Pittsburgh Insulin-Dependent Diabetes Mellitus Morbidity and Mortality Study: physical activity and diabetic complications

The long-term health consequences of chronic physical activity for patients with type I diabetes are unknown. In the current study, the association of physical activity to diabetic complications was assessed in 696 type I diabetic individuals diagnosed between 1950 and 1964. Participation in team sports in high school or college was not associated with a decreased prevalence of severe retinopathy or blindness later in life. There was, however, a suggestion of a negative association between physical activity and both cardiovascular disease and overall mortality, ie, individuals who participated in team sports were somewhat less likely to report macrovascular disease at follow-up or to have died than nonparticipants. The relationship between physical activity and diabetic complications only appeared in male subjects. The results suggest that activity early in life by patients with type I diabetes does not appear to be associated with an adverse health effect and may, in fact, be beneficial.     

The health benefits of physical activity in children and adolescents: implications for chronic disease prevention

Clinical, epidemiological and basic research evidence clearly supports the inclusion of regular physical activity as a tool for the prevention of chronic disease and the enhancement of overall health. In children, activities of a moderate intensity may enhance overall health, and assist in preventing chronic disease in at-risk youth. The numerous health benefits of regular exercise are dependent on the type, intensity and volume of activity pursued by the individual. These benefits include reduction of low density lipoproteins while increasing high density lipoprotein; improvement of glucose metabolism in patients with type II diabetes; improved strength, self esteem and body image; and reduction in the occurrence of back injuries. In addition, a progressive, moderate-intensity exercise program will not adversely effect the immune system and may have a beneficial effect on the interleukin-2/natural killer cell system. Furthermore, by decreasing sedentary behaviors and, thus, increasing daily physical activity, individuals may experience many stress-reducing benefits, which may enhance the immune system. Conclusion Moderate intensity exercise of a non-structured nature seems to facilitate most of the disease prevention goals and health promoting benefits. With new guidelines promoting a less intense and more time-efficient approach to regular physical activity, it is hoped that an upward trend in the physical activity patterns, and specifically children at risk for chronic disease, will develop in the near future. Received: 25 November 1998 / Accepted: 25 November 1998     

Current perspectives on physical activity and exercise for youth with diabetes

Regular physical activity (PA) for youth with diabetes improves cardiorespiratory fitness, body composition, bone health, insulin sensitivity, and psychosocial well‐being. However many youth with diabetes or pre‐diabetes fail to meet minimum PA guidelines and a large percentage of youth with diabetes are overweight or obese. Active youth with type 1 diabetes tend to have lower HbA1c levels and reduced insulin needs, whereas activity in adolescents at‐risk for type 2 diabetes improves various measures of metabolism and body composition. Insulin and nutrient adjustments for exercise in type 1 diabetes is complex because of varied responses to exercise type and because of the different times of day that exercise is performed. This review highlights the benefits of exercise and the established barriers to exercise participation in the pediatric diabetes population. A new exercise management algorithm for insulin and carbohydrate intake strategies for active youth with type 1 diabetes is presented.     

Exercise and type 1 diabetes mellitus in youth; review and recommendations

Regular physical activity has been one of the cornerstones of type 1 diabetes mellitus (T1DM) therapy for decades. The benefits attributed to regular physical activity include increased sense of well being, quality of life, improved body composition, improved blood pressure and more. The beneficial effect in individuals with T1DM includes decreased risk of diabetes-related complications and mortality. In view of the recent recommendations for physical activity in healthy youth, advocating daily participation in 60 minutes of moderate to vigorous physical activity, we review the recent literature regarding physical activity in the context of youth with T1DM. We discuss its physiological and metabolic effects in youth with T1DM, its health promoting benefits and challenges that exercise poses in these individuals.     

