My latest book, Diabetes & Keeping Fit for Dummies, was released this week, just in time to help you start the new year out right. It covers everything you need to know about getting or staying fit with diabetes or prediabetes. Even if you don’t have diabetes and want to improve your insulin action and prevent type 2 diabetes, this book is for you! Check it out today! Available on Amazon.com or Dummies.com.
Much of the research on length of life for individuals living with type 1 diabetes is pessimist, which makes a new study released recently a breath of fresh air. Data were collected for the ongoing nationwide, multicenter, Finnish Diabetic Nephropathy (FinnDiane) Study that tracked the death rate of 2,639 study participants for an average of 11.4 ± 3.5 years (1).
In this study, participants’ leisure time physical activity was reported via a self-report questionnaire. Importantly, their physical activity and its intensity, duration, and frequency were examined related to dying from all causes and from cardiovascular events; some of these adults with type 1 diabetes already had diabetic kidney disease.
The researchers also looked at potentially confounding factors like sex, how long people had been diagnosed with type 1 diabetes and how old they were when they got it, as well as physical measures like their systolic blood pressure, triglycerides (blood fats), BMI (body mass index), and HbA1c (a measure of overall blood glucose control over two to three months).
The conclusions of this study came as no surprise to me: exercise is associated with a lower risk of premature death from cardiovascular or any other cause in adults with type 1 diabetes. Overall, 270 people died during the follow-up period, 127 of whom had kidney disease. Only exercise intensity was associated with cardiovascular mortality, with intense activity being best for preventing early death from cardiovascular events. Both how much total physical activity they got and how frequently they exercised were associated with a lower risk of dying from any cause. Prior studies have shown that exercise frequency may also matter in preventing such events, with a higher frequency of physical activity lowering the risk (2).
People with type 2 diabetes have already been shown to have a lower risk of premature death when they are physically active (3); this is also true for the adult population in general (4; 5). However, not as many studies have looked specifically at the association between physical activity and lower mortality risk in adults with type 1 diabetes. Type 1 diabetes has previously been associated with a shorter lifespan in many adults with it, particularly related to endothelial dysfunction and cardiovascular disease (6).
Earlier studies, such as the DCCT, have shown that keeping blood glucose levels in a more normal range can help lower the risk of diabetes-related complications in people with type 1 diabetes. Most deaths in this population are related to either cardiovascular events or kidney failure. Exercise has an innate ability to lower oxidative stress, which has been implicated in the development of many complications, as well as improve endothelial function (6). While regular physical activity is associated with a lower risk of early death in adults with and without type 2 diabetes, this study is one of the first to examine this association in type 1 diabetes.
While the exact amount of exercise needed to lower the risk of cardiovascular events is unknown and not determined by this study, doing any activity is arguably better than remaining sedentary. As in people without diabetes, intense activity likely is even more cardioprotective than moderate or light activity.
However, the exercise in this study was self-reported and only collected at the start of the study, making it is hard to draw definitive conclusions about how much exercise people need to do and how intense it needs to be to reduce the risk of dying.
In conclusion, as confirmed by this latest study, being physically active on a regular basis is critical to living long and well with type 1 diabetes. Remaining sedentary is far worse for your health and your longevity, so go get active!
- Tikkanen-Dolenc H, Waden J, Forsblom C, Harjutsalo V, Thorn LM, Saraheimo M, Elonen N, Tikkanen HO, Groop PH: Physical Activity Reduces Risk of Premature Mortality in Patients With Type 1 Diabetes With and Without Kidney Disease. Diabetes Care 2017;16:dc17-0615
- Tikkanen-Dolenc H, Waden J, Forsblom C, Harjutsalo V, Thorn LM, Saraheimo M, Elonen N, Rosengard-Barlund M, Gordin D, Tikkanen HO, Groop PH: Frequent and intensive physical activity reduces risk of cardiovascular events in type 1 diabetes. Diabetologia 2017;60:574-580. doi: 510.1007/s00125-00016-04189-00128. Epub 02016 Dec 00124.
