Can J Diabetes 40 (2016) 503–508

Contents lists available at ScienceDirect

Canadian Journal of Diabetes

journal homepage:
w w w. c a n a d i a n j o u r n a l o f d i a b e t e s . c o m

Original Research

Techniques for Exercise Preparation and Management in Adults with

Type 1 Diabetes
Jordan E. Pinsker MD a, Amy Kraus BS b, Danielle Gianferante PhD b, Benjamen E. Schoenberg BS a,
Satbir K. Singh MD c, Hallie Ortiz d, Eyal Dassau PhD a,e, David Kerr MD a,*
a William Sansum Diabetes Center, Santa Barbara, California, United States
b
Type 1 Diabetes Exchange, Boston, Massachusetts, United States
c Department of Medicine, Santa Barbara Cottage Hospital, Santa Barbara, California, United States
d
University of California Santa Barbara, Santa Barbara, California, United States
e Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts, United States

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: People with type 1 diabetes are at risk for early- and late-onset hypoglycemia following exer-
Received 1 February 2016
cise. Reducing this risk may be possible with strategic modifications in carbohydrate intake and insulin
Received in revised form
use. We examined the exercise preparations and management techniques used by individuals with type 1
15 March 2016
Accepted 9 April 2016 diabetes before and after physical activity and sought to determine whether use of differing diabetes tech-
nologies affects these health-related behaviours.
Methods: We studied 502 adults from the Type 1 Diabetes Exchange’s online patient community, Glu, who
Keywords:
continuous glucose monitoring had completed an online survey focused on diabetes self-management and exercise.
exercise Results: Many respondents reported increasing carbohydrate intake before (79%) and after (66%) exer-
hypoglycemia cise as well as decreasing their meal boluses before (53%) and after (46%) exercise. Most reported adher-
technology ing to a target glucose level before starting exercise (77%). Despite these accommodations, the majority
type 1 diabetes reported low blood glucose (BG) levels after exercise (70%). The majority of users of both insulin pump
therapy (CSII) and continuous glucose monitoring (CGM) (Combined) reported reducing basal insulin around
exercise (55%), with fewer participants adjusting basal insulin when using other devices (SMBG only = 20%;
CGM = 34%; CSII = 42%; p<0.001). However, CSII and Combined users reported that exercise makes their
BG levels harder to control (p<0.05) and makes them feel less able to predict their BG levels while exer-
cising (p<0.001); they show agreement that fear of low BG levels keeps them from exercising (p<0.01).
Conclusions: These findings highlight the need for exercise-management strategies tailored to individu-
als’ overall diabetes management, for despite making exercise-specific adjustments for care, many people
with type 1 diabetes still report significant difficulties with BG control when it comes to exercise.
© 2016 Canadian Diabetes Association.

r é s u m é
Mots clés :
Objectifs : Les personnes atteintes de diabète de type 1 sont à risque de développer une hypoglycémie
exercice physique
hypoglycémie
avec un déclenchement précoce et tardif après l’exercice. La réduction de ce risque peut être possible
technologie par des modifications stratégiques dans l’apport en glucides et dans l’usage de l’insuline. Nous avons examiné
diabète de type 1 les préparatifs de l’exercice et les techniques de gestion utilisées par les individus atteints de diabète de
type 1 avant et après l’activité physique, et avons cherché à déterminer si l’utilisation de différentes tech-
niques de traitement du diabète affecte ces comportements liés à la santé.
Méthodes : Nous avons étudié 502 adultes issus de la communauté d’échange en ligne de patients atteints
de diabète de type 1, Glu, qui avaient complété un sondage en ligne axé sur l’autogestion du diabète et
l’exercice.
Résultats : De nombreux répondants ont rapporté augmenter l’apport en glucides avant (79%) et après
(66%) l’exercice, et aussi réduire leurs bols alimentaires avant (53%) et après (46%) l’exercice. La plupart
ont rapporté se baser sur un niveau cible de glucose avant de commencer l’exercice (77%). En dépit de
ces ajustements, la majorité a rapporté de faibles taux de glucose sanguin (BG) après l’exercice (70%). La

* Address for correspondence: David Kerr, MD, William Sansum Diabetes Center, 2219 Bath Street, Santa Barbara, California 93105, United States.
E-mail address: dkerr@sansum.org

1499-2671 © 2016 Canadian Diabetes Association.

