Empowered The Science of Exercise with Type 1 Diabetes Sam Scott, PhD & Simon Helleputte, PhD

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EMPOWERED

The Science of Exercise with Type 1 Diabetes 

 

Sam Scott, PhD

&

Simon Helleputte, PhD

 

With foreword by Dr. Thomas Züger, MD

Open Publication Information.

Publication Information

Title: Empowered: The Science of Exercise with Type 1 Diabetes

Authors: Sam Scott and Simon Helleputte

Illustrations: Federico Fontana

Publisher: Sestante Analytics

Publication Date: April 2025 (First Edition)

Place of Publication: United Kingdom (UK)

Cover Image: Federico Fontana

ISBN: 978-1-0684317-1-5

Copyright: © 2025 by Sestante Analytics Ltd. All rights reserved.

Permissions: No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise) without the prior written permission of the publisher.

Contact Information:

• Email: info@enhance-d.com
• Website: https://www.enhance-d.com/

Open General Introduction.

General Introduction

Who are we, and why did we write this book?  

We are exercise physiologists united by a shared passion for helping people living with type 1 diabetes (T1D) achieve their exercise goals. Over the past decade, our work has spanned clinical research, applied sports science with professional athletes with T1D, and technology start-ups.

T1D presents unique challenges in exercise metabolism, making it difficult for those with the condition to exercise safely and effectively. While neither of us lives with T1D, our work has led to numerous close friendships, new insights, and a strong desire to improve the standard of care regarding exercise and T1D.

This book is written for anyone interested in learning about the science of T1D and exercise. This includes people living with T1D, partners or caregivers of people with T1D, healthcare professionals, academics, and sports coaches. We also hope it can be a valuable resource for anyone studying exercise physiology and inspire more pe

Open About the Authors.

About the Authors

SAM SCOTT holds a PhD in Exercise Physiology and has clinical and applied research experience in the field of obesity, diabetes, and continuous glucose monitoring technology. His primary research focus has been on developing strategies to address the major barriers to exercise for people living with diabetes. For over five years, Sam was the Head of Research for Team Novo Nordisk, the professional cycling team comprised of athletes with type 1 diabetes. His research has resulted in a strong academic output, with over 30 publications in high-impact journals and numerous keynotes and invited presentations. Sam is the CEO of Enhance-d, a MedTech start-up that aims to create a glucose and exercise management platform for people living with diabetes.

SIMON HELLEPUTTE has a PhD in Rehabilitation Sciences from Ghent University, Belgium, with clinical research in cardiometabolic health and exercise metabolism in type 1 diabetes. He has also undertaken applied research into conti

Open About the Illustrations

About the Illustrations

The figures and illustrations were all produced by FEDERICO FONTANA. Where applicable, references to other sources are provided in the figure legends, and permission to reproduce has been obtained. Fede is the Chief Product Officer and Co-Founder of Enhance-d. Originally from Verona, Italy, Fede lives in Bolzano with his wife, dog and two sons. An avid ski mountaineer (basically climbing mountains with skis) and a proud rescue dog parent, Fede brings his unwavering attitude and determination to every project he undertakes. Fede holds a PhD in human physiology from the University of Verona, Italy, and the University of Calgary, Canada. Between 2012 and 2019, Fede was the Head of Performance for Team Novo Nordisk professional cycling team and was VP of Science for Supersapiens. His experience of working with professional athletes living with type 1 diabetes on a daily basis has given Fede a unique perspective on the challenges regarding glucose management and sports.

**THOM

Open Thanks & Acknowledgements.

Thanks & Acknowledgements

Writing a book is a collaborative effort, and this one is no exception. As co-authors, we would like to express our deep gratitude to the many individuals who have contributed their time, expertise, and support to make this book a reality.

First, thank our family and friends for your unwavering support and patience throughout this journey. Writing a book such as this requires sacrificing so many weekends and evenings. Your love and encouragement have been our constant source of strength.

We are indebted to the countless researchers and scientists whose work has laid the foundation for this book. Your dedication to advancing our understanding of exercise and diabetes has made this book possible. A heartfelt thank you to everyone who participated in the studies and shared their experiences. Your contributions have provided real-world insights that have greatly enriched this book.

We are grateful to Andrea Tryfonos, Christophe Kosinski, Pilar Scott, Henry Aspden, Wendy F

Open Foreword by Dr Thomas Züger.