- Loprinzi PD, Sng E: The effects of objectively measured sedentary behavior on all-cause mortality in a national sample of adults with diabetes. Prev Med 2016;86:55-57
- Biswas A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, Mitchell MS, Alter DA: Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis. Ann Intern Med 2015;162:123-132
- Chau JY, Grunseit AC, Chey T, Stamatakis E, Brown WJ, Matthews CE, Bauman AE, van der Ploeg HP: Daily sitting time and all-cause mortality: a meta-analysis. PLoS One 2013;8:e80000
- Bertoluci MC, Ce GV, da Silva AM, Wainstein MV, Boff W, Punales M: Endothelial dysfunction as a predictor of cardiovascular disease in type 1 diabetes. World J Diabetes 2015;6:679-692
Above you see part of the first page of a new consensus statement that comes from many of the individuals involved with the creation and launch of the new JDRF PEAK Performance Program, aimed at educating both clinicians and people with type 1 diabetes how to manage the complexities of being active. In my opinion, this recently published consensus statement on exercise and type 1 diabetes is long overdue and much needed. I managed to get the American Diabetes Association to let me chair an updated position statement (see my November blog) and include type 1 diabetes in it but, unfortunately, never just one addressing type 1 and exercise alone so this JDRF one fills a huge void.
The past decade has seen a growing number of publications related to diabetes management during exercise in people who have to either inject or pump insulin to stay alive. As you well know, whether insulin is injected or pumped, it is not being delivered where it normally ends up in a body that can release its own insulin, and this altered insulin delivery leads to alterations in hormones and blood glucose management by the liver. Normally, your liver would be able to either release or store glucose to keep your levels constant, but not without these proper hormonal signals.
Consequently, the only way you can keep your blood glucose levels normal (or near normal) with exercise is to take in carbohydrate/food, lower circulating insulin levels, or both during activities. Given that exercise is a huge stressor to normal metabolic control of blood glucose, it can make your diabetes more difficult to manage–even though exercising is generally beneficial for a number of other health reasons. This new consensus statement does an excellent job of covering all of the potential effects of engaging in differing physical activities, along with comprehensive management strategies involving changes in food intake and adjustments in basal and/or bolus insulin dosing. It also points out the many areas that need additional (or even any) research with regard to exercising with type 1 diabetes, either to enhance health or sports performance. Read it now if you haven’t already for some great advice!
(1) Riddell MC, Gallen IW, Smart CE, Taplin CE, Adolfsson P, Lumb AN, Kowalski A, Rabasa-Lhoret R, McCrimmon RJ, Hume C, Annan F, Fournier PA, Graham C, Bode B, Galassetti P, Jones TW, Millán IS, Heise T, Peters AL, Petz A, Laffel LM. Exercise management in type 1 diabetes: a consensus statement, Lancet Diabetes Endocrinol. 2017 Jan 23. pii: S2213-8587(17)30014-1. doi: 10.1016/S2213-8587(17)30014-1. [Epub ahead of print]
You may potentially be able to prevent, treat, or reverse impending hypoglycemia (low blood glucose) during exercise by some novel means (1). One mechanism is short sprints, while another is to alter the order in which you do different types of exercise.
Sprints: Doing a 10-second sprint either before or immediately after moderate exercise keeps blood glucose levels stable for at least two hours afterwards (2). Actually, this technique works anytime during exercise, but it doesn’t reduce the amount of carbohydrate needed to prevent hypoglycemia during the eight hours following such a sprint (3).
Sprinting will have a limited effect if you have high levels of insulin in your system or a blunted hormonal response. However, having been low beforehand doesn’t appear to diminish your body’s ability to respond to a short sprint by releasing enough glucose-raising hormones like adrenaline to raise blood glucose (4).
It’s also possible to keep your blood glucose higher during exercise by interspersing four-second sprints into an easier workout every two minutes or so (sort of like doing interval training) (5). These effects are due to a greater glucose release by your liver during exercise and less glucose uptake by muscles during exercise and recovery (6).
So, whenever you start to feel low during exercise, trying sprinting as hard as you can for 10 to 30 seconds to induce a greater release of glucose-raising hormones. This works best when you have only a limited amount of insulin circulating in your bloodstream and may not prevent hypoglycemia if you have a lot of injected or pumped insulin on board. When the hormonal effects wear off, though, be careful as you can develop hypoglycemia since sprinting uses up more of your muscle glycogen (stored carbs) that have to be replaced with blood glucose (3).