http://dx.doi.org/10.1016/j.jcjd.2016.04.010
504 J.E. Pinsker et al. / Can J Diabetes 40 (2016) 503–508

majorité des utilisateurs à la fois de la thérapie par pompe à insuline (CSII) et de la surveillance con-
tinue du glucose (CGM) (Combiné) a rapporté réduire l’insuline basale jouxtant l’exercice (55%), avec moins
de participants ajustant l’insuline basale lors de l’utilisation d’autres appareils (autosurveillance de la glycémie
(SMBG) seulement=20%; CGM=34%; CSII=42%; p<0,001). Cependant, les utilisateurs de la CSII et les
utilisateurs combinés ont rapporté que l’exercice rend leurs niveaux de glycémie plus difficiles à contrôler
(p<0,05), et les fait se sentir moins capables de prédire leurs niveaux de glycémie pendant l’exercice
(p<0,001); ils se montrent d’accord sur le fait qu’une crainte de niveaux faibles de glycémie les empêchent
de faire de l’exercice (p<0,01).
Conclusions : Ces résultats mettent en évidence la nécessité de développer des stratégies de gestion de
l’exercice ajustées à la gestion d’ensemble du diabète des individualités, car malgré des ajustements
spécifiques à l’exercice dans un but curatif, beaucoup de personnes avec un diabète de type 1 rapportent
encore des difficultés importantes dans le contrôle de la glycémie pour ce qui a trait à l’activité physique.
© 2016 Canadian Diabetes Association.

Introduction usually consume carbohydrates before planned physical activity.

Regular exercise has numerous physiologic and psychological
benefits for people of all ages who are living with type 1 diabetes
(1) and currently, the American Diabetes Association recom-
mends physical activity as part of managing all forms of diabetes
(2). Despite these recommendations, however, most adults with
type 1 diabetes participate less frequently in physical activity than
people without diabetes (3). Although the reasons for this are mul-
tifactorial, including low fitness levels, the overriding barrier to par-
ticipating in exercise for individuals with type 1 diabetes appears
to be fear of severe hypoglycemia coupled with a lack of knowl-
edge of effective strategies for hypoglycemia avoidance (4).
The impact of exercise on blood glucose (BG) levels in type 1
diabetes is influenced by the type and intensity of the activity, with
aerobic activities associated with a greater risk for hypoglycemia
than anaerobic activities (5–10). Duration of physical activity also
has an impact, with longer periods of exercise increasing the risk
for hypoglycemia. Therefore, for individuals with type 1 diabetes
interested in participating in exercise, there is an unmet need to
understand the risks, benefits and potential consequences associ-
ated with sustained physical activity and also to develop strate-
gies to minimize their personal risks for hypo- or hyperglycemia.
Recommendations include modifying rates of basal insulin, chang-
ing the dose of rapid-acting mealtime insulin before and after exer-
cise, consuming additional carbohydrates and using continuous
glucose monitoring (CGM) to monitor glucose levels more closely
than can be achieved by fingerstick alone (1,11–13).
The aim of this study was to identify the current strategies that
free-living adults with type 1 diabetes use to prepare, monitor and
adjust their diabetes management regimens before, during and after
physical activity and to determine how overall diabetes manage-
ment of physical activity may be influenced by the use of differing
diabetes-related technologies for glucose monitoring and insulin
delivery.
Methods
Information concerning the intensity and duration of exercise under-
taken by subjects was also captured.
Study procedure
Participants were recruited from the Type 1 Diabetes Exchange’s
online patient community, Glu (myGlu.org). Registered Glu users
who indicated preferences to be contacted about research oppor-
tunities were informed of the study through e-mail, a listing on the
Glu website or social media channels (Facebook and Twitter). Par-
ticipants were required to be 18 years of age or older and to have
self-reported diagnoses of type 1 diabetes. Prior to participating in
the study, each participant provided informed consent. All study
materials were approved by the Institutional Review Board at the
Jaeb Center for Health Research (Tampa, Florida, USA). Partici-
pants received no compensation for taking part in the study. Study
participants completed an online questionnaire that included ques-
tions related to their diabetes histories, exercise regimens, diabe-
tes management before, during and after exercise, diabetes
management for different types of exercise, and feelings about the
impact of exercise and the latest technologies on their glycemic
control. Data verification and quality assessments were per-
formed to ensure completeness and accuracy of the dataset. At least
50% of the survey items required valid responses so as to include
the participants’ data in the final analysis.
Statistical analysis
Data were analyzed using SPSS 23 Statistical Software (IBM,
Chicago, Illinois, USA). All scale data were tested for normality prior
to analyses by using Kolmogorov-Smirnov and Shapiro-Wilks tests
in addition to Q-Q plots. No transformations of the data were
required. Descriptive analyses included means, standard devia-
tions and cross-tabulations of multiple categoric variables. When
appropriate, we computed 1-way analyses of variance (ANOVA) and
chi-square values to evaluate group differences. For significance
testing, the alpha was set at 0.05.

