometabolic health markers [peak oxygen consumption (V˙o2peak), blood lipid profile, and aortic pulse wave velocity (aPWV)]. Capillary blood glucose (BG) concentrations were assessed before and after exercise to investigate changes in BG levels during exercise in the fed state. Results Six weeks of HIT or MICT increased V˙o2peak by 14% and 15%, respectively (P < 0.001), and aPWV by 12% (P < 0.001), with no difference between groups. There was no difference in incidence or percentage of time spent in hypoglycemia after training in either group (P > 0.05). In the fed state, the mean change (±SEM) in capillary BG concentration during the HIT sessions was −0.2 ± 0.5 mmol/L, and −5.5 ± 0.4 mmol/L during MICT. Conclusions Six weeks of HIT improved V˙o2peak and aPWV to a similar extent as MICT. That BG levels remained stable during HIT in the fed state but consistently fell during MICT suggests HIT may be the preferred training mode for some people with T1D. High-intensity interval training improved aerobic capacity and abolished the decline in blood glucose levels observed during moderate-intensity continuous training sessions in people with T1D.

Abstract Aims To compare the effect of a bout of high-intensity interval training (HIT) with a bout of moderate-intensity continuous training (MICT) on glucose concentrations over the subsequent 24-hour period. Methods Fourteen people with type 1 diabetes [T1D (duration of T1D, 8.2 ± 1.4 years)], all on a basal-bolus regimen, completed a randomized, counterbalanced, crossover study. Continuous glucose monitoring was used to assess glycemic control after a single bout of HIT (six 1-minute intervals) and 30 minutes of MICT on separate days compared with a nonexercise control day (CON). Exercise was undertaken after an overnight fast with omission of short-acting insulin. Capillary blood glucose samples were recorded before and after exercise to assess the acute changes in glycemia during HIT and MICT. Results There was no difference in the incidence of or percentage of time spent in hypoglycemia, hyperglycemia, or target glucose range over the 24-hour and nocturnal period (12:00 am to 6:00 am) between CON, HIT, and MICT (P > 0.05). Blood glucose concentrations were not significantly (P = 0.49) different from pre-exercise to post-exercise, with HIT (0.39 ± 0.42 mmol/L) or MICT (−0.39 ± 0.66 mmol/L). There was no difference between exercise modes (P = 1.00). Conclusions HIT or 30 minutes of MICT can be carried out after an overnight fast with no increased risk of hypoglycemia or hyperglycemia. If the pre-exercise glucose concentration is 7 to 14 mmol/L, no additional carbohydrate ingestion is necessary to undertake these exercises. Because HIT is a time-efficient form of exercise, the efficacy and safety of long-term HIT should now be explored. Fasted high-intensity interval training and moderate-intensity continuous exercise are not associated with a detrimental 24-hour blood glucose profile in people with type 1 diabetes.

Around 80% of individuals with Type 1 diabetes (T1D) in the United States do not achieve glycaemic targets and the prevalence of comorbidities suggests that novel therapeutic strategies, including lifestyle modification, are needed. Current nutrition guidelines suggest a flexible approach to carbohydrate intake matched with intensive insulin therapy. These guidelines are designed to facilitate greater freedom around nutritional choices but they may lead to higher caloric intakes and potentially unhealthy eating patterns that are contributing to the high prevalence of obesity and metabolic syndrome in people with T1D. Low carbohydrate diets (LCD; <130 g/day) may represent a means to improve glycaemic control and metabolic health in people with T1D. Regular recreational exercise or achieving a high level of athletic performance is important for many living with T1D. Research conducted on people without T1D suggests that training with reduced carbohydrate availability (often termed “train low”) enhances metabolic adaptation compared to training with normal or high carbohydrate availability. However, these “train low” practices have not been tested in athletes with T1D. This review aims to investigate the known pros and cons of LCDs as a potentially effective, achievable, and safe therapy to improve glycaemic control and metabolic health in people with T1D. Secondly, we discuss the potential for low, restricted, or periodised carbohydrate diets in athletes with T1D.

Dr. Kushner highlights that our review incorrectly states that the American Diabetes Association (ADA) Standards of Medical Care in Diabetes endorses a specific recommendation for the distribution of calories among carbohydrates, fats, and proteins for people with diabetes. [...]it is important to note that The National Academy of Medicine’s Dietary Reference Intakes still report the Adequate Macronutrient Distribution Range (AMDR) for carbohydrate as 45–65% of energy (http://nationalacademies.org/hmd/~/media/Files/Report%20Files/2019/DRI-Tables-2019/3_RDAAITWM.pdf?la=en). Delahanty, L.M.; Nathan, D.M.; Lachin, J.M.; Hu, F.B.; Cleary, P.A.; Ziegler, G.K.; Wylie-Rosett, J.; Wexler, D.J. Association of diet with glycated hemoglobin during intensive treatment of type 1 diabetes in the Diabetes Control and Complications Trial.