Foreword by Dr Thomas Züger

I can still remember it very well. It was late afternoon on the 31st of July 2019, the day before Swiss National Day, and I was working as a clinician in Bern when my phone rang. SamSco tt, the new postdoctoral researcher from England, had just arrived in Switzerland. Although Sam had arranged to move into his new apartment in Bern, the landlady responsible had left early for her holidays and wouldn’t return for at least four days. This being Switzerland on a national holiday, everything was closed, and all the hotels were full. Sam was stranded in a new country with nothing but his suitcase. With everything closed for the holiday celebrations, I offered him a place to stay for the long weekend. That's how I met Sam, and we have been good friends and colleagues since.

Sam was quickly introduced to my circle of colleagues and friends as he had no choice but to join me at the National Day celebrations. The ice quickly broke, and we soon discovered we shared a deep fascinati

Open Table of Contents.

Table of Contents

General Introduction ……………………………….……. III

About the Authors ………………………………………..... V

About the Illustrations …………………………………… VI

Thanks & Acknowledgements ……………………….….VII

Foreword by Dr. Thomas Züger ………………………. VIII

Chapter 1. General Introduction and Overview of Type 1 Diabetes .............. 1

Chapter 2. Why Physical Activity and Exercise are Important for People with Type 1 Diabetes ………...………………………...................................................…… 30

Chapter 3. The Hormonal and Metabolic Response to Exercise in People with Type 1 Diabetes ………….……………….............................................................….. 37

Chapter 4. Planning and Management of Exercise in Individuals with Type 1 Diabetes……………………….……………........................................................................... 54

Chapter 5. Applying Sports Science Principles to Training and Competition for Endurance Athletes with Type 1 Diabetes ...................................................

Open Chapter 1_text

Introduction

Type 1 diabetes (T1D) is a chronic autoimmune condition that targets and destroys β-cells in the pancreas [1]. Under normal circumstances, β-cells produce insulin, an essential hormone for several metabolic processes, with one of the main ones being the regulation of blood glucose levels. Without insulin, the body cannot effectively regulate glucose levels, leading to hyperglycaemia (high blood glucose concentration). As a result, for people living with T1D, every day is a constant challenge to keep blood glucose levels within a target range (typically between 3.9 and 10 mmol/L or 70 and 180 mg/dL). Deviations from this range can lead to serious health consequences.

The challenges associated with T1D are substantial and can negatively impact the quality of life. The necessity for constant monitoring of blood glucose levels, insulin administration, and the fear of potential complications such as vision impairment, nerve damage, kidney failure, and heart attack can significantly

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It’s important to note that the model of T1D development shown in Figure 1 is a simplified representation and does not fully capture the complexity of the condition [1, 18]. There is significant variation at every stage, which is not yet well understood. For example, there is variation in the starting β-cell mass and function, and genetic predisposition is now recognised as a stronger driver for immune abnormalities than initially thought. Other immunological abnormalities might appear before detectable autoantibodies, and β-cell loss can follow a relapsing or remitting pattern rather than a linear progression as shown in the original model. The rate of progression through the initial stages is also variable and likely influenced by immune, genetic, and environmental factors [1, 18].

In people with a high genetic risk for T1D, the first signs can appear very early in life, with the peak incidence of the first autoantibody appearance occurring before age two [29]. While many people with only on

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The Role of the Pancreas and Liver in Blood Glucose Homeostasis

The pancreas and the liver are the main organs involved in energy metabolism and blood glucose regulation. In individuals without diabetes, these organs work in harmony to maintain normal blood glucose levels (Figure 3). The following is the “normal” healthy response in someone without T1D:

In response to rising blood glucose levels, the pancreas releases insulin. This increase in insulin quickly stops the liver from producing and secreting glucose (Figures 3 and 4). High insulin levels almost completely stop the liver from breaking down glycogen (a process called hepatic glycogenolysis) and lower the rate of gluconeogenesis (the production of glucose by the liver) by approximately 20% [38]. In addition, increased insulin in the bloodstream suppresses glucagon secretion by the pancreas and stimulates glucose uptake in peripheral tissues, such as skeletal muscle and adipose tissue.

On the other hand, if blood glucose concentration

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Hypoglycaemia, Hyperglycaemia and Diabetic Ketoacidosis: What Are They and Why Do They Happen?

In T1D, metabolic disturbances happen because the body doesn’t produce enough insulin [23]. This lack of insulin can lead to several metabolic issues, such as ketoacidosis. On the other hand, too much insulin (hyperinsulinemia) can cause hypoglycaemia.