We conducted an online survey of individuals with type 1 dia-

betes that assessed exercise-management techniques and evalu-
ated how these techniques vary depending on the technologies relied
upon for diabetes management. These technologies included use
of 1) CGM without continuous subcutaneous insulin infusion (CSII);
2) CSII without CGM; 3) CSII and CGM together (Combined) or 4)
fingerstick self-monitoring of blood glucose (SMBG) only (without
CSII or CGM). The survey also focused on target BG levels before
and after exercise; whether there were BG levels for which indi-
viduals with type 1 diabetes wait to attain before participating in
exercise; and whether exercise causes changes in BG levels and when
these changes occur. This survey also contained questions focused
on a priori adjustments in insulin dosages and whether participants
Results
Participant characteristics, device uses and exercise behaviours
The 85-item survey (Supplement) was available on Glu for
23 days. Individual items were optional (participants were permitted
to skip an item and go forward). A total of 502 Glu users com-
pleted at least 70% of the survey and were included in the analy-
sis. Of this sample, 68% were women, and the mean age was
42.4±15.3 years (range, 18 to 82 years). For further analysis, par-
ticipants were divided into groups based on which devices they cur-
rently used to manage their type 1 diabetes: SMBG only (n=81); CSII
 J.E. Pinsker et al. / Can J Diabetes 40 (2016) 503–508 505

Table 1 Table 2
Demographics and exercise behaviour by device use group Preparing for exercise: Carbohydrate intake

Group demographics SMBG only CSII CGM Com Do you consume extra carbs SMBG only CSII CGM Com
before exercise? (n=81) (n=145) (n=32) (n=244)
n 81 145 32 244
% of women 62 74 53 70 Yes 19.8% 18.6% 18.8% 23.0%
Mean age (years) 41.9±16.7 43.7±16.4 45.2±15.6 41.4±16.5 No 22.2% 24.1% 21.9% 17.6%
Age range (years) 18–82 18–78 23–77 18–79 Sometimes 56.8% 53.8% 59.4% 58.6%
Mean years since diagnosis 19.2±17.2 25.3±16.3 24.3±16.2 22.8±14.7 Not applicable 0.0% 1.4% 0.0% 0.0%
Years since diagnosis range 0–61 1–69 1–58 0–70 Do you consume extra carbs
What type of exercise do during exercise?
you do most often? Yes 7.4% 9.7% 9.4% 11.5%
Low intensity 13.6% 22.1% 18.8% 14.8% No 51.9% 41.4% 31.3% 34.0%
Moderate intensity 45.7% 54.5% 43.8% 53.7% Sometimes 40.7% 46.2% 59.4% 52.5%
High intensity 35.8% 20.0% 34.4% 30.7% Not applicable 0.0% 1.4% 0.0% 0.4%
What is your usual Do you consume extra carbs
duration of exercise? after exercise?
0–15 minutes 2.5% 3.4% 6.3% 2.5% Yes 9.9% 16.6% 9.4% 11.9%
16–30 minutes 16.0% 17.2% 25.0% 15.6% No 33.3% 25.5% 21.9% 36.9%
31–45 minutes 25.9% 29.7% 12.5% 32.8% Sometimes 45.0% 52.4% 68.8% 48.4%
46–60 minutes 27.2% 30.3% 37.5% 27.5% Not applicable 1.2% 1.4% 0.0% 0.4%
61–75 minutes 18.5% 7.6% 3.1% 13.5%
Com, combination of CSII and CGM.
75–90 minutes 0% 6.2% 3.1% 5.3%
More than 90 minutes 8.6% 3.4% 12.5% 2.9%
On average, how many
times do you exercise
per week?
0 0% 2.8% 0% 1.6%
1 0% 5.5% 3.1% 5.3%
2 9.9% 9.7% 0% 16.8%
3 21.0% 30.3% 40.6% 26.6%
4 17.3% 21.4% 6.3% 16.8%
5 21.0% 13.1% 28.1% 16%
6 12.3% 7.6% 6.3% 8.2%
7 9.9% 4.1% 9.4% 5.7%
7+ 9.9% 4.1% 6.3% 2.9%
Com, combination of CSII and CGM.

