Q 14What advice about exercise participation should be given to adults with type 1 diabetes to maintain optimal blood glucose control?

Author/Title/Reference/YrPerry TL, Mann JI, Lewis-Barned NJ, Duncan AW, Waldron MA, Thompson C. Lifestyle intervention in people with insulin-dependent diabetes mellitus (IDDM). European Journal of Clinical Nutrition 1997;51:757–763 Reference ID: 254 (1449)
N=N= 61
New Zealand
Research DesignRandomised controlled study
AimTo investigate the impact of intensive lifestyle education on dietary practices, exercise and metabolic measurements
PopulationType 1 diabetes
InterventionGroup 1Trial period- Intensive advice and lifestyle program for six months
Post-trial observation period-
ComparisonGroup 2Trial period- Standard care for six months
Post trial observation period– Intensive advice and lifestyle program
OutcomeNutrient intakes, weight, blood pressure, Glycaemic control, Triglycerides and LDL cholesterol, HDL cholesterol and triglycerides, Physical fitness, VO2max
CharacteristicsGroup 1 Intensive treatment n = 31
male 15 female 16
age 41.5 ± 11.6
duration of diabetes 14.1 ± 11.9

Group 2 Standard treatment n = 30
male 20 female 10
age 42.8 ± 12.6
duration of diabetes 16.8 ± 13.4

Other characteristics in table
ResultsNutrient data
At recruitment, there were no significant differences between groups in nutrient intakes.
During the trial, both groups showed significant increases in percentage of energy from carbohydrate, carbohydrate and monounsaturated fat combined, and significant decreases in percentage of energy from total and saturated fat.
Recruitment to end of trial
There was a significant difference between groups with regard to total and saturated fat intake. Intake was significantly lower in group 1 compared with group 2 at the end of the trial (p = 0.047 and p = 0.018 for total and saturated fat respectively)
Post trial observation
Group 1 – Significant increases in total energy intake, and percentage energy from total, saturated and monounsaturated fat
Group 2 + intensive advice – Significant increase in percentage energy from monounsaturated fat and decreases in both sodium and percentage energy from saturated fat.

Blood Pressure
Blood pressure levels did not change during the trial

Glycaemic control
Glycated haemoglobin decreased significantly in both groups between recruitment and randomisation, the improvement being sustained during the six months of the randomised trial and for group 1 during the six months of post-trial observation. A further significant decrease was seen in Group 2 during the second six month period when they were given intensive advice.
HbA1 (%)
Group 1
Recruitment – 9.3 ± 2.8 Randomisation – 8.9 ± 2.6 Month 6 – 8.6 ± 2.1 Month 12 – 8.4 ± 1.8
Group 2 -
Recruitment – 9.5 ± 1.6 Randomisation – 8.7 ± 2.0 Month 6 - 8.8 ± 2.3 Month 12 – 7.9 ± 1.5 (p = 0.002 between month 6 and month 12)

Triglycerides and LDL cholesterol
A significant increase in LDL cholesterol was observed during the trial in Group 2 whilst they received standard care; however, during post trial observational phase there were significant deceases in both TC and LDL cholesterol levels.

HDL cholesterol and triglycerides
Levels in both groups increased significantly during the trial.
No significant differences were observed for HDL cholesterol between Group 1 and Group 2 during any phase of the study.
No significant changes in triglycerides during the study.

