JIMMA UNIVERSITY

SPORT ACADEMY
DEPARTMENT OF SPORT SCIENCE

BASKETBALL COACHING

TERM PAPER –FIRST ROUND

COURSE NAME: COACHING ATHLETES WITH DISABILITY AND STUDY ON

PARALYMPIC SPORTS

COURSE CODE: SPSC 504

TITLE: Diabetes militias and Exercise and sport

BY; ABDETA BIRHANU ASFAW

IDNO: RM 0864/15

SUBMITTED TO: DR.WONDIMAGEGN D.

SUBMISSION DATE: 15/09/2016 E.C.

JIMMA, ETHIOPIA
Table of Contents
INTRODUCTION .............................................................................................................. 1

EXERCISE AND SPORT ................................................................................................... 2

DEFINING THE DISEASE ................................................................................................. 2

Type 1 vs. Type 2 Diabetes ............................................................................................ 2

The Similar Effects of Type 1 vs. Type 2 Diabetes ..................................................... 2

Signs of both type 1 and type 2 diabetes include ...................................................... 2

DIABETES, EXERCISE AND COMPETITIVE SPORTS ...................................................... 3

EVALUATION OF THE PATIENT BEFORE EXERCISE ..................................................... 4

METABOLIC RESPONSES TO ACUTE EXERCISE ............................................................ 4

DIABETES AND EXERCISE .............................................................................................. 4

Moderate-intensity aerobic activity ............................................................................ 4

Resistance training ..................................................................................................... 5

Vigorous aerobic exercise .......................................................................................... 5

RECOMMENDATIONS FOR REDUCED SEDENTARY TIME .............................................. 6

WHAT IS THE OPTIMAL TIME OF DAY FOR EXERCISE? ................................................ 6

What Should Be Done Before Exercise? ..................................................................... 6

What Should Be Done During Exercise? ..................................................................... 7

What Should Be Done After Exercise? ........................................................................ 7

OTHER PRACTICAL CONSIDERATIONS ......................................................................... 8

BLOOD GLUCOSE MANAGEMENT DURING EXERCISE .................................................. 8

CLINICAL SIGNIFICANCE ............................................................................................... 8

Short-Term Effects of Exercise ................................................................................... 8

Long-Term Effects of Exercise.................................................................................... 9

TIPS FOR BETTER PERFORMANCE ................................................................................ 9

SUMMARY ..................................................................................................................... 10

REFERENCES ................................................................................................................ 11

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INTRODUCTION
Diabetes mellitus (DM), a metabolic syndrome consisting of two main groups, type 1 and 2,
is characterized by absolute or relative insulin deficiency or insulin resistance. Individuals
with DM take part in physical activity for health promotion, disease management, and or
recreational or competitive sports. Several studies confirm the beneficial role of physical
activity in favorably altering the prognosis of DM. Exercise as a therapeutic strategy has
potential risks, too. Hence, sports medicine physicians caring for athletes with diabetes have
several important responsibilities. Diabetic education; pre-participatory evaluation for
vascular, neurological, retinal or joint disease; diabetic status and control; promotion of blood
glucose self-monitoring; and individualized dietary, medication, and physical activity plans
are essential to achieve safe and enjoyable outcomes in individuals with diabetes who are
embarking on physical activity.

Diabetes mellitus leads to macro vascular and micro vascular complications, resulting in life-
threatening conditions. Exercise is considered an important therapeutic regimen for diabetes
mellitus. Exercise in patients with diabetes mellitus promotes cardiovascular benefits by
reducing cardiovascular risk and mortality, assists with weight management, and it improves
glycemic control. The increased tissue sensitivity to insulin produces a beneficial effect on
glycemic control.

The adoption and maintenance of physical activity are critical foci for blood glucose
management and overall health in individuals with diabetes and pre diabetes.
Recommendations and precautions vary depending on individual characteristics and health
status. In this Position Statement, we provide a clinically oriented review and evidence based
recommendations regarding physical activity and exercise in people with type 1 diabetes,
type 2 diabetes, gestational diabetes mellitus, and pre diabetes.

