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Management of exercise for children and adolescents with type 1 diabetes mellitus

Michael C Riddell, PhD
Section Editor
Joseph I Wolfsdorf, MB, BCh
Deputy Editor
Alison G Hoppin, MD


Regular exercise has important health and social benefits for children and adolescents with type 1 diabetes mellitus (T1DM) and should be encouraged [1]. Exercise also presents several important challenges to diabetes management. It requires special management by patients and clinicians, using protocols based on a sound understanding of the underlying physiology, adapted to the patient's individual characteristics.

This topic review will describe the physiology of glucose homeostasis during exercise, then present a clinical approach to management of glycemic control during and after exercise in young patients with T1DM. Similar issues in adults are discussed in a separate topic review. (See "Effects of exercise in adults with diabetes mellitus".)


Engaging in regular physical activity helps to protect against a number of future health risks for young patients with type 1 diabetes mellitus (T1DM). Exercise can help prevent cardiovascular disease, stroke, osteoporosis, and reduces the risk for some forms of cancer (eg, colon, breast, prostate). Other benefits of regular exercise for patients with T1DM include [2-4]:

Increased cardiovascular and cardiorespiratory fitness

Enhanced muscle mass and strength

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Literature review current through: Nov 2017. | This topic last updated: Aug 28, 2017.
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  1. Robertson K, Riddell MC, Guinhouya BC, et al. ISPAD Clinical Practice Consensus Guidelines 2014. Exercise in children and adolescents with diabetes. Pediatr Diabetes 2014; 15 Suppl 20:203.
  2. Chimen M, Kennedy A, Nirantharakumar K, et al. What are the health benefits of physical activity in type 1 diabetes mellitus? A literature review. Diabetologia 2012; 55:542.
  3. Maggio AB, Rizzoli RR, Marchand LM, et al. Physical activity increases bone mineral density in children with type 1 diabetes. Med Sci Sports Exerc 2012; 44:1206.
  4. Pivovarov JA, Taplin CE, Riddell MC. Current perspectives on physical activity and exercise for youth with diabetes. Pediatr Diabetes 2015; 16:242.
  5. Krause MP, Riddell MC, Hawke TJ. Effects of type 1 diabetes mellitus on skeletal muscle: clinical observations and physiological mechanisms. Pediatr Diabetes 2011; 12:345.
  6. Gusso S, Pinto TE, Baldi JC, et al. Diastolic function is reduced in adolescents with type 1 diabetes in response to exercise. Diabetes Care 2012; 35:2089.
  7. Lukács A, Mayer K, Juhász E, et al. Reduced physical fitness in children and adolescents with type 1 diabetes. Pediatr Diabetes 2012; 13:432.
  8. Williams BK, Guelfi KJ, Jones TW, Davis EA. Lower cardiorespiratory fitness in children with Type 1 diabetes. Diabet Med 2011; 28:1005.
  9. Elmesmari R, Reilly JJ, Martin A, Paton JY. Accelerometer measured levels of moderate-to-vigorous intensity physical activity and sedentary time in children and adolescents with chronic disease: A systematic review and meta-analysis. PLoS One 2017; 12:e0179429.
  10. Bjornstad P, Cree-Green M, Baumgartner A, et al. Renal function is associated with peak exercise capacity in adolescents with type 1 diabetes. Diabetes Care 2015; 38:126.
  11. Moy CS, Songer TJ, LaPorte RE, et al. Insulin-dependent diabetes mellitus, physical activity, and death. Am J Epidemiol 1993; 137:74.
  12. Kennedy A, Nirantharakumar K, Chimen M, et al. Does exercise improve glycaemic control in type 1 diabetes? A systematic review and meta-analysis. PLoS One 2013; 8:e58861.
  13. Miculis CP, De Campos W, da Silva Boguszweski MC. Correlation between glycemic control and physical activity level in adolescents and children with type 1 diabetes. J Phys Act Health 2015; 12:232.