without CGM (n=145); CGM alone (n=32); and a combination of CSII

and CGM together (Combined) (n=244) (Table 1).
There were no significant differences in body mass index or age
among users of differing devices (p=NS), although CSII, CGM and
Combined-device users tended to have had longer durations of dia-
betes than those who did not use these devices (all p<0.05) (Table 1).
ANOVA tests revealed a significant difference in exercise fre-
quency (days per week engaging in exercise) between device-
using groups (p<0.001). Post hoc multiple comparisons revealed that
CSII users, with and without CGM, exercised less (3.8±1.6 days/
week) than those who did not use CSII (4.54±1.6 days/week;
p<0.001).
Device use and glucose management related to exercise
The majority (74%) of participants reported that their BG levels
were generally lower after exercise, although a smaller propor-
tion (13%) reported that their levels were usually higher after exer-
cise. Approximately 13% reported that their BG levels were similar
before and after exercise. CGM and Combined users were more likely
to report lower glucose values after exercise (75%) as compared to
CSII users (67.6%) and SMBG-only users (56.8%) (p<0.05). When asked
about exercise intensity, the majority of respondents (52%) reported
that they usually perform moderate-intensity exercise.
Most survey participants reported always or sometimes con-
suming extra carbohydrates before (77.9%), during (59.4%) or after
exercise (64.7%). There was no difference in carbohydrate consump-
tion among users of various devices, either before, during or after
physical activity (p = ns) (Table 2).
The survey specifically asked participants about their usual target
pre-exercise BG levels as well as their preferred range of glucose
levels prior to exercise. The mean target pre-exercise BG was
140±27 mg/dL (range = 100 to 260) (7.8±1.5 mmol/L, range 5.6 to
Figure 1. Percent of respondents who adjust basal insulin rates for exercise (always
or sometimes), categorized by device-use group. Com, combination of CSII and CGM;
CGM, continuous glucose monitoring; CSII, continuous subcutaneous insulin infu-
sion; SMBG, self-monitoring blood glucose.
14.4). of respondents 77% reported that they delay the start of exer-
cise if their BG levels are below a certain level, with a mean of
97±24 mg/dL (range = 70 to 200) (5.4±1.4 mmol/L, range 3.9 to 11.1).
Approximately 50% of respondents reported that they delay the start
of exercise if their BG levels are above a certain level, with a mean
of 210±61 mg/dL (range = 100 to 300) (11.7±3.4 mmol/L, range 5.6
to 16.7).
There was no significant difference among device-use groups in
whether or not they had such BG target ranges or what their target
ranges were among those who reported having target ranges. There
was a significant relationship between device-use groups and
whether respondents reported having BG targets above which they
wait to exercise, with one-third of participants using only SMBG
without CSII or CGM having such a target, compared to 56% of CSII
users, 53% of CGM-only users and 53% of Combined users (p<0.01).
The Combined group also reported more frequently that their BG
responses after exercise varied with time of day (45.9%) vs. those
who did not use any devices (36%); those using just CGMs (37.5%);
and those using CSII alone (30%) (p<0.05).
When adjusting insulin doses in preparation for exercise, those
who used any of the other technologies (CSII, CGM or Combined)
more frequently described making basal insulin adjustments (48.9%)
compared to those who used only SMBG (19.7%) (p<0.001) (Figure 1).
However, the timing of basal insulin adjustment in relation to exer-
cise differed; those who used only SMBG or CGM alone more often
506 J.E. Pinsker et al. / Can J Diabetes 40 (2016) 503–508

Table 3 Table 4
Preparing for exercise: Basal insulin adjustments Preparing for exercise: Fast-acting insulin adjustments