Physical fitness
In group 1 VO2max increased from 2.53 ± 0.60 to 3.12 ± 0.87 after three months and 3.01 ± 0.78 at the end of the trial (p = 0.001)
In group 2, during the post-trial observation phase their VO2max increased from 2.51 ± 0.52 to 2.82 ± 0.59 p = 0.001.
Hierarchy of Evidence Grading1b
CommentsNine subjects did not complete the study (3 from intensive treatment six from standard). Five subjects withdrew because of health or family problems, 1 was too busy, two left the area and 1 died.
Decision to offer intensive therapy to control group after 6 months was taken after trial start.
No dietary data collected at randomisation.
All subjects had seen a dietitian in the past.
Participation in the study may provide the motivation to change habits rather than intervention itself.
Improvements in dietary intake may not be a result of intensive education but solely the participation in a study.
Study not powered
Study not blinded due to design
Exclusion – severe physical disability or major illness
Patients received different levels of monitoring/advice according to patient desire or perceived need.
Dietary goal was to obtain 50% of total energy from complex carbohydrates, to increase dietary fibre (specifically soluble fibre), and to decrease total saturated fat to 30 and 10% of total energy respectively while increasing the intake of foods high in monounsaturated fats.
Exercise sessions designed according to individual fitness levels and goals.
Reference/Citaion105
Author/Title/Reference/YrLaaksonen DE, Atalay M, Niskanen LK, et al. Aerobic exercise and the lipid profile in type 1 diabetic men: a randomized controlled trial. Medicine & Science in Sports & Exercise. 2000;32:1541–1548
Reference ID: 20 (1443)
N=N= 56
Finland
Research DesignRandomised controlled study
AimTo assess the effect of a 12- to 16-wk aerobic exercise program on cardiorespiratory fitness and the lipid profile in young men with type 1 diabetes.
PopulationType 1 diabetics
Intervention12–16 weeks of moderate intensity, sustained running.
ComparisonNo training
OutcomeGlycemic control (HbA1c, plasma glucose), daily insulin dosage, lipid profile
CharacteristicsGroup 1 Training n = 20
Age = 32.5 ± 5.7
HbA1c = 8.2 ± 1.1

Group 2 Control n = 22
age 29.5 ± 6.3
HbA1c = 8.3 ± 1.3

No differences in baseline characteristics. Other characteristics in table
ResultsNo significant difference with respect to glycaemic control, cardiovascular fitness, or lipid profile between trained and control group before training.
No significant changes in daily energy intake, fat intake, or dietary polyunsaturated/saturated fatty acid ratio occurred in either the training or control group.
HbA1c at baseline correlated with LDL (r = 0.27, P = 0.05), total cholesterol (r = 0.30, P = 0.028), and apo B (r = 0.26, P = 0.058) but not with BMI, percent body fat, or indices of cardiovascular fitness.

VO2max (ml/kg/min)
After 12–16 weeks of training, VO2 peak increased significantly only in the training group.
Baseline = Training 43.4 ± 8 vs control 42 ± 7.2
After training = Training 46.1 ± 6.6 (p=0.023, before vs after training) vs control 43.4 ± 7.2

Daily insulin dosage (Units/kg)
Baseline = Training 0.68 ± 0.19 vs control 0.71 ± 0.18
After training = Training 0.68 ± 0.2 vs control 0.70 ± 0.20

HbA1c (%)
Baseline = Training 8.2 ± 1.1 vs control 8.3 ± 1.3
After training = Training 8.0 ± 1.0 vs control 8.5 ± 1.6

Plasma glucose (mmol/L)
Baseline = Training 10.5 ± 6 vs control 10.1 ± 4.3
After training = Training 12.1 ± 6.0 vs control 11.9 ± 5.8

Lipids
After 12–16 weeks of training, total and LDL-cholesterol and apo B decreased, and HDL, apo A-I, and the HDL/LDL and apo A-I, apo B ratios increased only in the training group.
In contrast, only HDL, apo A-I, and the HDL/LDL ratio increased in the control group.

Serum total Cholesterol (mmol/L)
Baseline = Training 4.89 ± 0.97 vs control 4.71 ± 1.08
After training = Training 4.66 ± 0.94 (p = 0.001, before vs after training) vs control 4.79 ± 1.18

LDL cholesterol (mmol/L)
Baseline = Training 3.15 ± 0.81 vs control 2.99 ± 0.74
After training = Training 2.88 ± 0.75 (p = 0.048, before vs after training) vs control 2.92 ± 0.80

HDL cholesterol (mmol/L)
Baseline = Training 1.21 ± 0.28 vs control 1.21 ± 0.40
After training = Training 1.32 ± 0.28 (p = 0.012, before vs after training) vs control 1.31 ± 0.45 (p = 0.011, before vs after training)

HDL/LDL
Baseline = Training 0.41 ± 0.13 vs control 0.42 ± 0.13
After training = Training 0.49 ± 0.16 (p = 0.001, before vs after training) vs control 0.46 ± 0.15 (p = 0.001, before vs after training)

Serum triglycerides (mmol/L)
Baseline = Training 1.18 ± 0.50 vs control 1.12 ± 0.53
After training = Training 1.02 ± 0.50 vs control 1.25 ± 0.53

Apolipoprotein B (g/L)
Baseline = Training 0.82 ± 0.20 vs control 0.78 ± 0.18
After training = Training 0.75 ± 0.19 (p = 0.003, before vs after training) vs control 0.82 ± 0.2