  14. Beraki Å, Magnuson A, Särnblad S, et al. Increase in physical activity is associated with lower HbA1c levels in children and adolescents with type 1 diabetes: results from a cross-sectional study based on the Swedish pediatric diabetes quality registry (SWEDIABKIDS). Diabetes Res Clin Pract 2014; 105:119.
  15. Quirk H, Blake H, Tennyson R, et al. Physical activity interventions in children and young people with Type 1 diabetes mellitus: a systematic review with meta-analysis. Diabet Med 2014; 31:1163.
  16. Galler A, Lindau M, Ernert A, et al. Associations between media consumption habits, physical activity, socioeconomic status, and glycemic control in children, adolescents, and young adults with type 1 diabetes. Diabetes Care 2011; 34:2356.
  17. Herbst A, Bachran R, Kapellen T, Holl RW. Effects of regular physical activity on control of glycemia in pediatric patients with type 1 diabetes mellitus. Arch Pediatr Adolesc Med 2006; 160:573.
  18. Aman J, Skinner TC, de Beaufort CE, et al. Associations between physical activity, sedentary behavior, and glycemic control in a large cohort of adolescents with type 1 diabetes: the Hvidoere Study Group on Childhood Diabetes. Pediatr Diabetes 2009; 10:234.
  19. Singhvi A, Tansey MJ, Janz K, et al. Aerobic fitness and glycemic variability in adolescents with type 1 diabetes. Endocr Pract 2014; 20:566.
  20. Lukács A, Mayer K, Török A, et al. Better cardiorespiratory fitness associated with favourable metabolic control and health-related quality of life in youths with type 1 diabetes mellitus. Acta Physiol Hung 2013; 100:77.
  21. Gusso S, Pinto T, Baldi JC, et al. Exercise Training Improves but Does Not Normalize Left Ventricular Systolic and Diastolic Function in Adolescents With Type 1 Diabetes. Diabetes Care 2017; 40:1264.
  22. Kornhauser C, Malacara JM, Macías-Cervantes MH, Rivera-Cisneros AE. Effect of exercise intensity on albuminuria in adolescents with Type 1 diabetes mellitus. Diabet Med 2012; 29:70.
  23. Robertson K, Adolfsson P, Riddell MC, et al. Exercise in children and adolescents with diabetes. Pediatr Diabetes 2008; 9:65.
  24. Fahey AJ, Paramalingam N, Davey RJ, et al. The effect of a short sprint on postexercise whole-body glucose production and utilization rates in individuals with type 1 diabetes mellitus. J Clin Endocrinol Metab 2012; 97:4193.
  25. Guelfi KJ, Jones TW, Fournier PA. New insights into managing the risk of hypoglycaemia associated with intermittent high-intensity exercise in individuals with type 1 diabetes mellitus: implications for existing guidelines. Sports Med 2007; 37:937.
  26. Riddell MC. The endocrine response and substrate utilization during exercise in children and adolescents. J Appl Physiol (1985) 2008; 105:725.
  27. Wasserman DH. Four grams of glucose. Am J Physiol Endocrinol Metab 2009; 296:E11.
  28. Riddell MC, Bar-Or O, Hollidge-Horvat M, et al. Glucose ingestion and substrate utilization during exercise in boys with IDDM. J Appl Physiol (1985) 2000; 88:1239.
  29. Robitaille M, Dubé MC, Weisnagel SJ, et al. Substrate source utilization during moderate intensity exercise with glucose ingestion in Type 1 diabetic patients. J Appl Physiol (1985) 2007; 103:119.
  30. Coggan AR, Raguso CA, Williams BD, et al. Glucose kinetics during high-intensity exercise in endurance-trained and untrained humans. J Appl Physiol (1985) 1995; 78:1203.
  31. Raguso CA, Coggan AR, Gastaldelli A, et al. Lipid and carbohydrate metabolism in IDDM during moderate and intense exercise. Diabetes 1995; 44:1066.