Do you make changes to your basal SMBG only CSII CGM Com* Do you adjust the amount of SMBG only CSII CGM Com
long-acting insulin for exercise? (n=81) (n=145) (n=32) (n=244) fast-acting insulin you take for (n=81) (n=139) (n=32) (n=239)
the meal before exercise?
Yes 10% 19% 25% 33%
No 74% 36% 63% 24% No 42.0% 44.6% 31.3% 35.1%
Sometimes 10% 26% 9% 24% Not applicable 9.9% 6.5% 6.3% 2.5%
Not applicable 6% 19% 3% 19% Sometimes 16.0% 22.3% 12.5% 26.4%
If yes, when do you make the (n=16) (n=60) (n=11) (n=134) Yes 32.1% 26.6% 50.0% 36.0%
basal rate changes? How do you adjust the amount (n=38) (n=68) (n=19) (n=149)
Day before exercise 19% 0% 45% 4% of fast-acting insulin for the
Day of exercise 38% 75% 36% 69% meal before exercise?
Night after exercise 38% 8% 18% 9% Increase amount 0.0% 0.0% 0.0% 2.7%
Day after exercise 6% 2% 0% 4% Decrease amount 97.0% 95.6% 100.0% 90.6%
Other 0% 17% 0% 13% Other 3.0% 5.0% 0.0% 6.4%
How do you adjust the amount (n=16) (n=60) (n=11) (n=134) Do you adjust the amount of (n=81) (n=139) (n=32) (n=239)
of basal insulin for exercise? fast-acting insulin you take
Decrease amount 88% 88% 82% 95% for the meal after exercise?
Increase amount 6% 3% 0% 1% No 45.7% 60.9% 25.8% 48.3%
Other 6% 8% 18% 4% Not applicable 4.9% 7.2% 3.2% 1.3%
If you use a pump to adjust basal CSII Com Sometimes 30.9% 21.7% 32.3% 31.1%
insulin, by how much do you (n=60) (n=134) Yes 18.5% 10.1% 38.7% 19.3%
adjust it? How do you adjust the amount (n=38) (n=44) (n=21) (n=120)
10% 5% 5% of fast-acting insulin for the
100% 8% 10% meal after exercise?
20% 18% 15% Increase amount 0% 5% 0% 10.0%
30% 13% 8% Decrease amount 89.5% 86.4% 90.5% 80.0%
40% 8% 6% Other 10.5% 8.6% 9.5% 10.0%
50% 22% 34%
Com, combination of CSII and CGM; CGM, continuous glucose monitoring; CSII, con-
60% 0% 4%
tinuous subcutaneous insulin infusion; SMBG, self-monitoring blood glucose.
70% 3% 6%
80% 7% 4%
90% 4% 5%
Less than 10% 7% 2%
Unsure 5% 2%
CGM, continuous glucose monitoring; Com, combination of CSII and CGM; CSII, con-
tinuous subcutaneous insulin infusion; SMBG, self-monitoring blood glucose.

changed basal insulin doses the night before and the night after exer-
cise, compared to the CSII or Combined groups, who were more likely
to change their basal insulin infusion rates the day of exercise, with
a 50% adjustment being the most common alteration (Table 3).
Adjustments of rapid-acting insulin boluses for meals before or
after exercise were similar in all groups. In general, 50% of respon-
dents reported sometimes or often reducing meal boluses before
and after exercise (Table 4).