 

The Dangerous Situation of Diabetic Ketoacidosis (DKA)

The absence of insulin in T1D poses serious risks [23]. If insulin is not available, for example, due to an insulin pump malfunction or a blocked catheter, glucose can’t be used properly by the body’s tissues, and normal glucose metabolism (glycolysis) can’t take place. This results in insufficient amounts of oxaloacetate, which is needed for the Krebs cycle (a crucial energy-generating process). Without oxaloacetate, acetyl CoA concentrations will increase abnormally, and acetyl CoA will be diverted to an alternative metabolic pathway called ketogenesis, which results in the produc

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Glucagon: Use in Emergency Treatment and Prevention of Mild Hypoglycaemia

Glucagon is used for the urgent treatment of severe hypoglycaemia. Patients are advised to carry an intramuscular injection pen in an ‘emergency kit’ for this purpose. Alternatively, and more recently, nasal powder formulations have been developed [48], with Baqsimi® receiving FDA approval in 2019 as the first non-injectable glucagon therapy for severe hypoglycaemia. Intranasal glucagon is a safe and effective alternative to intramuscular glucagon and oral glucose for treating hypoglycaemia in both adults and children [48-51].

Beyond emergencies, the potential for glucagon to be used to prevent mild hypoglycaemia has been investigated, for instance, before exercise or in other situations where there is a risk of hypoglycaemia due to reduced food intake or delayed meals. Smaller doses of glucagon (micro- or mini-dosing) may provide an alternative to carbohydrate intake to treat mild hypoglycaemia. Studies have shown

Open Chapter 1/continued

Several CGM systems are currently available on the market, each with its unique features and specifications:

• Components: These systems typically consist of a sensor (subcutaneous needle) with its applicator, a transmitter (in most systems directly attached to the sensor), and the receiver or ‘reader’ (which can be a smartphone or a separate device).

• Calibration Requirements: Some systems require frequent calibration twice a day with fingerstick tests, while others are factory-calibrated and do not require fingerstick calibration.

• Wear Time: Depending on the system, this can range from a few days to several weeks.

Importantly, CGM provides a more comprehensive and real-time view of glycaemic management daily, offering insights that HbA1c cannot capture [67, 72]. As a result, CGM-derived metrics have become increasingly important, with new metrics being developed to reflect different aspects of glycaemic management [36, 69, 73, 76].  Time in range (TIR), time in hypo

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Time in Tight Range (TITR)

There have been discussions on whether the concept and targets of TIR need revising [85], and that’s where TITR comes in. TITR represents the time spent in a narrower glycaemic range (70-140 mg/dL or 3.9-7.8 mmol/L), sometimes referred to as ‘normoglycaemia’ or ‘euglycaemic range’ as this is where people without diabetes spend most of their time. Several reasons have been suggested for this new and stricter target range.

First, the growing popularity of TITR aligns with the goal of T1D management: achieving an ambulatory glucose profile that is “Flat, Narrow, and In Range”. Second, advocating for TITR is based on the rationale that:

(a)     “It has become possible.” In other words, spending considerable time in this glucose range will become more and more realistic with further technological advancements. Automated insulin delivery (AID) systems will likely make it possible for more patients to achieve strict glucose target range goals.

(b)    “**I

Open Chapter 2_text

Introduction

Physical activity and exercise are fundamental components of type 1 diabetes (T1D) management and are important for overall health. Physical activity, defined as “any voluntary bodily movement produced by skeletal muscles that results in an increase in energy expenditure,” [1, 2] plays an important role in managing T1D [3, 4]. Large-scale studies have shown that physical activity improves cardiovascular health 5, reduces the risk of diabetes-related complications [5-7], and even lowers the risk of early death [8-10]. 

Exercise is a subset of physical activity that is “planned, structured, and repetitive, aiming to improve or maintain physical fitness and health” [1, 2]. For people with T1D, exercise can help manage blood glucose levels, boost cardiovascular health, and improve insulin sensitivity. Exercise isn't just about movement – it’s about strategic and deliberate action to enhance your health.