  32. Cryer PE. Glucose counterregulation: prevention and correction of hypoglycemia in humans. Am J Physiol 1993; 264:E149.
  33. Camacho RC, Galassetti P, Davis SN, Wasserman DH. Glucoregulation during and after exercise in health and insulin-dependent diabetes. Exerc Sport Sci Rev 2005; 33:17.
  34. Younk LM, Mikeladze M, Tate D, Davis SN. Exercise-related hypoglycemia in diabetes mellitus. Expert Rev Endocrinol Metab 2011; 6:93.
  35. Sotsky MJ, Shilo S, Shamoon H. Regulation of counterregulatory hormone secretion in man during exercise and hypoglycemia. J Clin Endocrinol Metab 1989; 68:9.
  36. Zinker BA, Allison RG, Lacy DB, Wasserman DH. Interaction of exercise, insulin, and hypoglycemia studied using euglycemic and hypoglycemic insulin clamps. Am J Physiol 1997; 272:E530.
  37. Briscoe VJ, Tate DB, Davis SN. Type 1 diabetes: exercise and hypoglycemia. Appl Physiol Nutr Metab 2007; 32:576.
  38. Adolfsson P, Nilsson S, Albertsson-Wikland K, Lindblad B. Hormonal response during physical exercise of different intensities in adolescents with type 1 diabetes and healthy controls. Pediatr Diabetes 2012; 13:587.
  39. Sprague JE, Arbeláez AM. Glucose counterregulatory responses to hypoglycemia. Pediatr Endocrinol Rev 2011; 9:463.
  40. Wasserman DH. Regulation of glucose fluxes during exercise in the postabsorptive state. Annu Rev Physiol 1995; 57:191.
  41. Tansey MJ, Tsalikian E, Beck RW, et al. The effects of aerobic exercise on glucose and counterregulatory hormone concentrations in children with type 1 diabetes. Diabetes Care 2006; 29:20.
  42. Diabetes Research in Children Network (DirecNet) Study Group, Tsalikian E, Tamborlane W, et al. Blunted counterregulatory hormone responses to hypoglycemia in young children and adolescents with well-controlled type 1 diabetes. Diabetes Care 2009; 32:1954.
  43. Schneider SH, Vitug A, Ananthakrishnan R, Khachadurian AK. Impaired adrenergic response to prolonged exercise in type I diabetes. Metabolism 1991; 40:1219.
  44. Cline GW, Rothman DL, Magnusson I, et al. 13C-nuclear magnetic resonance spectroscopy studies of hepatic glucose metabolism in normal subjects and subjects with insulin-dependent diabetes mellitus. J Clin Invest 1994; 94:2369.
  45. Mallad A, Hinshaw L, Schiavon M, et al. Exercise effects on postprandial glucose metabolism in type 1 diabetes: a triple-tracer approach. Am J Physiol Endocrinol Metab 2015; 308:E1106.
  46. Tsalikian E, Mauras N, Beck RW, et al. Impact of exercise on overnight glycemic control in children with type 1 diabetes mellitus. J Pediatr 2005; 147:528.
  47. McMahon SK, Ferreira LD, Ratnam N, et al. Glucose requirements to maintain euglycemia after moderate-intensity afternoon exercise in adolescents with type 1 diabetes are increased in a biphasic manner. J Clin Endocrinol Metab 2007; 92:963.
  48. Diabetes Research in Children Network (DirecNet) Study Group. Impaired overnight counterregulatory hormone responses to spontaneous hypoglycemia in children with type 1 diabetes. Pediatr Diabetes 2007; 8:199.
  49. Davey RJ, Howe W, Paramalingam N, et al. The effect of midday moderate-intensity exercise on postexercise hypoglycemia risk in individuals with type 1 diabetes. J Clin Endocrinol Metab 2013; 98:2908.