Device use and attitudes toward exercise

These items were answered on a 5-point Likert scale, with options
ranging from strongly agree to strongly disagree. Responses were
coded from −2 to +2, with the choice “neutral” assigned a value of
0. ANOVA tests revealed significant differences among device-use
groups for the item “Exercise makes my BG levels harder to control”
(p=0.038). CSII and Combined users were more likely to agree with
this comment than were those who used SMBG only or CGM alone
(Figure 2).
Similarly, there was a significant difference among all 4 groups
for the item “I can usually predict my BG levels during exercise”
(p<0.001); non-CSII users (with and without CGMs) reported that
their levels were more unpredictable with exercise compared to the
reports of those who used insulin pumps.
The item “Fear of low BG levels keeps me from exercising” also
showed among-groups differences (p<0.01), with pump users’ (with
and without CGMs) being more likely to disagree, than those who
did not use any devices and those who used SMBG only and CGM
alone (Figure 2).
Discussion
The purpose of this study was to examine exercise preparation
and management techniques by individuals living with type 1
Figure 2. Differences in device use groups in negative attitudes toward exercise.
CGM, continuous glucose monitoring; CSII, continuous subcutaneous insulin infu-
sion; SMBG, self-monitoring blood glucose.
diabetes and to determine how use of differing diabetes technolo-
gies may affect health-related behaviours in relation to exercise. In
general, our findings suggest that individuals with type 1 diabetes
are well aware of the risk for hypoglycemia during physical activ-
ity, immediately after physical activity and overnight 7 to 11 hours
later (14), as well as understanding the potential for hyperglyce-
mia with exercise. The majority of participants adjusted carbohy-
drate intake or insulin dosing to account for these glucose changes.
A prior study showed that compared to individuals using mul-
tiple daily injections of insulin, insulin pump users who per-
formed regular moderate- to heavy-intensity physical activity
experienced better BG control postexercise, but differences in hypo-
glycemia between groups were not reported (15). Thus, technol-
ogy use may be an important differentiating factor in how individuals
with type 1 diabetes handle exercise management.
A major goal of the study was to determine how users of various
devices use diabetes-related technologies to adjust their diabetes
regimens for exercise, as compared to existing clinical guidelines.
For example, the International Society for Pediatric and Adoles-
cent Diabetes recommends setting a temporary basal rate 90 minutes
 J.E. Pinsker et al. / Can J Diabetes 40 (2016) 503–508
before activity, with a 50% reduction in insulin dosing, lasting until
the end of exercise (16). Further tuning of the basal rate reduction
can occur based on personal experience (17). The same guidance
is given by the Canadian Diabetes Association (18). These same
guidelines recommend an afternoon and bedtime basal insulin
reduction by 10% to 20% after an afternoon or evening exercise
session if the exercise has been more intense than usual or if an
activity is not performed regularly (16). The majority of partici-
pants followed guidelines that advocate consuming extra carbo-
hydrates before, during or after exercise, 45% of those using CSII and
53% of those using a combination of CSII and CGM reported adjust-
ing basal insulin around the time of exercise, consistent with fea-
tures of the technology that allow this (such as using a temporary
basal rate or disconnecting the pump). The most common adjust-
ment to insulin pump dosing was to reduce basal insulin by 50%
around the time of exercise, with the second most common strat-
egy being a 20% reduction, presumably after exercise and into the
evening (Table 3).
When considering exercise preparation, the American Diabe-
tes Association recommends consuming additional carbohydrates
if glucose levels are <100 mg/dL (<5.6 mmol/L) (19); to avoid physi-
cal activity if fasting glucose levels are >250 mg/dL (13.9 mmol/L)
and ketones are present; and to be cautious if glucose levels are
>300 mg/dL (>16.7 mmol/L) and no ketones are present (19). Our
findings demonstrated that respondents were generally following
this guidance, with the majority reporting that they had BG targets
below which they wait to exercise, averaging 97 mg/dL (range 70
to 200 mg/dL) (5.3 mmol/L, range 3.9 to 11.1 mmol/L). About half
of all respondents reported they had BG targets above which they
would wait before exercising, averaging 200 mg/dL (11.1 mmol/L).
We sought to determine whether users of diabetes technology,
particularly insulin pumps and CGM, show different preparation and
management techniques related to exercise in type 1 diabetes. We