Physical activity includes all movement that increases energy use, whereas exercise is
planned, structured physical activity. Exercise improves blood glucose control in type 2
diabetes, reduces cardiovascular risk factors, contributes to weight loss, and improves well-
being. Regular exercise may prevent or delay type 2 diabetes developments. Regular exercise
also has considerable health benefits for people with type 1 diabetes (e.g., improved
cardiovascular fitness, muscle strength, insulin sensitivity, etc. The challenges related to
blood glucose management vary with diabetes type, activity type, and presence of diabetes-
related complications. Physical activity and exercise recommendations, therefore, should be
tailored to meet the specific needs of each individual.

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EXERCISE AND SPORT
Exercise is a planned, structured, and repetitive bodily movement the objective of which is
to improve or maintain physical fitness. Sport is defined as a subset of exercise that can be
under taken individually or as a part of team for the sake of competition.

DEFINING THE DISEASE

Type 1 vs. Type 2 Diabetes
In order to understand diabetes and the Type 1 vs. Type 2 Diabetes, you need to first understand
how your body processes sugar.

Terms to Know

1. Glucose

Our bodies use glucose for energy. Glucose, a type of sugar, comes from two places:

 Food
 The liver

2. Insulin

Insulin, a hormone, helps move glucose from our blood to the cells, which then use the sugar for
energy. Insulin plays a key role. Without insulin, glucose stays in your blood, and you can’t use
that energy.

3. Pancreas

This organ creates the insulin your body needs to get and use glucose.

4. Islet Cells

These cells make insulin in your pancreas. Your pancreas has other functions that can continue,
even if your islet cells fail to create insulin.

The Similar Effects of Type 1 vs. Type 2 Diabetes

Damage to any part of the process that moves glucose from your blood to your cells results in
diabetes.

Signs of both type 1 and type 2 diabetes include:

 Extreme thirst  Fatigue  Irritability

 Hunger  Blurry vision  Increased urination

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  Headaches

People with type 2 diabetes may also experience:

 Frequent or recurring infections  Problems with gums
 Poor wound healing  Itching
 Numbness or tingling in the hands or  Problems having an erection
feet

Dangers of All Types of Diabetes

Untreated diabetes is dangerous. A buildup of glucose in your blood can:

 Hurt vital organs, usually the blood vessels, heart, kidneys, eyes and nerves, causing them
to shut down
 Force your body into ketoacidosis, an imbalance that leads to coma or death, arising
from your body’s attempt to find other forms of energy;

Ketoacidosis symptoms include:

 Vomiting and nausea  Dry skin and mouth

 Abdominal pain  Fruity breath odor
 Dehydration (not enough fluid in the  Rapid pulse
body)  Low blood pressure
 Drowsiness  Coma
 Abnormally deep and fast breathing
Different Causes: Type 1 vs. Type 2 Diabetes

Diabetes type 1 and type 2 come from different causes:

 In diabetes type 1, the pancreas does not make insulin; because the body’s immune
system attacks the islet cells in the pancreas that make insulin.
 In diabetes type 2, the pancreas makes less insulin than used to, and your body becomes
resistant to insulin. This means your body has insulin, but stops being able to use it.

DIABETES, EXERCISE AND COMPETITIVE SPORTS

Regular exercise is highly recommended for many people who have either Type 1 or Type 2
Diabetes Mellitus (DM). People with diabetes must use extra vigilance (pay close attention) in
preparing for exercise because they lack insulin (Type 1 DM) or because the insulin they have is
defective in its ability to stimulate glucose uptake (Type 2 DM).
 If diabetes is untreated, blood sugar rises to dangerously high levels that can eventually
cause blindness, nerve damage, and other complications.
 Blood sugar can be controlled by the appropriate administration of insulin and other
drugs and/or by the manipulation of dietary carbohydrate and exercise.

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  Regular exercise training is usually beneficial for those with diabetes because exercise
can reverse many of the adverse metabolic effects of the disease, including the likelihood
of becoming obese.

Although precautions must be taken, athletes with uncomplicated diabetes (no other serious
diseases) have become champions at elite levels in a wide variety of sports. One of the most
impressive of these athletes is Sir Steven Redgrave, winner of gold medals in rowing for Great
Britain at five successive Olympic Games from 1984 to 2000. He was diagnosed with diabetes
about two years before the Sydney 2000 Olympic Games.