A personalized approach to exercise promotion in adolescents with type 1 diabetes

Faulkner MS, Michaliszyn SF, Hepworth JT. A personalized approach to exercise promotion in adolescents with type 1 diabetes. Purpose: This exploratory study tested the feasibility of conducting a novel, personalized exercise intervention based upon the current fitness levels of adolescents with type 1 diabetes (T1DM). The relationships of perceptions of benefits and barriers to exercise, exercise self‐efficacy and family support to exercise adherence and changes in cardiovascular (CV) fitness, quality of life (QOL), and glycemic control were studied. Methods: Adolescents who were sedentary received a graded exercise test to determine their current fitness level (VO_2peak). A 16‐wk personalized exercise program was developed for each adolescent based upon individual fitness level and exercise preferences. Pretest and posttest measures of exercise self‐efficacy, benefits and barriers to exercise, family support, and diabetes QOL were completed. A1c levels were obtained using the DCA2000^®. Adherence to exercise was measured using the Actigraph? Accelerometer. Results: Twelve adolescents completed the study. Accelerometry data revealed adherence to 60 min of moderate‐to‐vigorous physical activity (MVPA) per day for a mean of 45.5 (SD = 23.9)% of the days the accelerometer was worn. Adolescents' perceptions of family support for exercise improved following the intervention (p = 0.03). Adolescents who had more daily bouts of exercise lasting 60 min increased their CV fitness (r = 0.59, p = 0.04). A1c remained unchanged. Conclusions: Encouraging 60 min of accumulated exercise bouts/d can improve fitness levels in adolescents with T1DM, minimizing future CV risks. Although physical activity increased in adolescents, family based strategies are required to promote current physical activity recommendations.     

Endocrine problems in adolescence

OBJECTIVE: To present and discuss clinical aspects concerning the most frequent endocrine diseases in adolescents and their effects on physical and psychoaffective fields in affected patients. METHODS: Review of national and international literature combined with the author? own experience with the aim of proposing some guidelines for the management of endocrine diseases in adolescents. RESULTS: The physical and psychological impacts of these diseases on adolescent? health may have different intensity. Diabetes mellitus as a chronic, self-limiting disease, with increased risk of late complications, is analyzed in more detail. Thyroid diseases and gynecomastia usually have a milder evolution, but may cause suffering and low self-esteem. CONCLUSIONS: The repercussion of these diseases, especially diabetes mellitus and gynecomastia, on the sexuality of adolescents should be taken into consideration.     

The role of new technologies in treating children and adolescents with type 1 diabetes mellitus

Abstract:  Given the physiological and psychological impact of type 1 diabetes in children and adolescents, these patients present special challenges to pediatric health care providers. The goals of intensive management of diabetes have been clearly established since the publication of the Diabetes Control and Complication Trial (DCCT) in 1993 (1), which demonstrated that tight metabolic control achieved with intensive insulin therapy is superior to conventional treatment in reducing the risk of long-term microvascular complications. Thus, current recommendations mandate that youth with type 1 diabetes should aim to achieve metabolic control as close to normal as possible. However, strict glycemic control is hard to achieve requiring frequent blood glucose measurements and several insulin injections per day, and in addition is associated with an increased risk of severe hypoglycemia (1). Recurrent episodes of hypoglycemia, especially at young ages, may cause adverse effects on neurocognitive function, may lead to hypoglycemia unawareness, and may be associated with significant emotional morbidity for the child and parents. Since the discovery of insulin in 1921 there has been constant progress in the way patients with type 1 diabetes are treated. The introduction of recombinant insulin and insulin analogs as well as new insulin delivery systems and glucose monitoring devices enhanced the ability of both patients and medical teams to better define the therapeutic goals and to develop more effective therapeutic strategies. Recent advances in devices for insulin administration and glucose monitoring and the introduction of telemedicine are having a profound effect on the lives of youth with type 1 diabetes. This review focuses on the new technologies which have been developed for treating children and adolescents with type 1 diabetes.     

Exercise and physical activity in children with cystic fibrosis

Regular exercise and habitual physical activity are important for patients with cystic fibrosis (CF). Research has demonstrated the benefits of aerobic, anaerobic, and strength exercise training programs for health and quality of life, however, the CF patient is faced with unique barriers and challenges to participation. Recently, increased levels of habitual physical activity have been shown to slow the decline in lung function in patients with CF, and regular participation in a variety of activities may result in greater adherence in the long term. Research is now available to justify the incorporation of exercise into the routine care of patients with CF. This paper provides the background and rationale for the implementation of exercise and habitual physical activity recommendations by the health care team. Education of health care providers regarding the importance of exercise and habitual physical activity for patients with CF is needed in order for exercise and physical activity to be incorporated as key components of clinical practice and into the lives of patients with CF.     