Exercise Order: Another strategy you can use for preventing exercise-induced lows is related to the order of the types of exercise you do (cardio and resistance training) (1). Blood glucose levels tend to fall more during moderate cardio training and less afterwards compared to resistance training, which causes less of a decline during and more overnight (7).
Doing both activities in one day can be done strategically. If you’re starting out with your blood glucose on the low side, do resistance training first, followed by cardio to keep your glucose higher throughout the first half of your workouts. If you’re starting out higher, begin with cardio training first (assuming it’s moderate and not intense) to lower your blood glucose levels and follow it up with resistance work, which keeps blood glucose stable (8).
Try these techniques today to stay on top of your lows and remain more active. Your body will thank you for it!
- Yardley JE, Sigal RJ. Exercise strategies for hypoglycemia prevention in individuals with type 1 diabetes. Diabetes spectrum : a publication of the American Diabetes Association 2015;28:32-8.
- 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;50:1815-8.
- Davey RJ, Bussau VA, Paramalingam N, et al. A 10-s sprint performed after moderate-intensity exercise neither increases nor decreases the glucose requirement to prevent late-onset hypoglycemia in individuals with type 1 diabetes. Diabetes care 2013;36:4163-5.
- Davey RJ, Paramalingam N, Retterath AJ, et al. Antecedent hypoglycaemia does not diminish the glycaemia-increasing effect and glucoregulatory responses of a 10 s sprint in people with type 1 diabetes. Diabetologia 2014;57:1111-8.
- Dube MC, Lavoie C, Weisnagel SJ. Glucose or Intermittent High-Intensity Exercise in Glargine/Glulisine Users with T1DM. Med Sci Sports Exerc 2013;45:3-7.
- Fahey AJ, Paramalingam N, Davey RJ, Davis EA, Jones TW, Fournier PA. The effect of a short sprint on postexercise whole-body glucose production and utilization rates in individuals with type 1 diabetes mellitus. The Journal of clinical endocrinology and metabolism 2012;97:4193-200.
- Yardley JE, Kenny GP, Perkins BA, et al. Resistance versus aerobic exercise: acute effects on glycemia in type 1 diabetes. Diabetes care 2013;36:537-42.
- Yardley JE, Kenny GP, Perkins BA, et al. Effects of performing resistance exercise before versus after aerobic exercise on glycemia in type 1 diabetes. Diabetes care 2012;35:669-75.
Has your exercise performance been less than you’d hoped recently? There are many different things that can cause fatigue, but here are some potential causes (and solutions) to consider.
Inadequate rest time: A really simple answer to your exercise issues is that you may be getting through your workouts well, but then fail to perform when you have races and events simply because you didn’t take enough rest time to restore glycogen, repair muscle damage (caused by every workout), and fully recover. It’s critical to cut back on your workouts (“taper”) for at least 1-2 days before a big event. During that time, you also want to keep your blood glucose in good control so your glycogen levels will be as full as possible on race/event day.
Blood glucose and glycogen stores: Another thing to consider is your blood glucose control. It’s harder for your body to restore your muscle glycogen (stored carbs) between workouts unless you’re eating enough carbs and have functioning insulin available. Doing longer and harder workouts can deplete glycogen stores, and you may simply just not be restoring them fully fast enough due either to your carb intake or your blood glucose management. Your carb intake doesn’t have to be tremendous—probably just 40% of your total calories coming from carbs will suffice—but you may need more if you’re not eating enough calories. Your blood glucose absolutely needs to be in good control for your muscles to store all the carbs you need to exercise optimally, so make sure your insulin is adequate and working effectively.
Iron levels: For starters, having low iron stores can cause you to feel tired all the time, colder than normal, and just generally lackluster. You can get a simple blood test done to check your hemoglobin (iron in red blood cells) and your overall iron status (serum ferritins). It’s possible to be iron deficient without having full-blown anemia. If your body’s iron levels are low (due to diabetes or non-diabetes causes), taking iron supplements can help, along with eating more red meat since it has the most absorbable form of iron.
Magnesium deficiency: Most people also have issues with magnesium deficiency, especially if you take insulin or your blood glucose levels are not well controlled. Magnesium is involved in over 300 enzyme-controlled steps in metabolism, including protein synthesis, muscle and nerve function, blood glucose control, and blood pressure regulation. If you’re deficient in this mineral, your exercise will be compromised and you may even experience some muscle cramping (unrelated to dehydration). It’s always good to eat more foods with magnesium in them—such as nuts and seeds, dark leafy greens, legumes, oats, fish, and even dark chocolate—but taking a supplement (magnesium in the aspartate, citrate, lactate, and chloride forms is absorbed better than magnesium oxide and sulfate) may help. Low magnesium can also lead to potassium imbalances, which can also affect your ability to exercise well.