EVALUATION OF THE PATIENT BEFORE EXERCISE

Before increasing usual patterns of physical activity or an exercise program, the individual with
diabetes mellitus should undergo a detailed medical evaluation with appropriate diagnostic
studies. This examination should carefully screen for the presence of macro and micro vascular
complications that may be worsened by the exercise program. Identification of areas of concern
will allow the design of an individualized exercise prescription that can minimize risk to the
patient. Most of the following recommendations are excerpts from The Health Professional’s
Guide to Diabetes and Exercise.
A careful medical history and physical examination should focus on the symptoms and signs of
disease affecting the heart and blood vessels, eyes, kidneys, feet, and nervous system.

METABOLIC RESPONSES TO ACUTE EXERCISE

In contrast to most hormones, concentrations of insulin in the blood decline during exercise in
people without diabetes because less insulin is secreted from the pancreas. Given that skeletal
muscle is quantitatively the most important tissue in the body for glucose uptake, especially
during exercise, and given the fact that insulin is the primary stimulus for glucose uptake into
resting cells, this decline in insulin secretion during exercise at first seems paradoxical. However,
the insulin requirement for glucose uptake diminishes during exercise, because muscle
contractions per se stimulate glucose uptake into muscle even when insulin is absent.

DIABETES AND EXERCISE

Type 1 and type 2 patients with diabetes are encouraged to do 30 to 60 minutes of moderate-
intensity aerobic activity. Patients suffering from diabetes should also be encouraged to perform
resistance training at least twice per week. Patients with moderate to severe proliferative
retinopathy have contraindications for resistance training. Otherwise, for physically fit patients, a
shorter duration of more vigorous aerobic exercise is recommended.

Moderate-intensity aerobic activity:

Aerobic training increases mitochondrial density, insulin sensitivity, oxidative enzymes,
compliance and reactivity of blood vessels, lung function, immune function, and cardiac output.

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Moderate to high volumes of aerobic activity are associated with substantially lower
cardiovascular and overall mortality risks in both type 1 and type 2diabetes.
Perform 30 to 60 minutes of moderate-intensity aerobic activity on most days of the week. Begin
with 10 minutes of stretching and warm-up; follow that with 15 to 20 minutes of aerobic exercise
of person’s choice such as walking, running, swimming, dancing, cycling, or rowing to name
few. Maintain regularity in exercise regimen at least three to five times per week. Continue to
perform exercise at the same time in relation of meals and insulin injections. Gradual increment
in duration and intensity as tolerated by the patient should be planned. Goal is to perform 150
minutes of moderate-intensity aerobic exercise per week.
Examples of moderate-intensity physical activities include:
 Walking briskly.  Swimming.
 Doing housework.  Bicycling.
 Mowing the lawn.  Playing Sports
 Dancing.
Resistance training: The guidelines and principles provided by the American Diabetes
Association and other organizations are primarily based on literature specific to endurance
(aerobic) exercise. In general, people with Type 2 DM who perform chronic resistance exercise
gain the same metabolic and muscle hypertrophy benefits as do no diabetics. This is a major
shortcoming because there is some indication that people with Type 1 DM have higher systolic
and diastolic blood pressures during bicycle and handgrip exercise compared to non-diabetic
control subjects. Heavy exercise of all types, but particularly resistance exercise, increases
arterial pressure to very high levels in people without diabetes. Such high pressures could
damage the blood vessels in the eyes of those with diabetes. Therefore, until resistance exercise
is proven harmless, the person with diabetes who has preexisting retinal damage should avoid
this type of exercise.
Exercise with free weights or weight machines. In the absence of contraindications listed above,
patients should perform resistance training at least twice per week. Patients should involve the
larger group of muscles for exercise training, such as core, upper and lower body.

In summary, the benefits of resistance exercise for people with Type 1 DM are not yet
established. Because of its potential to develop and maintain muscle mass, this form of exercise
should be aggressively studied from a risks/benefit perspective. One might speculate that the
benefits of a correctly designed program of resistance exercise would far exceed the risks to
adequately screened people with Type 1 DM.

Vigorous aerobic exercise: Patients with diabetes who are generally fit, exercising
regularly and have higher aerobic capacity may perform 75 minutes per week of more vigorous
aerobic exercise. The preferable regimen is jogging 9.6 km per hour. An alternative regimen can
be low-volume, high-intensity training, during which patients exercise more vigorously for a
shorter amount of time, such as cycling at 85% to 90% percent of individual maximal heart rate
for 60 seconds, followed by 60 seconds of rest, with a total of 10 repetitions. The long-term
health effects of low-volume, high-intensity training is unknown. Again, as with moderate excise

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regimen, a gradual increment in duration and intensity as tolerated by the patient should be
planned.