Apolipoprotein A-I (g/L)
Baseline = Training 1.42 ± 0.27 vs control 1.44 ± 0.34
After training = Training 1.50 ± 0.25 (p = 0.014, before vs after training) vs control 1.54 ± 0.38 (p = 0.036, before vs after training)

HDL/Apolipoprotein A-I(g/L)
Baseline = Training 0.84 ± 0.08 vs control 0.84 ± 0.10
After training = Training 0.88 ± 0.07 (p = 0.042, before vs after training) vs control 0.84 ± 0.10

Apo I/ApoB
Baseline = Training 1.83 ± 0.51 vs control 1.9 ± 0.47
After training = Training 2.09 ± 0.52 (p = 0.001, before vs after training) vs control 1.96 ± 0.51

Subgroup analysis
Relative changes in HDL/LDL and Apo AI/Apo B ratios produced by training are more prominent in type 1 diabetics with low HDL/LDL levels at baseline
Hierarchy of Evidence GradingIb
CommentsMultiple linear regression analysis undertaken to examine relationships between baseline measures.
Study not powered
Interesting changes in lipid profile in control group (possibly due to seasonal changes.
Compliance with completing food records was poor, may mean subtle changes in diet are not detected.
Dietary records after 6 weeks and 12 weeks were pooled.
14 out of 56 men enrolled in study dropped out – no discussion of reasons for withdrawal
Ten patients were smokers.
Exclusion – any cardiovascular or pulmonary disease and chronic medication other than insulin, including lipid-lowering medications (highly selected population)
Blood samples taken before and after training period 1.5–4h after eating light carbohydrate-rich breakfast or lunch in morning or midday.
Study not blinded due to design
Reference/Citation102
Author / Title / Reference / YrLehmann R, Kaplan V, Bingisser R, Bloch KE, Spinas GA. Impact of physical activity on cardiovascular risk factors in IDDM.
Diabetes Care. 1997;20:1603–1611 Reference ID: 37 (1448
N=N= 20
Switzerland
Research DesignCohort study
AimTo study the impact of physical activity on glycaemic control and plasma lipids, blood pressure, weight and abdominal fat.
PopulationWell-controlled Type 1 diabetics
InterventionRegular supervised exercise program (at least 135 minutes/week) for 3 months involving endurance sports e.g. biking, running or hiking.
ComparisonNo exercise
OutcomeGlycaemic control, HDL cholesterol (HDL-C), HDL-C fractions, triglycerised, lipopreotein a, blood pressure, weight and abdominal fat.
Characteristicsmale n = 13 female n = 7
mean age 33 ± 7.7 years
Mean diabetes duration 11 ± 7
HbA1c 7.6 ± 1.0

Other characteristics in table
ResultsPhysical activity
Mean time of physical activity increased from 195 ± 176 at baseline to 356 ± 164 minutes per week (p less than 0.001)
There was a significant correlation between changes in physical activity and increased in VO2 max – coefficient of correlation r = 0.75 (p less than 0.005)

Physical fitness
Men had significantly higher VO2max levels at baseline and after 3 months
Men baseline – 3421 ± 700 ml/min, 46.1 ml/min/kg
Women baseline – 1974 ± 369 ml/min, 31.5 ml/min/kg
Men 3 months – 3563 ± 739ml/min, 53.3 ± 10.2 ml/min/kg
Women 3 months – 2218 ± 357 ml/min, 35.9 ± 11.2 ml/min/kg

Insulin sensitivity
After the 3 month exercise program, both the steady state plasma glucose (SSPG) and steady state plasma insulin (SSPI) were significantly lower compared with pre-exercise levels indicating higher insulin clearance rate and insulin-mediated glucose metabolism.
Steady state plasma glucose
Baseline 10.5 ± 4.8 vs post 3 month exercise 7.0 ± 3.3 mmol/l (p less than 0.01)
There was a significant correlation between the decrease in SPPG and increased physical activity (r = −0.62, p less than 0.01)
Steady state plasma insulin (SSPI)
Baseline 381.1 ± 47.3 vs 282.4 ± 39.4 pmol/l (p less than 0.001)