Physical activity, sport, and pediatric diabetes

The benefits derived from regular physical activity include improved cardiovascular fitness, increased lean mass, improved blood lipid profile, enhanced psychosocial well-being, and decreased body adiposity. The benefits for children with diabetes may also include blood glucose control and enhanced insulin sensitivity. However, for these children, engagement in vigorous physical activity and sport must be properly controlled through modifications in insulin therapy and nutritional intake so that the benefits of exercise outweigh the risks. The following review describes the various physiological and metabolic factors which occur both during exercise and during sport while describing specific recommendations to control glucose excursions by proper insulin management and diet.     

Treatment for Childhood Type 2 Diabetes

Urine glucose screening at school implemented in Japan is useful for detecting childhood type 2 diabetes at the early stage of the disease. Most patients detected by the screening can improve hyperglycemia and reduce overweight within one to three months by changing lifestyle with diet and exercise. For patients who are unable to alter their lifestyle and for those who have hyperglycemia despite maintaining these changes, a variety of oral hypoglycemic agents, including α-glucosidase inhibitors, sulfonylureas, glitinides, metformin, thiazolidenediones, and insulin are available. Metformin is considered to be the most effective oral agent as monotherapy for Japanese young persons with type 2 diabetes, because most of them are obese with insulin resistance. The approach to insulin therapy in patients with type 2 diabetes often differs from that most frequently used in patients with type 1 diabetes. Adjustment of the dose of insulin at each injection using sliding scales or algorithms is not required in most cases. In some cases, combination therapy with metformin and sulfonylureas or use of insulin is more effective for stabilization of blood glucose values. Therapeutic means for childhood type 2 diabetes should be variable depending on each patient’s characteristics.     

Psychological aspects of continuous glucose monitoring in pediatric type 1 diabetes

Abstract:  Clinical use of near-continuous glucose monitors (CGMs) could have substantial impact on family management of pediatric type 1 diabetes and could generate both beneficial and adverse psychological reactions. In addition to glycemic benefits, CGM could possibly yield educational and motivational benefits. Conversely, CGM may also lead to information overload and increased treatment burden. Further, patients and families with certain affective, behavioral, and cognitive characteristics might derive greater benefit from CGM use. As information about these processes could facilitate optimal clinical use of CGM, the Diabetes Research in Children Network (DirecNet) included measurement of selected psychological variables in a recent randomized trial of the GlucoWatch G2^® Biographer (GW2B, Cyngus, Inc., Redwood City, CA, USA). A multicenter sample of 200 youths with type 1 diabetes was randomized to 6 months of either continued usual care (UC) using a conventional home glucose meter for diabetes or supplementation of standard care with use of the GW2B. Diabetes treatment adherence, diabetes-specific quality of life, and diabetes-related anxiety were measured at baseline and at the end of the study. Satisfaction with use of the GW2B was measured at the end of the study. The results indicated neither adverse nor beneficial psychological effects of CGM use. More frequent GW2B use over the 6-month study was found among youths whose parents reported higher scores for treatment adherence and diabetes-related quality of life at baseline. The study illustrates the empiric assessment of the psychological context of CGM use and establishes methods that are applicable to new CGM devices as they emerge.     

Paediatric diabetes: achieving practical, effective insulin therapy in type 1 and type 2 diabetes

Both type 1 and type 2 diabetes can occur in children and adolescents. Type 1 diabetes is the most common chronic disease in children in the developed countries and the number of adolescents with type 2 diabetes is rising as a consequence of the obesity epidemic. As they grow, children and adolescents with diabetes have special and changing needs; these must be recognized and addressed as there are major physiological, medical, psychological, social and emotional differences in adults with diabetes. Glycaemic control is important to prevent or delay long-term complications also in the paediatric age group. This goal is often achieved using insulin. However, practical issues associated with insulin use in paediatric patients include attainment of target glycaemic levels without increased risk of hypoglycaemia, hormone-driven fluctuations in insulin requirements, and the psychological and social impacts of weight gain and puberty. This article reviews the advances that are helping to overcome these issues and enable paediatric patients to achieve their treatment goals. CONCLUSION: Advanced insulin formulations, particularly insulin analogues, tailored insulin regimens and delivery systems combined with age-appropriate education, patient/carer involvement and ongoing support from the wider diabetes team will assist in the effective management of diabetes among children and adolescents.     