RECOMMENDATIONS FOR REDUCED SEDENTARY TIME

Recommendations

 All adults, and particularly those with type 2 diabetes, should decrease the amount of
time spent in daily sedentary behavior.
 Prolonged sitting should be interrupted with bouts of light activity every 30 min for
blood glucose benefits, at least in adults with type 2 diabetes.
 The above two recommendations are additional to, and not a replacement for, increased
structured exercise and incidental movement.

WHAT IS THE OPTIMAL TIME OF DAY FOR EXERCISE?

Disturbances in blood glucose are less likely if exercise is performed in the morning before
breakfast and before the morning administration of insulin. This is because circulating insulin is
low at this time, and if a regular meal was consumed the night before, both liver and muscle
glycogen stores should be filled.

What Should Be Done Before Exercise?

1. Measure blood glucose concentration to determine how well it is under control.
 If blood glucose is <5 mM (90 mg/dl), extra carbohydrate before exercise will
likely be required.
 If blood glucose is 5–15 mM (90–270 mg/dl), extra carbohydrate may not be
required.
 If blood glucose is >15 mM (270 mg/dl), delay exercise and measure urine
ketones.
If urine ketones are negative, exercise can be performed, and extra carbohydrate is not
required.
If urine ketones are positive, take insulin and delay exercise until ketones are negative.

2. Determine the appropriate pre-exercise carbohydrate meal.

Before exercise one can estimate the intensity, duration, and the energy requirement of the
exercise by consulting standard tables. By dividing the estimated calorie requirement by four
(each gram of carbohydrate is equivalent to four calories), the potential carbohydrate
requirement in grams can be predicted. Diabetics should eat or drink an appropriate
carbohydrate-containing snack or meal 1–3 h prior to exercise. Drinks that contain simple
carbohydrates and electrolytes are excellent for helping avoid hypoglycemia and plasma volume
depletion during. Even whole milk, skim milk, and orange juice are better than water alone On
the other hand, meal replacement drinks designed to provide complete supplementation, i.e.,

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carbohydrate, fat and protein, can lead to an inappropriate rise in blood glucose during and after
exercise.

What Should Be Done During Exercise?

 Monitor blood glucose during long exercise sessions. For running, cycling, swimming
and other endurance types of activities, this may require setting a circular course so that
glucose meters are periodically available.
 Always replace fluid losses adequately. The goal should be to replace all or nearly all of
the body weight lost as sweat during the exercise period itself. This weight loss can be
estimated by recording the difference in body weight before and after exercise on prior
occasions.
 If required, use supplemental carbohydrate feedings (an additional 40–50 g for adults,
20–30 g for children) every 60 min during extended periods of moderate intensity
exercise.

What Should Be Done After Exercise?

 Monitor blood glucose, including overnight monitoring if exercise is not habitual and/or
is performed in the late afternoon. Avoid alcohol consumption after exercise because
alcohol diminishes the ability to monitor marked or subtle feelings that would otherwise
alert the person with diabetes to the fact that blood glucose is either too high or too low.
 Adjust insulin administration downward to decrease immediate and delayed actions of
insulin. If required, increase carbohydrate intake for up to 24 hours after activity,
depending on the intensity and duration of exercise (more intense and prolonged exercise
requires more carbohydrate) and the risk-based on prior experience of the occurrence of
low blood glucose. Ingestion of ~1.5 g carbohydrate/kg body weight (0.7 g/lb) soon after
exercise will help restore muscle and liver glycogen after very prolonged or exhausting
exercise. It should be noted, however, that although low blood glucose can occasionally
occur several hours after exercise in diabetics, some insulin is needed late after exercise
to fully restore muscle glycogen levels.
 Ingest the appropriate amount of carbohydrate on a daily basis.
The type of exercise; endurance, sprint, resistance, intensity of exercise; high, medium, low,
and duration of exercise; brief, moderate, prolonged—(or as in most sports some
combination of these) must be considered:
o If aerobic exercise of a moderate intensity is to be undertaken on a daily basis and
usually lasts less than 1 hour, the diabetic athlete should ingest 5–6 g of
carbohydrate/kg body weight on a daily basis.
o If the athlete trains more than 1–2 hours per day, 6–8 g of carbohydrate/kg body
weight may be required daily.