B vitamin intake: For people with diabetes, thiamin deficiency is also a likely culprit for exercisers, especially if they’re not eating properly. In general, the eight B vitamins are integrally involved in metabolism and even red blood cells formation. Thiamin (B1) in particular can be depleted by alcohol intake, birth control pills, and more. People who take metformin to control diabetes can also end up deficient in vitamins B6 and B12, both of which are essential to nerve function and muscle contractions. Taking a generic B complex vitamin daily can help you avoid these issues, and excesses of most of the B vitamins are harmless (and end up in your urine).
Insulin delivery method: While insulin pumps can help manage blood glucose acutely, they deliver rapid-acting insulin analogs like Humalog, Novolog, and Apidra, and these altered insulins are metabolized in the body differently than the long-acting basal one called Lantus. Rapid ones have little to no insulin-like growth factor (IGF) affinity, and most adults are reliant on IGF to stimulate muscle growth and repair rather than human growth hormone (which is only higher in youth). Lantus does stimulate IGF one, though, so you may want to talk with your doctor about combining insulin pump use (for meal boluses) with Lantus (for basal insulin coverage) to get more IGF activity to promote muscle repair. (Go with Lantus, though, as Levemir is less effective at raising levels of bioactive IGF.)
Thyroid issues: Many people with diabetes also have thyroid hormone imbalances. Having lower levels of functioning T3 and T4 can cause early fatigue and poor exercise performance, among other things. However, it may not be enough to just check your main thyroid hormones (TSH, T3 and T4); you may also want to consider getting your thyroid antibodies checked if your thyroid hormones levels are normal and nothing else is helping your exercise (specifically check for antibodies to thyroid peroxidase), especially if you have celiac disease.
Still stumped? If you’ve been through this whole list and had everything check out okay, then consider other possible issues like your hydration status, daily carb intake (adding even just 50 grams per day to your diet may help), other possible vitamin and mineral deficiencies (vitamin D, potassium, etc.), statin use (some statins taken to lower blood cholesterol cause unexplained muscle fatigue), frequent hypoglycemia, and hypoglycemia-associated autonomic failure.
If you experience painful, involuntary contractions of your muscles, you’re having a muscle cramp. They can occur in any muscle but are most common in the legs, feet, and muscles that cross two joints, such as your calf muscle (the gastrocnemius, which crosses your knee and your ankle joints), quadriceps and hamstrings (the front and back of your thighs), and your feet. Not all of them are that painful; they range in intensity from a slight twitch to severe cramping that makes the muscle feel rock hard and that can last from a few seconds to several minutes. They can also ease up and then re-cramp several times before disappearing.
Although the exact cause of muscle cramps remains unknown, they are not inevitable. More than likely they’re likely related to either poor flexibility, muscle fatigue, and/or doing new physical activities. Athletes are more likely to get cramps in the preseason when less conditioned and more subject to fatigue. Cramps often develop near the end of unaccustomed intense or prolonged exercise or during the night following the activity.
Of course, if you’re exercising in the heat, cramps can also be related to dehydration and depletion of electrolytes (sodium, potassium, magnesium, and calcium) lost through sweating. When these nutrients fall to certain levels, you’re more likely to experience cramping, and it’s good to keep in mind that many people with diabetes already have low blood levels of magnesium. In people with diabetes, taking magnesium supplements may help reduce cramping issues. The other electrolytes like potassium and sodium can also become unbalanced during periods of uncontrolled hyperglycemia when water losses through urine are usually greater. Finally, cramps may also occur as a side effect of certain medications and other substances, such as lipid-lowering agents (statins in particular), antihypertensives, beta-agonists, insulin, oral contraceptives, and alcohol.
Cramps usually go away on their own without treatment, but there are effective ways to deal with them. For starters, stop the activity that is causing your muscles to cramp (if you can). Then, gently stretch and massage the cramping muscle, holding your joint in a stretched position until the cramp stops (such as pulling your toes toward the top of your foot if your calf muscle is cramping).