In this chapter, we will discuss the many benefits of physical activity and exe

Open Chapter 3_text

Introduction

Exercise is arguably one of the most challenging aspects of managing type 1 diabetes (T1D). Depending on various factors, it can substantially increase the risk of both hyper- and hypoglycaemia, which can be discouraging, to say the least. Understanding the body’s hormonal responses to different forms of exercise is essential for people living with T1D as it enables the individual to better understand why glucose responds as it does. This chapter aims to explain how exercise-related metabolism changes in people living with T1D and how blood glucose tends to respond depending on the type and intensity of the exercise. The Hormonal Response to Exercise in People without T1D Before we dive into what happens in people with T1D, it’s helpful to understand how the body typically responds to exercise in people without diabetes. As discussed in Chapter 1, people without diabetes have robust mechanisms to stabilise blood glucose within the normal range throughout the day. During exercise, the bo

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Intermediate Summary

People with T1D face a distinctive challenge in that they cannot mimic the complex neurohormonal regulatory responses required for various types and durations of exercise. The combination of changes in fuel selection and oxidation leads to a mismatch between peripheral glucose disposal (i.e., increased muscle glucose uptake) and glucose provision by the liver (i.e., decreased output/supply from the liver). This imbalance often leads to rapid declines in glucose levels during exercise, contributing to a substantial risk of hypoglycaemia both during and after activity in people with T1D.

How Exercise Affects Blood Glucose Levels in People with T1D

Exercise significantly impacts glucose levels in people with T1D [4, 25, 44-46], but the responses vary greatly from person to person. While many factors (such as age, sex, fitness level, time of day, stress level, menstrual cycle, previous exercise or hypoglycaemia) influence how blood glucose responds to a bout of exercise [4,

Open Chapter 3/continued

Resistance Exercise and T1D

The hormonal and metabolic responses to resistance exercise in people with T1D likely vary depending on the specific workout routine. In people without T1D, high-resistance, low-repetition workouts trigger similar responses to anaerobic activities like high-intensity running, potentially increasing blood glucose levels [58]. On the other hand, high-repetition, low-resistance programs with short rests between sets are more aerobic and may decrease blood glucose levels.

There haven’t been many studies on how blood glucose responds to resistance exercise in people with T1D. Of the limited research in this area, most studies have used a moderate-intensity protocol involving three sets of eight repetitions [59-62]. Yardley and colleagues [59] found that a resistance training protocol performed in the afternoon was associated with a decline in blood glucose, although to a lesser extent than a comparable period of moderate-intensity aerobic exercise (60% 𝑉̇O2peak). Resistance

Open Chapter 4_text

Introduction

Many people with type 1 diabetes (T1D) wish to be physically active and exercise regularly. However, exercising adds complexities to the already challenging task of daily glucose management. Chief among these considerations are insulin dose adjustments and the effects of meals surrounding exercise. Monitoring blood glucose levels during these times and establishing ideal glucose targets for safe and effective exercise is very important. This chapter addresses the unique challenges of managing blood glucose levels before, during, and after exercise, offering general tips and advice for exercise and glucose management.

 

Part 1. Tips and Considerations Before and During Your Workout

We’ve broken down this section into seven parts, each focusing on a key aspect of glucose management before and during exercise. Remember, these are general guidelines since everyone’s situation and needs may vary:

1. Starting Blood Glucose Concentration: Check your glucose

Open Chapter 4/continued

Factor 1. Pre-Exercise Glucose Levels

Blood glucose concentration before exercise can affect how glucose levels change during exercise [1-3]. The ideal starting glucose level depends on the duration and intensity of the exercise and the amount of insulin on board. Pre-exercise glucose levels also determine when carbohydrates should be consumed before and during exercise and whether you need to reduce your pre-exercise bolus insulin, especially if you exercise after a meal (see below for more information on postprandial exercise).

General Guidelines:

• Ideal Starting Glucose Level: Aim to start the exercise with stable blood glucose levels between 7.0 and 14.0 mmol/L (126-250 mg/dL), with low blood ketone levels (i.e., <0.6 mmol/L) or trace amounts in urine [4].

• Low Glucose Levels: If glucose levels are below 5.0 mmol/L (90 mg/dL) before exercising, consider having 10–20 grams of glucose before starting.

• Moderately Low Glucose Levels: If levels are between

Open Chapter 4/continued

Relevance of the Postprandial Period and Exercise

The postprandial period – the timeframe following a meal – is clinically relevant to address in individuals with T1D [29]. Elevated peak postprandial glucose can negatively impact overall glycaemic management, as measured by HbA1c [29-31], and may contribute to the development of diabetic complications [30-34]. Meals can often result in hyperglycaemic spikes and increased variability, which can significantly impact daily life and diabetes-related stress. Therefore, managing peak postprandial glucose and post-meal glycaemic fluctuations is an important aspect of T1D management. Skeletal muscle plays a key role in maintaining blood glucose homeostasis, as it is a major tissue for glucose disposal both after a meal [35, 36] and during exercise [37-39].  Hence, postprandial exercise may be a good strategy to help with glucose management by reducing post-meal hyperglycaemic excursions. However, although exercising soon after a meal can help