Physical and psychological effects of aerobic exercise in delinquent adolescent males

Aerobic exercise has been associated with improved psychological status and physical fitness in adults, but its effects in adolescents have been less clear. This study evaluated the effects of aerobic exercise on the self-concept, depression level, and physical fitness of juvenile delinquents. Ninety-eight incarcerated youths who volunteered to participate were assigned in a blind fashion to one of two exercise programs lasting three months. Sixty-nine completed all phases of the study and are the subjects of this report. One exercise program (32 subjects) emphasized aerobic exercise; the other (37 subjects), limited exertion. Before and after participating, each subject underwent measurement of self-concept, mood, and physical fitness. While the aerobic and comparison groups were initially similar, the data demonstrated an association between participation in the aerobic exercise program and improved self-concept, mood, and fitness. Improvement in psychological variables was not dependent on improved physical fitness and was not related to preintervention measures.     

SOCIO-PSYCHOLOGICAL FACTORS AND METABOLIC CONTROL IN JUVENILE DIABETES

Abstract. The influence of exogenous and environmental factors on metabolic control was studied in 58 insulin treated juvenile diabetics, 6–17 years of age. Duration of diabetes varied between 3–14 years and age at onset of diabetes between 1–13 years. The social situation as well as knowledge about and attitudes towards diabetes among the patients and their parents were estimated by interviews, questionnaires and special tests. The quality of the diet, exercise and insulin treatment was assessed. An index of diabetic control was calculated on the basis of the patients daily urinalysis made at home. Multiple regression analysis and a special statistical “instrumental” variable technique were used in an effort to analyse the correlations between all variables. The social situation of the diabetic children was comparable with that of other Swedish children, but many parents felt the economic burden of the diabetic treatment as a problem. Knowledge tests showed that 25% of the parents and 62% of the patients above 12 years had unsatisfactory knowledge about diabetes. However, 93% of the patients seemed to have predominantly positive attitudes towards the treatment. Severe psychological problems had occurred in 7 cases. Food habits were appropriate among 21% of the patients and 26% had very regular exercise customs. Physical exercise seemed to be the most important of the exogenous factors for the diabetic control (p<0.001). Among teenagers knowledge was positively correlated to positive attitudes which in turn were positively correlated to physical exercise. Instrumental variable technique gave further indications of a positive influence of knowledge on control, and the correlation between diabetic control on one hand and knowledge combined with positive attitudes on the other was significantly positive. The results emphasize the importance of assisting young diabetic patients and their families in their socio-psychological adaptation to the strains of diabetic therapy.     

Transient chorea in a patient with type 1 diabetes may induce a reduction in insulin demand through increased spontaneous movements

The importance of physical activity in the management of diabetes is well established. The effect of programmed exercise and measurable skeletal activities on diabetes has been variously studied. Chorea induces an increase in spontaneous movement. Its occurrence in a teenager with type 1 diabetes provides new insights into our knowledge of metabolic outcomes. In our patient, the reduction in daily insulin demand was linked to choreic movement: a 67% decrease in insulin supply was needed to avoid episodes of hypoglycaemia; moreover, improved metabolism (measured as glycated haemoglobin) was obtained. Since no dietary changes were made and clinical events (including fever, drugs, weight loss, voluntary physical activity, psychological opposition or refusal of treatment) interfering with metabolic control of diabetes occurred, it appeared that only increased physical movements due to chorea reduced the patient's insulin requirement. As spontaneous movements declined with healing, metabolic control was lost, requiring an increase in insulin dosage to restore it. This article sheds additional light on our current understanding of hypoglycaemia and the variability of exogenous insulin demand in childhood and adolescent diabetes, when there are spontaneous movements and play. This finding highlights the importance of movement in type 1 diabetes.     