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OTHER PRACTICAL CONSIDERATIONS

Here are some additional tips for the diabetic exerciser:

 Frequent glucose monitoring is obviously essential for safe exercise.

 Carry some form of carbohydrate snack (simple sugars).
 Carry medical identification.
 If convenient, exercise with a friend who knows you have diabetes. Carry a cell phone in
case of a diabetic emergency.
 Invest in good footgear if walking; jogging, and/or running are among your chosen
activities.
 Use extra care to avoid large fluctuations in plasma glucose when exercising in the cold
or heat.

BLOOD GLUCOSE MANAGEMENT DURING EXERCISE

General principles for patients with diabetes mellitus for exercise regimens:
 Maintain a high level of fluid intake before, during, and after exercise
 Maintaining blood sugar logs before, during, and after exercise
 If blood glucose is less than 100 mg/dL, it is recommended to ingest food, such as
glucose tablets, juice. About 15 to 30 grams of quickly absorbed carbohydrate is
recommended to be ingested 15 to 30 minutes before exercise. Extra ingestion of food
may be warranted during exercise based on blood glucose testing during the
exercise. Immediately after excise slowly absorbed carbohydrates such as dried fruit,
granola bars or trail mix are recommended as patients are at risk of late hypoglycemia.
 Vigorous exercise is to be avoided in the presence of substantial hyperglycemia greater
than 250 mg/dl.
 Hypoglycemia is not common in patients with type 2 diabetes not treated with insulin or
oral hypoglycemic. Ingestion of extra carbohydrates is not required.
 Use insulin about 60 to 90 minutes before exercise to prevent increased insulin
absorption along with injecting in a site other than muscle to be exercised. For example,
inject into arms when cycling exercise and into the abdomen when the exercise involves
both the arms and legs.

CLINICAL SIGNIFICANCE

Short-Term Effects of Exercise

Type 2 Diabetes: Exercise leads to an increase in insulin sensitivity. Patients on oral

hypoglycemic have decreased blood glucose concentration after exercise. Studies have suggested

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that patients who were fasting, no change in blood glucose concentrations noted; whereas, blood
concentrations decreased in patients who exercised after eating.
Type 1 Diabetes
 Patients with well-controlled diabetes on insulin regimen: Higher serum insulin
concentration is noted during exercise due to increased temperature and blood flow
leading to increased absorption from subcutaneous depots. Exogenous insulin can’t be
shut off. Hence, these patients have a drop in blood glucose levels much larger than in
normal individuals.
 Patients with diabetes and poor metabolic control: Exercise causes a paradoxical
elevation in blood glucose concentrations

Long-Term Effects of Exercise

Patients have impaired exercise capacity due to generally increased body mass index and
advanced age. Reduced skeletal muscle oxidative capacity due to mitochondrial dysfunction has
been responsible for impaired exercise capacity. Patients are insulin resistant due to many defects
in glucose metabolism.
 Decreased number and function of both insulin receptors and glucose transporters
 Decreased activity of some intracellular enzymes
 Low maximal oxygen uptake during exercise
An exercise program leads to increased activity of mitochondrial enzymes, increased insulin
sensitivity, and muscle capillary recruitment. Adding resistance training to aerobic exercise
provides an additional benefit of increased insulin sensitivity.

TIPS FOR BETTER PERFORMANCE

With proper experience, planning, conditioning, and strategies for managing diet and insulin, the
person with uncomplicated diabetes can engage in any type of exercise at any level of intensity.
The goal is to complete the exercise and recovery period with minimal changes in blood glucose.
For non-obese people with Type 2 diabetes mellitus (insulin is produced by the pancreas but is
ineffective at stimulating glucose uptake from the blood into the cells of the body) who can
control their disease simply with diet and regular exercise, no additional precautions are
required.

The key components of a successful regimen for those with Type 1 diabetes mellitus (no insulin
is produced) are to reduce the amount of insulin administered prior to exercise and/or to
supplement the diet with carbohydrate. While these are seemingly simple strategies, it is the fine-
tuning of these actions that spells success or failure.

Many of the recommendations that follow have been adapted from the publications cited in the
list of suggested additional resources at the end of this supplement.