  50. Gomez AM, Gomez C, Aschner P, et al. Effects of performing morning versus afternoon exercise on glycemic control and hypoglycemia frequency in type 1 diabetes patients on sensor-augmented insulin pump therapy. J Diabetes Sci Technol 2015; 9:619.
  51. Metcalf KM, Singhvi A, Tsalikian E, et al. Effects of moderate-to-vigorous intensity physical activity on overnight and next-day hypoglycemia in active adolescents with type 1 diabetes. Diabetes Care 2014; 37:1272.
  52. Dubé MC, Lavoie C, Galibois I, Weisnagel SJ. Nutritional strategies to prevent hypoglycemia at exercise in diabetic adolescents. Med Sci Sports Exerc 2012; 44:1427.
  53. Riddell MC, Milliken J. Preventing exercise-induced hypoglycemia in type 1 diabetes using real-time continuous glucose monitoring and a new carbohydrate intake algorithm: an observational field study. Diabetes Technol Ther 2011; 13:819.
  54. Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group. Prolonged nocturnal hypoglycemia is common during 12 months of continuous glucose monitoring in children and adults with type 1 diabetes. Diabetes Care 2010; 33:1004.
  55. MacDonald MJ. Postexercise late-onset hypoglycemia in insulin-dependent diabetic patients. Diabetes Care 1987; 10:584.
  56. Jones TW, Porter P, Sherwin RS, et al. Decreased epinephrine responses to hypoglycemia during sleep. N Engl J Med 1998; 338:1657.
  57. Graveling AJ, Warren RE, Frier BM. Blunted Counterregulatory hormone responses to hypoglycemia in young children and adolescents with well-controlled type 1 diabetes: response to the Diabetes Research in Children Network (DirecNet) Study Group. Diabetes Care 2010; 33:e67; author reply e68.
  58. Iscoe KE, Corcoran M, Riddell MC. High rates of nocturnal hypoglycemia in a unique sports camp for athletes with type 1 diabetes: lessons learned from continuous glucose monitoring. Can J Diab 2008; 32:182.
  59. Maran A, Pavan P, Bonsembiante B, et al. Continuous glucose monitoring reveals delayed nocturnal hypoglycemia after intermittent high-intensity exercise in nontrained patients with type 1 diabetes. Diabetes Technol Ther 2010; 12:763.
  60. Taplin CE, Cobry E, Messer L, et al. Preventing post-exercise nocturnal hypoglycemia in children with type 1 diabetes. J Pediatr 2010; 157:784.
  61. Diabetes Research in Children Network (DirecNet) Study Group, Tsalikian E, Kollman C, et al. Prevention of hypoglycemia during exercise in children with type 1 diabetes by suspending basal insulin. Diabetes Care 2006; 29:2200.
  62. Iscoe KE, Campbell JE, Jamnik V, et al. Efficacy of continuous real-time blood glucose monitoring during and after prolonged high-intensity cycling exercise: spinning with a continuous glucose monitoring system. Diabetes Technol Ther 2006; 8:627.
  63. Marliss EB, Vranic M. Intense exercise has unique effects on both insulin release and its roles in glucoregulation: implications for diabetes. Diabetes 2002; 51 Suppl 1:S271.
  64. Berger M, Berchtold P, Cüppers HJ, et al. Metabolic and hormonal effects of muscular exercise in juvenile type diabetics. Diabetologia 1977; 13:355.
  65. Turner D, Gray BJ, Luzio S, et al. Similar magnitude of post-exercise hyperglycemia despite manipulating resistance exercise intensity in type 1 diabetes individuals. Scand J Med Sci Sports 2016; 26:404.
  66. Turner D, Luzio S, Gray BJ, et al. Impact of single and multiple sets of resistance exercise in type 1 diabetes. Scand J Med Sci Sports 2015; 25:e99.
  67. Campbell MD, Walker M, Trenell MI, et al. Metabolic implications when employing heavy pre- and post-exercise rapid-acting insulin reductions to prevent hypoglycaemia in type 1 diabetes patients: a randomised clinical trial. PLoS One 2014; 9:e97143.