Clinical practice

Childhood obesity has reached epidemic proportions in many parts of the world. This epidemic has also affected children and adults with congenital heart disease (CHD). Over one quarter of children with CHD are overweight or obese. Important comorbidities are associated with obesity including type 2 diabetes, systemic hypertension, hyperlipidemia, and obstructive sleep apnea. Obese children with CHD often have the traditional risk factors such as genetic predisposition, sedentary lifestyle, and poor dietary habits. However, they may also have unique risk factors such as higher caloric needs in early infancy and exercise restriction in childhood. Similar to children with normal hearts, those with CHD have higher left ventricular mass and abnormal vascular function and are more likely to have systemic hypertension. In the long term, these comorbidities may have a more profound effect on children who have underlying functional and/or anatomical abnormalities of the heart. As more children with CHD are now surviving into adulthood, investigating therapeutic interventions to treat and prevent obesity in this population is of utmost importance. Recommendations for safe physical activity, recreation sport, and exercise training for children with CHD have recently been published. These guidelines may help health care providers to change their practice of exercise restriction.     

The importance of carbohydrate counting in the treatment of children with diabetes

Abstract:  Carbohydrate (Carb) counting is a meal planning approach for patients with diabetes mellitus that focuses on carbohydrate as the primary nutrient affecting postprandial glycemic response. The concept of carb counting is not new. In the early 1990`s the Diabetes Control and Complications Trial (DCCT) used carb counting as one of its education tools. More recently, short acting insulin analogues and insulin pumps have made the role of carb counting important and popular. Carb counting can be used in conjunction with a meal plan to set carbohydrate targets at each meal and snack. It is also used, perhaps more commonly, to estimate carbohydrate intake and adjust insulin around mixed meals and snacks using insulin to carbohydrate ratio. This effectively addresses the variable eating habits of most children and adolescents. The method may be adapted for patients who use a conventional insulin regimen and may meet the needs of patients who use multiple daily injections (MDI) or an insulin pump. Carb counting can make food planning flexible and enjoyable for patients, and the meal planning approach is very important for the physical growth and psychological development of children with diabetes. This paper describes the importance of carb counting for childhood diabetes as well as some of the special aspects associated with it.     

Physical activity recommendations for children with specific chronic health conditions: Juvenile idiopathic arthritis, hemophilia, asthma and cystic fibrosis

As a group, children with a chronic disease or disability are less active than their healthy peers. There are many reasons for suboptimal physical activity, including biological, psychological and social factors. Furthermore, the lack of specific guidelines for 'safe' physical activity participation poses a barrier to increasing activity. Physical activity provides significant general health benefits and may improve disease outcomes. Each child with a chronic illness should be evaluated by an experienced physician for activity counselling and for identifing any contraindications to participation. The present statement reviews the benefits and risks of participation in sport and exercise for children with juvenile arthritis, hemophilia, asthma and cystic fibrosis. Guidelines for participation are included.     

Metabolic control and insulin administration in a girl with Turner syndrome and type 1 diabetes during long-term growth hormone therapy

Many surveys have indicated that short stature affects at least 95% of all patients with Turner syndrome (TS). It is also clear that growth hormone (GH) therapy can accelerate the physical development in girls with TS. According to some clinical experience diabetes type 1 may be considered as a contraindication for GH therapy leading to low efficacy and high risk of late complications due to hyperglycaemia and elevated IGF-1 level. We present the results of growth hormone therapy on the metabolic control in a girl with TS and type 1 diabetes treated with continuous subcutaneous insulin infusion. The parameters of metabolic control and insulin doses were compared before and after introducing GH therapy. The correct diurnal glycemia profile was obtained after 4-fold increase of basal insulin and 2-fold increase of the total daily dose. The acceleration of growth was observed during 3.5-year therapy and average linear growth velocity was 7 cm/year. Growth hormone administration in children with Turner syndrome and type 1 diabetes can be efficacious and safe.