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SUMMARY
 Physical activity and exercise should be recommended and prescribed to all individuals with
diabetes as part of management of glycemic control and overall health. Specific
recommendations and precautions will vary by the type of diabetes, age, activity done, and
presence of diabetes-related health complications. Recommendations should be tailored to
meet the specific needs of each individual. In addition to engaging in regular physical
activity, all adults should be encouraged to decrease the total amount of daily sedentary time
and to break up sitting time with frequent bouts of activity. Finally, behavior-change
strategies can be used to promote the adoption and maintenance of lifetime physical activity.
People with either Type 1 or Type 2 DM can reach very high levels of athletic performance.
Once they reach this level of accomplishment, they have learned how to coordinate their
carbohydrate and/or insulin administration regimens so that they can compete without severe
changes in blood glucose concentrations. For the recreational or beginning exerciser, there
will be a period of trial-and-error because the ideal quantity and timing of insulinization and
carbohydrate supplementation is highly individualistic.
Better glucose control is gained by reducing the pre-exercise dose of insulin by 50–80%,
depending on the type, duration, and intensity and familiarity of exercise.
The benefits of regular exercise in people with diabetes are similar to those in persons
without the disease—as long as the diabetic is in good glucose control and has no major
complications of the disease. Those benefits outweigh potential problems caused by the
metabolic stress of exercise, providing that proper medical screening has occurred.
Resistance exercise for people with Type 1 DM is becoming popular and is probably
appropriate. However, current recommendations should be based on "best clinical judgment"
because of the absence of data from controlled scientific studies.

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REFERENCES

1. American Diabetes Association (2002). Clinical Practice

Recommendations:2002. Diabetes Care 25 (suppl. 1):S64–S68.
2. Bævre, H., O. Søvik, A. Wisnes, and E. Heiervang (1985). Metabolic responses to
physical training in young insulin-dependent diabetics. Scand. J. Clin. Lab.
Invest. 45:109–114.
3. Campaigne, B.N., T.B. Gilliam, M.L. Spencer, R.M. Lampman, and M.A. Schork (1984).
Effects of a physical activity program on metabolic control and cardiovascular fitness in
children with insulin-dependent diabetes mellitus. Diabetes Care 7:57–62.
4. Eriksson, K., and F. Lindgarde (1991). Prevention of Type 2 (noninsulin dependent
diabetes) diabetes mellitus by diet and physical exercise. Diabetalogia 34:891–898.
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D. LeRoith, S.I. Taylor, and J.M. Olefsky (eds.) Diabetes
Mellitus. Philadelphia:Lippincott-Raven, pp. 395–402.
6. Landt, K.W., B.N. Campaigne, F.W. James, and M.A. Sperling (1985). Effects of
exercise training on insulin sensitivity in adolescents with type I diabetes. Diabetes
Care 8:461–465.
7. Torffvit, O., J. Castenfors, U. Bengtsson, and C.D. Agardh (1987). Exercise stimulation
in insulin-dependent diabetics, normal increase in albuminuria with abnormal blood
pressure response. Scand. J. Lab. Invest. 47:253–259.
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Prevention of Type 2 Diabetes Mellitus by changes in lifestyle among subejcts with
impaired glucose tolerance. N. Eng. J. Med. 344:1343–1350.
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Schneider, and A. Kriska (eds.) Handbook of Exercise in Diabetes. Alexandria,
VA:American Diabetes Association, pp. 463–496.
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diabetes mellitus. Diabetes 28:82–88.
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insulin-dependent diabetes mellitus. Med. Sci. Sports Exerc. 21:356–361.
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(1984). Influence of physical training on formation of muscle capillaries in type I
diabetes. Diabetes 33:851–857.
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physical training in female type1 (insulindependent) diabetic patients: Absence of
significant effect on glycemic control and lipoprotein levels. Diabetologica: 29:53–57.
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and disease. In: N.B. Ruderman, J.T. Devlin, S.H. Schneider, and A. Kriska
(eds.) Handbook of Exercise in Diabetes. Alexandria, VA: American Diabetes
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15. Waxman, S., and R. Nesto (2002). Cardiovascular Complications. In: N.B. Ruderman,
J.T. Devlin, S.H. Schneider, and A. Kriska (eds.) Handbook of Exercise in Diabetes.
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