Open Chapter 5_text

Introduction: Pushing the Limits in Endurance Sports with T1D

The realm of endurance and ultra-endurance sports, once thought to be out of reach for those with type 1 diabetes (T1D), is now achievable for many. Countless inspiring stories have emerged of people with T1D conquering gruelling, sometimes extreme, endurance events lasting hours or even days. These achievements include World Tour cycling stage races 1, marathons and ultramarathons [2-5], Ironman competitions [6], multi-day hikes [7], and long-distance cross-country skiing [8, 9].

These accomplishments are a testament to human resilience and demonstrate what’s possible with careful planning, rigorous glucose monitoring, and strategic nutritional adjustments. Advances in diabetes technologies and management strategies have also significantly enabled these endurance feats among people with T1D [10].

For endurance sports athletes with T1D, managing blood glucose levels is an extra challenge compared to those without the conditi

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Carbohydrate Requirements for Training and Competition: Adapting Strategies for Glucose Management and Meeting Fuel and Recovery Demands

A.     Carbohydrate Intake During Exercise: To Fuel or Not to Fuel? Given that everyone with T1D is unique and there is limited research on carbohydrate intake during long-duration exercise for those with T1D, there is no one-size-fits-all guide for insulin adjustments or carbohydrate intake during prolonged endurance exercise. Nevertheless, two key factors generally determine the amount of carbohydrate that an athlete with T1D needs:

1.         Blood Glucose Management: Carbohydrate intake may be required to maintain stable and safe glucose levels, primarily to avoid hypoglycaemia. This differs from athletes without T1D, who mainly need carbohydrates for performance alone.

2.         Performance: Fuelling the workout is essential for maintaining and optimising performance for a given exercise intensity.

In athletes without diabetes

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C.     Carbohydrate Loading for Athletes with T1D

Storage of Carbohydrates in the Human Body: Glycogen

Carbohydrates can be stored as glycogen in the liver (between 70-100 grams) and in the muscles (a major site for glucose disposal after a meal; between ~400-600 grams, depending on age, sex, and especially the amount of muscle mass). Over the past six decades, skeletal muscle glycogen metabolism has been extensively studied, largely thanks to the development of the muscle biopsy technique [23, 51]. In contrast, the role of liver glycogen during exercise has received less attention, primarily because obtaining tissue samples from the liver is more challenging and dangerous than muscle biopsies. However, advances in non-invasive techniques like 13C-magnetic resonance spectroscopy (13C-MRS) have enabled more detailed investigations. As this method is non-invasive, it allows for repeated measurements of liver glycogen content without triggering the adrenaline response that can som

Open Chapter 6_text

Introduction

An observational study published in 2024 that followed over 2,000 adults with type 1 diabetes (T1D) from the T1D Exchange Registry showed that despite advanced technologies like continuous glucose monitors (CGM) and automated insulin delivery (AID), over 40% of participants were not meeting the HbA1c (glycated haemoglobin) targets set by the American Diabetes Association [1, 2].  

The high percentage of individuals struggling to meet HbA1c targets with current treatments suggests the need for alternative intervention strategies to improve blood glucose control in people living with T1D. Encouragingly, research indicates that dietary modifications, such as reducing carbohydrate intake, could offer a promising solution. These dietary changes may be effective for weight management and preventing episodes of hypo- and hyperglycaemia [3].

But how strong are the arguments in favour of low-carbohydrate diets (LCDs), and how solid is the research backing them? If you're consi

Open Chapter 6/continued

The discovery of insulin in 1921 revolutionised T1D treatment. The starvation diet was quickly abandoned in favour of insulin therapy, with a cautious reintroduction of carbohydrates. For the next 50 years, dietary guidance for T1D emphasised controlled carbohydrate consumption and avoiding refined sugars. Strict meal plans and "exchange systems" (i.e., one exchange is the equivalent of 15 grams of carbs) were developed to monitor food portions, especially carbohydrates, to maintain blood glucose levels within a safe range.