To try to prevent cramps, increase your fitness level and avoid becoming excessively fatigued during an activity. They appear to be best prevented by reducing the risk of developing premature muscle fatigue. Warm up before you start intense workouts and stretch regularly when you’re done exercising, focusing primarily on your calves, hamstrings, and quads. Avoid pointing your toes if your calves are involved. Also, always make sure to stay adequately hydrated, especially when exercising in hot and humid environmental conditions, and eat a wide variety of healthy foods that will help replenish lost electrolytes naturally. Supplementing with sports drinks can help replenish electrolytes as well, but they add excess calories and extra (rapidly-absorbed) carbohydrates, making them less desirable in most instances except when more carbohydrates are needed during exercise to prevent hypoglycemia (low blood sugars).
In summary, there are many possible causes of muscle cramps, but they do not inevitably result from physical activity prevention. Taking some simple precautions can prevent them (such as preventing dehydration and extreme fatigue during activities), and cramps can also be effectively treated if they do occur on occasion.
Last year I participated in a discussion on a Facebook group for athletes with diabetes about how hard it can be to lose weight through exercise. While I would never claim to have all the answers on this topic, here are some ideas about what can make you gain weight or keep you from losing weight with diabetes, based on my decades of professional and personal experience with diabetes and weight management, and what you can do about it.
My former graduate student with type 1 diabetes went on an insulin pump and promptly gained about 10 pounds, even though his blood glucose control improved only marginally. Why did this happen to him (and why does it happen to so many other insulin users)?
As a naturally occurring anabolic hormone, insulin promotes the uptake and storage of glucose, amino acids, and fat into insulin-sensitive cells around your body (mainly muscle and fat cells). It doesn’t matter whether it’s released naturally, injected, or pumped—all insulin and insulin analogs have these same effects. Going on intensive insulin therapy is associated with fat weight gain (1), for people with both type 1 and type 2 diabetes. Some of the weight gain comes from that if you’re using insulin to keep your blood glucose in control, you’ll be keeping and storing all of the calories that you’re eating instead of losing some glucose through urine (during hyperglycemia). Unfortunately, this realization has led some people to try skipping or limiting their insulin use to help them lose weight (2), but that is a dangerous practice that can lead to loss of excess muscle mass and life-threatening conditions like DKA.
The best way to balance your insulin use and your body weight, in my opinion, is to be physically active to keep your overall insulin levels lower. It’s easier to lose weight, too, when you’re taking less insulin—or releasing less of your own if your pancreas still does that.
Having said that, I have to say that what you choose to eat has a huge impact on your insulin needs as well as your body weight. My graduate student found that by doing frequent dosing with his insulin pump, he was eating more overall, just because he could without having to take another injection with a needle. Just because insulin use can make it easier for you to eat cake and other formerly “forbidden” foods doesn’t mean that you need to eat them!
There are advocates out there for all sorts of diets for people with diabetes, including ultra-low-carb ones (like Dr. Bernstein’s), vegan ones, etc. Personally, what I have always founds works best for weight management with diabetes is a balanced diet, nothing too extreme in any direction. People don’t necessarily lose weight on low-carb diets, even though their insulin requirements are lower because fat is so much denser in calories (at over 9 calories/gram of fat) than carbs or protein (both 4 calories per gram). If you cut carbs out of your diet, you have to eat something in its place. It’s just too easy to overdose on fat calories without realizing it, and even when your muscles become insulin resistant for any reason, insulin still usually works to put fat into storage depots around the body.
My trick is not to completely avoid carbs, but rather to choose them wisely—eating more lower glycemic index, or GI, carbs that are absorbed more slowly and don’t cause spikes in blood glucose that you have to try to match with large doses of insulin that often lead to hypoglycemia later on when the carbs are long gone and the insulin is still hanging around. Remember, most carbs are fully absorbed in the first hour or two after you eat them, and even rapid-acting insulin can linger for up to 8 hours afterward.
Besides, insulin requirements are determined by more than just carbs, as finally proven in a study in 2013 showing that eating fat with the same number of carbs increases insulin requirements (3). (I knew this through personal experience already!) It’s not just about carb counting anymore (and never has been for me); it’s about picking the right balance and type of carbs, as well as total amounts of protein (good for preventing lows 3 to 4 hours later) and fat (fully absorbed in 5 to 6 hours, causing insulin resistance).