  68. Mitchell TH, Abraham G, Schiffrin A, et al. Hyperglycemia after intense exercise in IDDM subjects during continuous subcutaneous insulin infusion. Diabetes Care 1988; 11:311.
  69. Bussau VA, Ferreira LD, Jones TW, Fournier PA. A 10-s sprint performed prior to moderate-intensity exercise prevents early post-exercise fall in glycaemia in individuals with type 1 diabetes. Diabetologia 2007; 50:1815.
  70. Turner D, Luzio S, Gray BJ, et al. Algorithm that delivers an individualized rapid-acting insulin dose after morning resistance exercise counters post-exercise hyperglycaemia in people with Type 1 diabetes. Diabet Med 2016; 33:506.
  71. Pervanidou P, Chrousos GP. Metabolic consequences of stress during childhood and adolescence. Metabolism 2012; 61:611.
  72. Phan-Hug F, Thurneysen E, Theintz G, et al. Impact of videogame playing on glucose metabolism in children with type 1 diabetes. Pediatr Diabetes 2011; 12:713.
  73. Moberg E, Kollind M, Lins PE, Adamson U. Acute mental stress impairs insulin sensitivity in IDDM patients. Diabetologia 1994; 37:247.
  74. Hargreaves M, Angus D, Howlett K, et al. Effect of heat stress on glucose kinetics during exercise. J Appl Physiol (1985) 1996; 81:1594.
  75. Berger M, Halban PA, Assal JP, et al. Pharmacokinetics of subcutaneously injected tritiated insulin: effects of exercise. Diabetes 1979; 28 Suppl 1:53.
  76. Urban A, Collazo MP, Tamborlane WV. Delayed hypoglycemia following exercise in an athletic teenager with type 1 diabetes. Diabetic Hypoglycemia 2013; 6:11.
  77. Campbell MD, Walker M, Trenell MI, et al. A low-glycemic index meal and bedtime snack prevents postprandial hyperglycemia and associated rises in inflammatory markers, providing protection from early but not late nocturnal hypoglycemia following evening exercise in type 1 diabetes. Diabetes Care 2014; 37:1845.
  78. Riddell M, Perkins BA. Exercise and glucose metabolism in persons with diabetes mellitus: perspectives on the role for continuous glucose monitoring. J Diabetes Sci Technol 2009; 3:914.
  79. Yardley JE, Iscoe KE, Sigal RJ, et al. Insulin pump therapy is associated with less post-exercise hyperglycemia than multiple daily injections: an observational study of physically active type 1 diabetes patients. Diabetes Technol Ther 2013; 15:84.
  80. Jimenez CC, Corcoran MH, Crawley JT, et al. National athletic trainers' association position statement: management of the athlete with type 1 diabetes mellitus. J Athl Train 2007; 42:536.
  81. Graveling AJ, Frier BM. Risks of marathon running and hypoglycaemia in Type 1 diabetes. Diabet Med 2010; 27:585.
  82. Dubé MC, Weisnagel SJ, Prud'homme D, Lavoie C. Exercise and newer insulins: how much glucose supplement to avoid hypoglycemia? Med Sci Sports Exerc 2005; 37:1276.
  83. Hernandez JM, Moccia T, Fluckey JD, et al. Fluid snacks to help persons with type 1 diabetes avoid late onset postexercise hypoglycemia. Med Sci Sports Exerc 2000; 32:904.
  84. Iafusco D. Diet and physical activity in patients with type 1 diabetes. Acta Biomed 2006; 77 Suppl 1:41.
  85. Riddell MC, Iscoe KE. Physical activity, sport, and pediatric diabetes. Pediatr Diabetes 2006; 7:60.
  86. Riddell MC, Bar-Or O, Ayub BV, et al. Glucose ingestion matched with total carbohydrate utilization attenuates hypoglycemia during exercise in adolescents with IDDM. Int J Sport Nutr 1999; 9:24.