In the 1960s, concerns emerged about the potential risks of a low carbohydrate, high saturated fat diet for individuals at elevated risk of cardiovascular complications [6]. This led to a shift in dietary recommendations for the general population, advocating for reduced fat intake (to less than 35% of total energy) and increased carbohydrate consumption to approximately 50-55% of total energy intake, predominantly from "complex" foods like peas and whole grains. Gradually

Open Chapter 7_text

Introduction

In the previous chapter, we explored the general landscape of low carbohydrate diets (LCDs) and their potential benefits for people living with type 1 diabetes (T1D). Now, we will delve deeper into the specific applications of LCDs in the context of exercise performance and adaptation. This is an incredibly captivating topic (in our opinion!), as striking the right balance could enhance training adaptations and aid in glucose management for elite and recreational athletes with T1D.

Despite ongoing debate among athletes, coaches, and sports scientists regarding low carbohydrate training, there is a notable lack of research addressing athletes with T1D. Studies conducted on individuals without T1D have shown the effectiveness of a periodic “train low, compete high” approach. This strategy involves intentionally undertaking selected training sessions with reduced carbohydrate availability to activate certain molecular pathways, thereby enhancing skeletal muscle adaptation (as

Open Chapter 8_text

Introduction

The title of this chapter may have sparked a reaction in you, perhaps even evoking feelings of frustration or rage. And we understand your sentiments completely. The topic we’re about to explore is indeed controversial and potentially unsettling. But please, bear with us. We know that living with type 1 diabetes (T1D) is far from advantageous. We wrote this chapter to explore uncharted territory and stimulate discussions. To our knowledge, there are no detailed discussions on this topic anywhere else.

The discovery of insulin by Frederick Banting and Charles Best in 1921 is widely regarded as one of the most significant breakthroughs in the history of medicine, providing a dramatic example of how basic science can be translated into remarkable patient benefits [1, 2]. If we were to travel back in time to just over a century ago, a diagnosis of T1D was akin to a death sentence. Fast forward to today, and the narrative has shifted dramatically. Thanks to insulin and other ad

Open Chapter 9_text

Introduction

Sport can be unpredictable. Factors such as competition stress or changes in environmental conditions can significantly impact glucose management. Even if you are not a competitive athlete, numerous scenarios can dramatically affect your glucose levels or require additional considerations. These may include changes in altitude or a drop in temperature during winter sports, variables related to playing Sunday league football, or scuba-diving while on holiday.

When exercise conditions vary, it is essential to be strategic and consider specific factors to manage glucose levels effectively, whether training or competing. This chapter will delve into more advanced topics related to exercise and type 1 diabetes (T1D). This includes team sports (both contact and non-contact), pre-competition stress, swimming and diving, and how to handle environmental extremes such as variations in temperature and altitude. We’ll finish by offering some insights into how exercise guidelines a

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Glucose Management During a Competitive Game or Event

During competition, aiming for a glucose level of 7-8 mmol/L (126-145 mg/dL) is a good starting point to help achieve peak performance. Having fast-acting carbohydrates and insulin readily available (depending on the constraints of the event) is crucial for immediate adjustments as needed. Environmental factors, such as weather conditions, can also impact glucose levels, with both heat and cold affecting the body’s response (see below for more details). For example, ice hockey players may experience different glucose responses than field hockey players due to the cold environment.

Proper hydration is essential, as dehydration can cause glucose levels to drop rapidly. This is particularly important in high-intensity sports like basketball and hockey, where fluid loss can be significant. Stress levels may rise at key moments of a game, which can also impact glucose levels. Higher-stakes games may cause a more significant adrenaline

Open Chapter 10_text

Follow the link to continue your journey:

https://www.enhance-d.com/

One platform for all your exercise management.

Open References_list

REFERENCES CHAPTER 1

1.             DiMeglio, L. A., et al. Type 1 diabetes. Lancet. 2018;391(10138):2449-2462.

2.             Sussman, M., et al. Estimated Lifetime Economic Burden of Type 1 Diabetes. Diabetes technology & therapeutics. 2020;22(2):121-130.

3.             JDRF. Type 1 Diabetes Index 2024 [Available from: https://www.t1dindex.org/].

4.             Green, A., et al. Type 1 diabetes in 2017: global estimates of incident and prevalent cases in children and adults. Diabetologia. 2021;64(12):2741-2750.

5.             Redondo, M. J., et al. Genetics of type 1A diabetes. Recent progress in hormone research. 2001;56:69-89.

6.             Harjutsalo, V., et al. Time trends in the incidence of type 1 diabetes in Finnish children: a cohort study. Lancet (London, England). 2008;371(9626):1777-82.

7.             Gong, B., et al. Global, regional, and national burden of type 1 diabetes in adolescents and young adults. Pediatric research. 2024.

8.             Maahs, D. M.