Lipids
Significant decreases were observed in the following plasma lipids
Cholesterol:HDL-C decreased significantly from 2.92 ± 0.17 to 2.68 ± 0.13 (p less than 0.01)
LDL-C: HDL-C decreased significantly from 1.67 ± 0.16 to 2.68 ± 0.13 (p less than 0.001)
Triglycerides, HDL-TG, Lp (a) and cholesterol did not change significantly

Body composition
Significant decreases were observed in body weight, percentage body fat, and waist to hip ratio.
Body weight decreased significantly from 70.7 ± 10.9 to 68.7 ± 10.3 (p less than 0.03)
Percentage body fat decreased significantly from 21.9 ± 8.2 to 18 ± 6.3 (p less than 0.001)
Waist to hip ratio decreased significantly from 0.88 ± 0.055 to 0.86 ± 0.053 (p less than 0.001)
LBM increased significantly from 54.9 ± 12.2 to 56.8 ± 11.0 (p less than 0.01)
There was a significant correlation between changes in physical activity and changes in HDL-C, HDL3-C, apolipoprotein A1 and B, LBM and percentage body fat.

Glycaemic control
No significant changes in fasting blood glucose, HbA1c and microalbuminuria.

Heart Rate and blood pressure
A significant reduction in diastolic and systolic blood pressure and resting heart rate was observed at office readings and with ambulatory BP recording.
The changes in resting heart rate, systolic and diastolic blood pressure correlated significantly with changes in physical activity

Adverse effects
Mild hypoglycaemic episodes occurred in most patients at some points

Multiple regression analysis
69% of the variance in total HDLCholestreol could be explained by daily insulin dose (units per kg), VO2max, percentage body fat and age. (p less than 0.001)
38% of the variance of HDL2 was explained by waist-to-hip ratio, sex and daily insulin dose (units/kg) (p = 0.002)
51% of the variance of HDL3 was explained by insulin dose, VO2max, waist to hip ratio and percentage body fat. (p = 0.005)
26% of the variance of LDL was explained by VO2 max, insulin dose and age. (p = 0.05)
23% of the variance of triglyceride levels was explained by age and VO2max. (p = 0.05)
42% of the variance of systolic blood pressure (p less than 0.001) and 23% of diastolic blood pressure (p less than 0.05) could be explained by waist to hip ratio, percentage body fat and VO2max.
VO2max was significantly correlated with total cholesterol, Apo B, triglycerides, Lp(a) and heart rate. (p less than 0.02)
Increase in VO2max is correlated with a decrease in systolic blood pressure. (p = 0.03)

Short term effects of intensified physical activity and necessary adaptations in the diabetes regimen during a sport camp of 7 days duration
Daily activity before sport camp 34 ± 27 vs daily activity during sport camp 214 ± 32 (p less than 0.001)
Carbohydrate intake (g) before sport camp 212 ± 49 vs carbohydrate intake during sport camp 259 ± 65 (p less than 0.001)
Total insulin requirement (U/day) before sport camp 48.4 ± 15.1 vs total insulin requirement during sport camp 40.4 ± 13 (p less than 0.001)
Regular insulin (U) before sport camp 27.7 ± 9.3 vs regular insulin during sport camp 23.4 ± 7.8 (p=0.005)
NPH insulin (U) before sport camp 20.7 ± 8.2 vs NPH insulin during sport camp 17.0 ± 7.9 (p less than 0.001)
Blood glucose profile (average seven reading per day mmol/l) before sport camp 7.9 ± 1.7 vs blood glucose profile during sport camp 7.5 ± 1.6 (p = NS)
Hypoglycaemias grade I per day before sport camp 0.04 ± 1.2 vs hypoglycaemias grade I per day during sport camp 0.38 ± 0.5 (p less than 0.001)
Hypoglycaemias grade II/III per day before sport camp 0 vs hypoglycaemias grade II/III during sport camp 0 (p = NS)
Body weight (kg) before sport camp 68.5 ± 11.1 vs daily activity during sport camp 68.7 ± 10.5 (p = NS)
Hierarchy of Evidence GradingIIa
CommentsStudy not powered
Study not blinded or randomised due to design
Each patient participated in a comprehensive teaching program for self-management of diabetes during exercise to prevent exercise induced hypoglyceamic episodes.
Variable amounts of exercise undertaken
All patients completed the study
Each patient served as own control
Multiple regression analysis undertaken
Exclusion criteria symptomatic CHD, autonomic neuropathy and inability to incrase amount of physical activity.
Dietary advice not detailed; however adjustment of insulin dose and carbohydrate intake maintained glycaemic control.
Reference / Citation104
Author / Title / Reference / YrLigtenberg PC, Blans M, Hoekstra JB, van dT, I, Erkelens DW. No effect of long-term physical activity on the glycemic control in type 1 diabetes patients: a cross-sectional study. Netherlands Journal of Medicine. 1999;55:59–63 Reference ID: 24 (1445)
N=N= 14
Spain
Research DesignCohort study
AimTo evaluate the effect of physical exercise on blood pressure, the lipid profile, lipoprotein (a) and low-density lipoportein (LDL) modifications in untrained diabetic patients.
PopulationType 1 diabetics
InterventionIndividualised aerobic exercise program for 3 months
ComparisonNo exercise
Outcomecholesterol, high density lipoproteins, low density lipoproteins, very low density lipoproteins, triglycerides
Characteristics7 mean 7 women
mean age 25.5 ± 6 years range 17–42
Mean diabetes duration 6 ± 5 years (0.7 to 16.2)

