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  • Review article
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Exercise in adults with type 1 diabetes mellitus

Nature Reviews Endocrinology volume 19, pages 98–111 (2023)Cite this article

Subjects

Abstract

Regular physical activity improves cardiometabolic and musculoskeletal health, helps with weight management, improves cognitive and psychosocial functioning, and is associated with reduced mortality related to cancer and diabetes mellitus. However, turnover rates of glucose in the blood increase dramatically during exercise, which often results in either hypoglycaemia or hyperglycaemia as well as increased glycaemic variability in individuals with type 1 diabetes mellitus (T1DM). A complex neuroendocrine response to an acute exercise session helps to maintain circulating levels of glucose in a fairly tight range in healthy individuals, while several abnormal physiological processes and limitations of insulin therapy limit the capacity of people with T1DM to exercise in a normoglycaemic state. Knowledge of the acute and chronic effects of exercise and regular physical activity is critical for the formulation of clinical strategies for the management of insulin and nutrition for active patients with T1DM. Emerging diabetes-related technologies, such as continuous glucose monitors, automated insulin delivery systems and the administration of solubilized glucagon, are demonstrating efficacy for preserving glucose homeostasis during and after exercise in this population of patients. This Review highlights the beneficial effects of regular exercise and details the complex endocrine and metabolic responses to different types of exercise for adults with T1DM. An overview of basic clinical strategies for the preservation of glucose homeostasis using emerging technologies is also provided.

Key points

  • Type 1 diabetes mellitus is associated with marginal impairments in skeletal muscle health and cardiorespiratory fitness; however, these impairments can be offset with good glycaemic control and exercise training.

  • In general, endurance exercise activities reduce glycaemia and explosive activities raise glycaemia, while high-intensity interval training and resistance training activities can have a moderating effect.

  • Reductions in basal and/or bolus insulin delivery are typically required for endurance activities, along with supplemental carbohydrate feeding for performance reasons or if glucose level falls below ~7.0 mmol/l (126 mg/dl) during the activity.

  • Increases in insulin delivery after explosive exercise, resistance exercise and/or high-intensity interval training might be required if hyperglycaemia develops; however, the risk of post-exercise hypoglycaemia is heightened in the 12–24 h after exercise so frequent glucose monitoring is required.

  • Automated insulin delivery systems and continuous glucose monitoring technologies have the potential to improve glucose control around most forms of exercise.

  • However, several user-initiated actions are still required for endurance-type activities to help raise the pre-exercise glycaemic target, minimize insulin on board and maintain glycaemia on target (5–10 mmol/l; 90–180 mg/dl) during the activity when using automated insulin delivery and continuous glucose monitoring.

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Fig. 1: Change in relative maximal strength over time in adult men and women with and without T1DM.
Fig. 2: General trends in glycaemia in response to different forms of exercise in T1DM.
Fig. 3: Factors thought to influence the glucose response to exercise in T1DM.

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Acknowledgements

The authors thank D. Shakeri from the School of Kinesiology and Health Science at York University, Toronto, Canada, for editorial assistance (managing the references and proofreading) with this manuscript.

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  1. Muscle Health Research Centre, School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada

    Michael C. Riddell

  2. LMC Diabetes and Endocrinology, Toronto, Ontario, Canada

    Michael C. Riddell

  3. Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

    Anne L. Peters

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Riddell, M.C., Peters, A.L. Exercise in adults with type 1 diabetes mellitus. Nat Rev Endocrinol 19, 98–111 (2023). https://doi.org/10.1038/s41574-022-00756-6

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