found that although users of CSII and CGM were more aware of
hypoglycemia during and after exercise, giving a higher rating to
the questions “Exercise makes my BG levels harder to control and
Fear of low BG levels keeps me from exercising and giving a lower
rating to I can usually predict my BG levels during exercise”, the
only significant difference in insulin adjustment around the time
of exercise was CSII and Combined users’ reducing basal insulin, most
commonly a 50% reduction. Changes in rapid-acting insulin dosing
for the meal before exercise was performed about 50% to 75% of
the time, with no significant differences seen among device-use
groups despite extensive published guidance concerning strate-
gies to reduce pre-exercise bolus doses (17,18,20,21). A significant
number of participants reduced meal boluses after exercise, and the
majority in all groups reported adjusting carbohydrate intake before,
during and after exercise. Also of interest, CGM users reported higher
rates of hypoglycemia after exercise but reported no differences in
exercise preparation and management techniques. This may reflect
a greater awareness of BG levels after exercise due to CGM use.
Our results suggest that CSII and Combined users often take the
most advantage of their diabetes-related technologies to make
adjustments for exercise under free-living conditions. However, CSII
users (with or without CGM) reported that exercise makes their BG
levels harder to control compared to others, feel less like they can
predict their BG levels while exercising, and show more agree-
ment that fear of low BG keeps them from exercising. Those who
used CGM (with or without CSII) reported the greatest incidence
of hypoglycemia after exercise. We suspect that many of the par-
ticipants in the survey experience postexercise hypoglycemia, but
only those using CGM had a greater awareness of these changes in
BG levels, consistent with other studies showing high incidences
of hypoglycemia with exercise when CGM was used (22).
Future technology advancements such as automated glucose
control (the artificial pancreas) (AP) are designed to provide superior
507
ability to manage glucose variability with limited to no user inter-
action. These new devices revolutionize insulin delivery from the
current basal-bolus strategy to microboluses every 5 to 15 minutes.
With the ability to predict future glucose changes in some of the
more sophisticated designs, the AP will provide a better method
of improving care around exercise, attenuating insulin delivery
during exercise to prevent pending hypoglycemia (23). Second gen-
erations of AP devices will most likely include some additional
sensors that can detect the onset and end of the exercise session
so as to modify the AP behaviour during exercise and in the hours
after exercise (24). Technology has the potential not only allow to
better and improved glucose management with less glucose vari-
ability but also to reduce the need for patients to spend hours man-
aging their diabetes.
One limitation of this study relates to the distribution of advanced
diabetes technology (e.g. CSII and CGM) in our sample popula-
tion, which included 390 (78.2%) CSII users and 276 (55.2%) CGM
users. Although the study sample was representative of the Glu com-
munity in general, studies of larger patient populations, such as the
Type 1 Diabetes Exchange Clinic Registry, estimate that approxi-
mately 63% of adults with type 1 diabetes use insulin pumps and
21% use CGM technology to manage their diabetes (25,26). We also
acknowledge that our survey was not previously validated, so we
were unable to conduct an analysis of reliability or analyze subscales.
However, because this was largely an exploratory analysis of exer-
cise preparation and technology use by people with type 1 diabe-
tes and was so specific, there are no existing validated measures
for this topic.
Taken together, our findings indicate that although most respon-
dents adjusted carbohydrate intake and insulin use around exer-
cise, the majority still reported experiencing hypoglycemia after
exercise. This highlights the need for exercise-management strat-
egies tailored to individuals’ overall diabetes management, for despite
making exercise-specific adjustments to care, many people with
type 1 diabetes still report significant difficulties with BG control
around exercise.
Authors’ Contributions
JEP, AK, DEG, BES, SKS and ED authored, edited and reviewed
the manuscript; DEG and HO performed statistical analysis for the
manuscript; DK edited and reviewed the manuscript, was the prin-
cipal investigator of this project and is the guarantor of this work;
as such, DK had full access to all the data in the study and takes
responsibility for the integrity of the data and the accuracy of the
data analysis.
Acknowledgments
We acknowledge Type 1 Diabetes Exchange, a program of Unitio,