BMI less than 30kg/m2, haemoglobin A1c less than 8.5%, absence of kidney failure, absence of liver thyroid disease and absence of regular exercise
ResultsPhysical fitness
Significant improvements were observed in VO2 max and O2 pulse
Maximal heart rate did not change significantly

VO2max (mL/kg/min) – baseline 33.7 ± 7; after 3 months exercise 38.5 (p less than 0.05)
O2 pulse (mL/beat) – baseline 12.2 ± 2.8; after 3 months exercise 13.4 ± 3.7 (p less than 0.05)
Maximal heart rate – baseline 185 ± 10; after 3 months exercise 185 ± 10

Glycaemic control
HbA1c, fructosamine and fasting blood glucose did not change significantly.
HbA1c (%) – baseline 6.5 ± 0.8; after 3 months exercise 6.7 ± 1
Fructosamine (umol/L) – baseline 309 ± 53; after 3 months exercise 310 ± 61
Glucose (mmol/L) – baseline 7.9 ± 3.6; after 3 months exercise 7.7 ± 4.2

Lipid and lipoprotein parameters
A significant increase in HDL-C was seen after 3 months exercise
All other outcomes did not change significantly

cholesterol (mmol/L) – baseline 4.44 ± 0.81; after 3 months exercise 4.58 ± 0.87
HDL-C (mmol/L) – baseline 1.48 ± 0.45; after 3 months exercise 1.66 ± 0.66 (p less than 0.05)
LDL-C (mmol/L) – baseline 2.70 ± 0.74; after 3 months exercise 2.56 ± 0.65
VLDL-C (mmol/L) – baseline 0.35 ± 0.27; after 3 months exercise 0.33 ± 0.15
Triglycerides(mmol/L) – baseline 0.76 ± 0.57; after 3 months exercise 0.92 ± 0.83
Chlesterol/HDL-C – baseline 3.21 ± 0.87; after 3 months exercise 3.07 ± 1.14
Hierarchy of Evidence GradingIIa
CommentsStudy duration 3 months
All treated with diet and insulin therapy
Study also looked at type 2 diabetics
Study not powered
Study not randomised or blinded
Different exercise programmes used for different periods of time.
Sub analysis of selected patient group according to baseline Lp (A) levels, but not divided according to type 1 and type 2 diabetes
No patents suffered from severe hypoglycaemic event
Patients in this study had favourable lipoprotein profile. Studies have shown that patients with adverse lipid profile benefit more from physical training.
Patient acceptance and compliance not commented upon.
Reference / Citation103
Author / Title / Reference / YrRigla M, Sanchez-Quesada JL, Ordonez-Llanos J, et al. Effect of physical exercise on lipoprotein(a) and low-density lipoprotein modifications in type 1 and type 2 diabetic patients. Metabolism: Clinical & Experimental 2000;49:640–647
N=N= 14
Spain
Research DesignCohort study
AimTo evaluate the effect of physical exercise on blood pressure, the lipid profile, lipoprotein (a) and low-density lipoportein (LDL) modifications in untrained diabetic patients.
Operational DefinitionBMI less than 30kg/m2, haemoglobin A1c less than 8.5%, absence of kidney failure, absence of liver thyroid disease and absence of regular exercise.
PopulationType 1 diabetics
InterventionIndividualised aerobic exercise program for 3 months
ComparisonNo exercise
Outcomecholesterol, high density lipoproteins, low density lipoproteins, very low density lipoproteins, triglycerides
Characteristics7 mean 7 women
mean age 25.5 ± 6 years range 17–42
Mean diabetes duration 6 ± 5 years (0.7 to 16.2)
ResultsPhysical fitness
Significant improvements were observed in VO2 max and O2 pulse
Maximal heart rate did not change significantly