I was contacted once by a US Olympic team handball player with type 1 diabetes who wanted to ask me why she was gaining fat weight while doing all her training. My first question to her was, “Are you treating a lot of lows?” I knew she was going to answer yes before I even heard back from her.
This phenomenon (gaining weight from treating lows) is not uncommon in people using insulin, whether they are active or not. One of the biggest deterrents to successful weight loss and prevention of weight gain with diabetes is being forced to treat frequent bouts of hypoglycemia with glucose, sugary drinks, or food. Even though these calories are necessary to treat a medical condition, they still count as calories in the body, and they can result in weight gain.
One way to cut back on lows is to decrease your insulin intake to prevent them, which may include decreasing meal-time insulin doses before exercise, insulin taken for food after exercise, and basal insulin doses to prevent later-onset hypoglycemia following activities. It also helps to more precisely treat lows instead of overtreating them (it’s harder to follow this advice when you’re low, though!) Immediately treat lows first with glucose—in the form of tablets, gels, or candy containing dextrose like Smarties)—and then reassess later if you need additional food intake (often a mix of carbs, protein, and fat) to fully correct the low and prevent lows later on. Juice, although often touted as a treatment for hypoglycemia, contains fructose (fruit sugar) that is much, much more slowly absorbed than glucose and can lead to overtreating lows while you’re waiting for the juice to kick in. Don’t eat more calories treating a low than you need to!
Lack of Physical Movement
Finally, and I probably should have listed this section first, expending more calories can help prevent weight gain, even if you take insulin. In adults with type 1 diabetes, having an active lifestyle compared to a more sedentary one has been associated with a lower BMI (body mass index) and percentage of total and truncal fat mass (5). The more you move, the less insulin your body needs to get the same glucose-lowering effect. Requiring smaller doses of insulin allows you to 1) treat lows with fewer calories overall, and 2) avoid having as many lows from being off on your dosing.
In anyone who is insulin resistant (most people with type 2 diabetes and many with type 1 who are inactive), total insulin requirements will be so much higher that there is a lot more room for error. Injected or pumped insulin is generally absorbed at a speed dictated by the dose, meaning that larger doses take longer to fully absorb and the insulin “tail” hangs around for longer. Taking or releasing less insulin due to being physically active means that all of the carbs you take will be stored as carbs in muscle or liver and not converted into fat to be stored. Stay regularly active—even if that means just standing up more or taking more daily steps–to keep your calorie expenditure high and your insulin needs low.
- Conway B, Miller RG, Costacou T, Fried L, Kelsey S, Evans RW, and Orchard TJ. Temporal patterns in overweight and obesity in Type 1 diabetes. Diabet Med 27: 398-404, 2010. (http://www.ncbi.nlm.nih.gov/pubmed/20536510)
- Ackard DM, Vik N, Neumark-Sztainer D, Schmitz KH, Hannan P, and Jacobs DR, Jr. Disordered eating and body dissatisfaction in adolescents with type 1 diabetes and a population-based comparison sample: comparative prevalence and clinical implications. Pediatr Diabetes 9: 312-319, 2008. (http://www.ncbi.nlm.nih.gov/pubmed/18466215)
- Wolpert HA, Atakov-Castillo A, Smith SA, and Steil GM. Dietary Fat Acutely Increases Glucose Concentrations and Insulin Requirements in Patients With Type 1 Diabetes: Implications for carbohydrate-based bolus dose calculation and intensive diabetes management. Diabetes care 36: 810-816, 2013. (http://www.ncbi.nlm.nih.gov/pubmed/23193216)
- Brown RJ, Wijewickrama RC, Harlan DM, and Rother KI. Uncoupling intensive insulin therapy from weight gain and hypoglycemia in type 1 diabetes. Diabetes Technol Ther 13: 457-460, 2011. (http://www.ncbi.nlm.nih.gov/pubmed/21355723)
- Brazeau AS, Leroux C, Mircescu H, and Rabasa-Lhoret R. Physical activity level and body composition among adults with type 1 diabetes. Diabet Med 29: e402-408, 2012. doi: 410.1111/j.1464-5491.2012.03757.x. (http://www.ncbi.nlm.nih.gov/pubmed/22817453)