  87. Rodriguez NR, DiMarco NM, Langley S, et al. Position of the American Dietetic Association, Dietitians of Canada, and the American College of Sports Medicine: Nutrition and athletic performance. J Am Diet Assoc 2009; 109:509.
  88. Rabasa-Lhoret R, Bourque J, Ducros F, Chiasson JL. Guidelines for premeal insulin dose reduction for postprandial exercise of different intensities and durations in type 1 diabetic subjects treated intensively with a basal-bolus insulin regimen (ultralente-lispro). Diabetes Care 2001; 24:625.
  89. Miller AR, Nebesio TD, DiMeglio LA. Insulin dose changes in children attending a residential diabetes camp. Diabet Med 2011; 28:480.
  90. Gunasekera H, Ambler G. Safety and efficacy of blood glucose management practices at a diabetes camp. J Paediatr Child Health 2006; 42:643.
  91. Riddell MC, Gallen IW, Smart CE, et al. Exercise management in type 1 diabetes: a consensus statement. Lancet Diabetes Endocrinol 2017; 5:377.
  92. Delvecchio M, Zecchino C, Salzano G, et al. Effects of moderate-severe exercise on blood glucose in Type 1 diabetic adolescents treated with insulin pump or glargine insulin. J Endocrinol Invest 2009; 32:519.
  93. Admon G, Weinstein Y, Falk B, et al. Exercise with and without an insulin pump among children and adolescents with type 1 diabetes mellitus. Pediatrics 2005; 116:e348.
  94. Abraham MB, Davey RJ, Cooper MN, et al. Reproducibility of the plasma glucose response to moderate-intensity exercise in adolescents with Type 1 diabetes. Diabet Med 2017; 34:1291.
  95. Adolfsson P, Nilsson S, Lindblad B. Continuous glucose monitoring system during physical exercise in adolescents with type 1 diabetes. Acta Paediatr 2011; 100:1603.
  96. Yardley JE, Sigal RJ, Kenny GP, et al. Point accuracy of interstitial continuous glucose monitoring during exercise in type 1 diabetes. Diabetes Technol Ther 2013; 15:46.
  97. de Bock M, Dart J, Roy A, et al. Exploration of the Performance of a Hybrid Closed Loop Insulin Delivery Algorithm That Includes Insulin Delivery Limits Designed to Protect Against Hypoglycemia. J Diabetes Sci Technol 2017; 11:68.
  98. Garg SK, Weinzimer SA, Tamborlane WV, et al. Glucose Outcomes with the In-Home Use of a Hybrid Closed-Loop Insulin Delivery System in Adolescents and Adults with Type 1 Diabetes. Diabetes Technol Ther 2017; 19:155.
  99. Breton MD. Handling Exercise During Closed Loop Control. Diabetes Technol Ther 2017; 19:328.
  100. Colberg SR, Riddell MC. Physical Activity: Regulation of Glucose Metabolism, Clinical Management Strategies, and Weight Control. In: American Diabetes Association/Juvenile Diabetes Research Foundation Type 1 Diabetes Sourcebook, Peters AL, Laffel LM (Eds), 2013. p.249-291.
  101. Dear Gde L, Pollock NW, Uguccioni DM, et al. Plasma glucose responses in recreational divers with insulin-requiring diabetes. Undersea Hyperb Med 2004; 31:291.
  102. Bonomo M, Cairoli R, Verde G, et al. Safety of recreational scuba diving in type 1 diabetic patients: the Deep Monitoring programme. Diabetes Metab 2009; 35:101.
  103. Kruger DF, Owen SK, Whitehouse FW. Scuba diving and diabetes. Practical guidelines. Diabetes Care 1995; 18:1074.
  104. Adolfsson P, Ornhagen H, Jendle J. Accuracy and reliability of continuous glucose monitoring in individuals with type 1 diabetes during recreational diving. Diabetes Technol Ther 2009; 11:493.