VO2max (mL/kg/min) – baseline 33.7 ± 7; after 3 months exercise 38.5 (p less than 0.05)
O2 pulse (mL/beat) – baseline 12.2 ± 2.8; after 3 months exercise 13.4 ± 3.7 (p less than 0.05)
Maximal heart rate – baseline 185 ± 10; after 3 months exercise 185 ± 10

Glycaemic control
HbA1c, fructosamine and fasting blood glucose did not change significantly.

HbA1c (%) – baseline 6.5 ± 0.8; after 3 months exercise 6.7 ± 1
Fructosamine (umol/L) – baseline 309 ± 53; after 3 months exercise 310 ± 61
Glucose (mmol/L) – baseline 7.9 ± 3.6; after 3 months exercise 7.7 ± 4.2

Lipid and lipoprotein parameters
A significant increase in HDL-C was seen after 3 months exercise
All other outcomes did not change significantly

cholesterol (mmol/L) – baseline 4.44 ± 0.81; after 3 months exercise 4.58 ± 0.87
HDL-C (mmol/L) – baseline 1.48 ± 0.45; after 3 months exercise 1.66 ± 0.66 (pless than 0.05)
LDL-C (mmol/L) – baseline 2.70 ± 0.74; after 3 months exercise 2.56 ± 0.65
VLDL-C (mmol/L) – baseline 0.35 ± 0.27; after 3 months exercise 0.33 ± 0.15
Triglycerides(mmol/L) – baseline 0.76 ± 0.57; after 3 months exercise 0.92 ± 0.83
Chlesterol/HDL-C – baseline 3.21 ± 0.87; after 3 months exercise 3.07 ± 1.14
Hierarchy of Evidence GradingIIa
CommentsStudy duration 3 months
All treated with diet and insulin therapy
Study also looked at type 2 diabetics
Study not powered
Study not randomised or blinded
Different exercise programmes used for different periods of time.
Subanalysis of selected patient group according to baseline Lp (A) levels, but not divided according to type 1 and type 2 diabetes
No patents suffered from severe hypoglyceamic event
Patients in this study had favourable lipoprotein profile. Studies have shown that patients with adverse lipid profile benefit more from physical training.
Patient acceptance and compliance not commented upon.
Reference / Citation
Author / Title / Reference / YrSchneider SH, Khachadurian AK, Amorosa LF, Clemow L, Ruderman NB. Ten-year experience with an exercise-based outpatient life-style modification program in the treatment of diabetes mellitus. Diabetes Care. 1992;15:1800–1810
Reference ID: 67 (1458)
N=N= 55
USA
Research DesignCohort study
AimTo examine the effects of a programme of diet and exercise on various metabolic and haemodynamic parameters, and to assess the ability of patients to perform physical training safely.
PopulationType 1 diabetics
InterventionEducation (series of 10 two hour lectures)
Nutritional recommendations based on the guidelines developed by the American Diabetes Association
Physical training – 3 to 4 times per week
ComparisonNo exercise
OutcomeHeart rate, systolic blood pressure, diastolic blood pressure, weight, body mass index, fasting plasma glucose, serum insulin, serum triglycerides, serum cholesterol, serum high density lipoprotein cholesterol.
CharacteristicsOlder subjects (aged greater than 40 yr)
male 12 female 4
age 49.6 ± 1.8
duration of diabetes 19.7 ± 2.7
fasting plasma glucose (mM) 9.6 ± 1.3
HbA1 (%) 12.6 ± 0.8

Younger subjects (aged less than 40 yr)
male 25 female 14
age 26.4 ± 1
duration of diabetes 11.4 ± 1.2
fasting plasma glucose (mM) 12.1 ± 0.8
HbA1 (%) 11.5 ± 0.6
Other characteristics in table
ResultsHemodynamic response to physical training ( n = 25)

At rest
A significant decrease in heart rate and systolic blood pressure at rest was seen after 3 months compared with controls.

