Fear of hypoglycemia limits physical activity in adults with type 1 diabetes

Despite high use of continuous glucose monitoring and insulin pump therapy, fear of hypoglycemia (low blood sugar) remains a significant barrier to physical activity and exercise for adults with type 1 diabetes (T1D), according to new research to be presented at this year's Annual Meeting of The European Association for the Study of Diabetes (EASD), Madrid (9-13 Sept).

However, the findings suggest that if exercise and diabetes management are discussed in the clinic, this fear could be reduced.

Regular exercise can help individuals with diabetes to achieve their blood glucose goals, improve their body composition and fitness, as well as reduce their risk of heart attacks and strokes which is higher in people with type 1 diabetes. Yet many people living with type 1 diabetes do not maintain a healthy body weight or manage to do the recommended amount of physical activity each week."

Dr. Catriona Farrell, lead author from the University of Dundee, Scotland, UK

A number of previous studies have examined barriers to exercise in T1D, but these have been limited by their small sample size.

To fill this important evidence gap, researchers from the University of Dundee assessed knowledge and barriers to physical activity in adults with T1D and associated predictive factors.

Adults with T1D were recruited from the NHS Research Scotland Diabetes Network (research register) and internationally via social media.

Overall, 463 adults, 221 men and 242 women, with T1D answered an anonymous web-based questionnaire to assess barriers to physical activity (measured on the modified Barriers to Physical Activity in Type 1 Diabetes [BAPAD-1] scale), diabetes management, and attitudes to exercise and sport.

Participants were asked to rate on a 7-point Likert scale (1, extremely unlikely to 7, extremely likely) the chance that each of 13 factors would keep them from doing regular physical activity in the next 6 months. Factors included: loss of control over diabetes, the risk of hypoglycemia, the fear of being tired, the fear of getting hurt, a low fitness level, and lack of social support.

Researchers calculated average scores for each factor and assessed which were most correlated with perceived barriers to physical activity, as well as identifying independent predictors.

The participant reported median age of respondents was 45-54 years, median disease duration 21-25 years, and median HbA1c 50-55 mmol/mol (an ideal level is 48 50-55 mmol/mol or below).

Over three-quarters (79%) of respondents reported using continuous or flash glucose monitoring, around two-thirds (64%) said they were treated with multiple daily insulin injections, and over a third (36%) reported used insulin pump therapy.

The researchers identified that despite advances in technologies and diabetes management, risk of hypoglycemia with exercise remains a significant barrier to physical activity.

Importantly, participants who best understood the importance of adjusting insulin dose before and after exercise as well as adjusting carbohydrate intake for exercise were found to be less fearful of hypoglycemia associated with physical activity. This knowledge is essential in order to adapt insulin and/or carbohydrate intake to prevent hypoglycemia induced by exercise.

The researchers also found that being asked about exercise or sport within a diabetes clinic was negatively correlated with fear of hypoglycemia, and identified exercise confidence as the strongest independent predictor of fear of physical activity.

"Our findings demonstrate that in order to break down the barriers to physical activity, and empower our patients to exercise safely and effectively, we need to improve the education we provide and our dialogue about exercise in clinics," said Dr Farrell. "In turn, this should help them to achieve the multitude of health benefits that exercise offers."