Inc., for supporting this study, and we thank the Glu community
for their participation.
References
1. Colberg SR, Laan R, Dassau E, Kerr D. Physical activity and type 1 diabetes: Time
for a rewire? J Diabetes Sci Technol 2015;9:609–18.
2. American Diabetes Association. 4 Foundations of care: Education, nutrition, physi-
cal activity, smoking cessation, psychosocial care, and immunization. Diabetes
Care 2015;38(Suppl 1):S20–30.
3. Leroux C, Brazeau AS, Gingras V, et al. Lifestyle and cardiometabolic risk in adults
with type 1 diabetes: A review. Can J Diabetes 2014;38:62–9.
4. Brazeau AS, Rabasa-Lhoret R, Strychar I, Mircescu H. Barriers to physical activ-
ity among patients with type 1 diabetes. Diabetes Care 2008;31:2108–9.
508 J.E. Pinsker et al. / Can J Diabetes 40 (2016) 503–508
5. Yardley JE, Kenny GP, Perkins BA, et al. Resistance versus aerobic exercise: Acute
effects on glycemia in type 1 diabetes. Diabetes Care 2013;36:537–42.
6. Iscoe KE, Riddell MC. Continuous moderate-intensity exercise with or without
intermittent high-intensity work: Effects on acute and late glycaemia in ath-
letes with type 1 diabetes mellitus. Diabet Med 2011;28:824–32.
7. Guelfi KJ, Ratnam N, Smythe GA, et al. Effect of intermittent high-intensity com-
pared with continuous moderate exercise on glucose production and utiliza-
tion in individuals with type 1 diabetes. Am J Physiol Endocrinol Metab
2007;292:E865–70.
8. Guelfi KJ, Jones TW, Fournier PA. New insights into managing the risk of
hypoglycaemia associated with intermittent high-intensity exercise in indi-
viduals with type 1 diabetes mellitus: Implications for existing guidelines. Sports
Med 2007;37:937–46.
9. Guelfi KJ, Jones TW, Fournier PA. The decline in blood glucose levels is less with
intermittent high-intensity compared with moderate exercise in individuals with
type 1 diabetes. Diabetes Care 2005;28:1289–94.
10. Guelfi KJ, Jones TW, Fournier PA. Intermittent high-intensity exercise does not
increase the risk of early postexercise hypoglycemia in individuals with type 1
diabetes. Diabetes Care 2005;28:416–18.
11. Franc S, Daoudi A, Pochat A, et al. Insulin-based strategies to prevent
hypoglycaemia during and after exercise in adult patients with type 1 diabe-
tes on pump therapy: The DIABRASPORT randomized study. Diabetes Obes Metab
2015;17:1150–7.
12. Campbell MD, Walker M, Trenell MI, et al. Large pre- and postexercise rapid-
acting insulin reductions preserve glycemia and prevent early- but not
late-onset hypoglycemia in patients with type 1 diabetes. Diabetes Care
2013;36:2217–24.
13. Franc S, Dardari D, Biedzinski M, et al. Type 1 diabetes: Dealing with physical
activity. Diabetes Metab 2012;38:466–9.
14. McMahon SK, Ferreira LD, Ratnam N, et al. 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;92:963–8.
15. Yardley JE, Iscoe KE, Sigal RJ, et al. Insulin pump therapy is associated with less
post-exercise hyperglycemia than multiple daily injections: An observational
study of physically active type 1 diabetes patients. Diabetes Technol Ther
2013;15:84–8.
16. Robertson K, Riddell MC, Guinhouya BC, et al. ISPAD Clinical Practice Consen-
sus Guidelines 2014. Exercise in children and adolescents with diabetes. Pediatr
Diabetes 2014;15(Suppl 20):203–23.
17. Perkins BA, Riddell MC. Type 1 diabetes and exercise: Using the insulin pump
to maximum advantage. Can J Diabetes 2006;30:72–9.
18. Sigal RJ, Armstrong MJ, Colby P, et al. Physical activity and diabetes. Can J Dia-
betes 2013;37(Suppl 1):S40–4.
19. American Diabetes Association. Physical activity/exercise and diabetes. Diabe-
tes Care 2004;27(Suppl 1):S58–62.
20. Perry E, Gallen I. Guidelines on the current best practice for the management
of type 1 diabetes, sport and exercise. Pract Diabetes Int 2009;26:116–
23.
21. Chu L, Hamilton J, Riddell MC. Clinical management of the physically active patient
with type 1 diabetes. Phys Sportsmed 2011;39:64–77.
22. Wilson DM, Calhoun PM, Maahs DM, et al. Factors associated with nocturnal
hypoglycemia in at-risk adolescents and young adults with type 1 diabetes. Dia-
betes Technol Ther 2015;17:385–91.
23. Dassau E, Brown SA, Basu A, et al. Adjustment of open-loop settings to improve
closed-loop results in type 1 diabetes: A multicenter randomized trial. J Clin
Endocrinol Metab 2015;100:3878–86.
24. Dasanayake IS, Bevier WC, Castorino K, et al. Early detection of physical activ-
ity for people with type 1 diabetes mellitus. J Diabetes Sci Technol 2015;9:1236–
45.
25. Miller KM, Foster NC, Beck RW, et al. Current state of type 1 diabetes treat-
ment in the U.S.: Updated data from the type 1 diabetes exchange clinic reg-
istry. Diabetes Care 2015;38:971–8.
26. Wong JC, Foster NC, Maahs DM, et al. Real-time continuous glucose monitor-
ing among participants in the type 1 diabetes exchange clinic registry. Diabe-
tes Care 2014;37:2702–9.