Heart rate (beats/min) – baseline 86 ± 7 vs after 3 months 81 ± 2 (p less than 0.05 compared with control)
Systolic pressure (mmHg) - baseline 144 ± 9 vs after 3 months 130 ± 3 (p less than 0.01 compared with control)
Diastolic Pressure (mmHg) - baseline 82± 2 vs after 3 months 83 ± 1

100 watts
A significant decrease in heart rate and diastolic blood pressure at 100 watts intensity was seen after 3 months compared with controls.

Heart Rate (beats/min) - baseline 156 ± 7 vs after 3 months 136 ± 3 (p less than 0.01 compared with control)
Systolic pressure (mmHg) - baseline 188 ± 26 vs after 3 months 178 ± 5
Diastolic Pressure (mmHg) - baseline 91 ± 3 vs after 3 months 83 ± 2 (p less than 0.01 compared with control)

Maximal Effort
A significant decrease in diastolic blood pressure at maximal effort was seen after 3 months compared with controls.

Heart Rate (beats/min) - baseline 169 ± 7 vs after 3 months 170 ± 3
Systolic pressure (mmHg) - baseline 191 ± 18 vs after 3 months 213 ± 4
Diastolic Pressure (mmHg) - baseline 88 ± 3 vs after 3 months 82 ± 2 (p less than 0.05 compared with control)

Metabolic response to 3 months of physical training ( n = 25)
No significant changes were observed in metabolic response when comparing baseline with 3 months of physical training

Weight (kg) – baseline 74.2 ± 2.2 vs after 3 months 72.3 ± 4.2
Body mass index (kg/m2) - baseline 24 ± 0.6 vs after 3 months 24.6 ± 0.7
Fasting plasma glucose (mM) - baseline 11.6 ± 0.9 vs after 3 months 11.6 ± 1.2
Serum Tricglycerides (mg/dL) - baseline 119 ± 14 vs after 3 months 120 ± 18
Serum Cholesterol (mg/dL) - baseline 202 ± 7 vs after 3 months 207 ± 14
Serum High-density Lipoprotein Cholesterol (mg/dL) - baseline 49 ± 3 vs after 3 months 48 ± 5
Hierarchy of Evidence GradingIIa
CommentsStudy not powered
Study not blinded or randomised due to design
Study examined mixed population of type 1 and type 2 diabetics.
Some results were pooled and therefore not presented.
All type 1 patients were insulin treated.
Patients received different levels of monitoring according to risk.
Exercise sessions 40–60 min duration
A high proportion of patients had distal sensory-motor neuropathy
No rigid exclusion criteria apart from significant ischaemic heart disease.
Substantial dropout occurred at each time point if good compliance is rated as participation in at least 75% scheduled sessions.
Females more likely to continue than males.
Hypoglycemia occurred at some point in all patients.
No explanation why only 25/55 type 1 patients are included in analysis of haemodynamic response and metabolic response results.
Reference / Citation106
Author / Title / Reference / YrSelam JL, Casassus P, Bruzzo F, Leroy C, Slama G. Exercise is not associated with better diabetes control in type 1 and type 2 diabetic subjects. Acta Diabetologica. 1992;29:11–13
Reference ID: 69 (1459)
N=N= 50
France
Research DesignCohort Study
AimTo evaluate whether exercise is associated with better diabetes control and/or risk of hypoglycaemia.
PopulationType 1 diabetics
InterventionDiabetics undergoing range of physical activity assessed by investigator-led questionnaire
ComparisonNo exercise
OutcomeDiabetes control as assessed by HbA1c, episodes of hypoglycaemia and insulin dose
Characteristicsmale n = 25 female n = 25
mean age 41 ± 11 years
Mean diabetes duration 16 ± 8
HbA1c 8.1 ± 1.1
Physical Energy Expenditure (kcal/week) = 1808 ± 320
ResultsHbA1c
There was no significant correlation between physical exercise energy expenditure (PEEE) and HbA1c in a) all type 1 diabetes patients or b) exercising type 1 diabetes patients
All patients HbA1c vs PEEE – correlation coefficient = 0.036 (P = NS; n = 50)
Exercising patients HbA1c vs PEEE – correlation coefficient = 0.080 (p = NS; n = 32)
Exercising patients HbA1c = 8.3 ± 0.2
Non-exercising patients HbA1c = 7.9 ± 0.2

Hypoglycaemic events
There was no significant correlation between PEEE and mild hypoglycaemic events in type 1 exercising patients
Exercising patients mild hypoglycaemic events vs PEEE – correlation coefficient = 0.2 (p = NS; n = 32)
Exercising patients
mild hypoglycaemic episodes per month = 5.3 ± 0.9
severe hypoglycaemic episode per month = 0.9 ± 0.3
Non-exercising patients
mild hypoglycaemic episodes per 5 years = 4.4 ± 1.4
severe hypoglycaemic episodes per 5 years = 2.2 ± 0.9

Insulin doses
Insulin doses correlated significantly with PEEE in type 1 patients.
Daily insulin dose vs PEEE - correlation coefficient = −0.266 (p less than 0.05; n = 49)
Hierarchy of Evidence GradingIIa
CommentsQuestionnaire administered by investigator and filled in by technician
99% response to questionnaire from diabetics, 95% response from controls
Questions addressed type, weekly frequency and duration of sessions of exercise.
Subjects divided into groups (no physical exercise at all, intense voluntary exercise programs e.g. tennis, or physical activity limited to deliberate walking sessions)
Retrospective, subjective unvalidated questionnaire
Study not powered
No other diseases that might influence exercise habits e.g. coronary heart disease, arthropathy or claudication were evident
Reference / Citation
Author / Title / Reference / YrWiesinger GF, Pleiner J, Quittan M, et al. Health related quality of life in patients with long-standing insulin dependent (type 1) diabetes mellitus: benefits of regular physical training. Wiener Klinische Wochenschrift. 2001;113:670–675
N=N= 23
Austria
Research DesignCohort study
AimTo examine whether health related quality of life (HRQOL) can be improved by a regular physical training program.
PopulationType 1 diabetics
Intervention4 months aerobic exercise training
ComparisonNo training
OutcomePhysical and metabolic parameters (BMI, BP, Heart rate, HbA1c, insulin dose, cholesterol, oxygen uptake, exercise capacity, muscle strength)
CharacteristicsGroup 1 Training n = 15
8 women and 7 men
Age = 41 ± 2
HbA1c = less than 8.5%

Group 2 Control n = 8
3 women and 5 men
age 33 ± 11
HbA1c = 8.5%

Other characteristics in table
ResultsBody Mass index (kg/m2)
Baseline = Training 24.0 ± 0.88 vs control 26.7 ± 1.4
After 4 months = Training 23.8 ± 0.8 vs control 27.4 ± 1.4

Mean arterial blood pressure (mmHg)
Baseline = Training 79 ± 4 vs control 80 ± 3
After 4 months = Training 80 ± 3 vs control 85 ± 2

Resting heart rate (bpm)
Baseline = Training 84 ± 4 vs control 76 ± 3
After 4 months = Training 75 ± 7 vs control 78 ± 4

HbA1c (%)
Baseline = Training 7.3 ± 0.2 vs control 7.4 ± 0.4
After 4 months = Training 7.4 ± 0.4 vs control 7.4 ± 0.2

Insulin dose
After 4 months of training the insulin dose was significantly reduced by 18% in group 1
Baseline = Training 0.62 ± 0.07 vs control 0.66 ± 0.10
After 4 months = Training 0.51 ± 0.05 (pless than 0.05 vs baseline) vs control 0.64 ± 0.1

Total Cholesterol (mmol/L)
Baseline = Training 202 ± 12 vs control 198 ± 16
After training = Training 188 ± 12 vs control 192 ± 14

Peak oxygen uptake VO2max (ml/kg/min)
After 4 months training peak oxygen uptake was increased in group 1
Baseline = Training 29.1 ± 1.3 vs control 29.6 ± 2.3
After training = Training 35.7 ± 9.8 (p = less than 0.05 vs baseline) vs control 29.7 ± 2.4

Maximum exercise capacity, Watt
Baseline = Training 154 ± 14 vs control 207 ± 16 (p less than 0.05 between groups)
After training = Training 183 ± 19 vs control 204 ± 16
Hierarchy of Evidence GradingIIa
CommentsStudy not powered
Significant difference in baseline maximum exercise capacity between intervention and control group.
Study not randomised.
Study not blinded due to design
Reference / Citation

From: Appendix D, Evidence tables

Cover of Type 1 Diabetes in Adults
Type 1 Diabetes in Adults: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care.
NICE Clinical Guidelines, No. 15.1.
National Collaborating Centre for Chronic Conditions (UK).
Copyright © 2004, Royal College of Physicians of London.

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