**6. Results**

a standard healthy base. Thus, the daily active energy expenditure should be at least 11

**•** GrS (n=25)-children and adolescents who participated in their daily PA at school according

**•** GrR (n=28)-children and adolescents who participated in their daily PA during a rehabili‐

The first group of subjects (GrS) were asked to wear an accelerometer for 7 consecutive days, starting on the day immediately after they had received monitors at school. The second group (GrR) was monitored during the second week of a summer camp for children and adolescents

Blood samples were collected in the morning using venipuncture after overnight fast. To analyze the children and adolescents' glycemia, the measurements of glucose concentrations, and doses of insulin were repeated 6-8 times per day. The analyses of all individual daily insulin doses were compared to differences in glucose concentrations (Medtronic MiniMed Paradigm 715). Glycated hemoglobin (HbA1c) concentrations were checked (Ames DCA-2000TM Immunoassay Analyzer-normal range: 4.2-6.5%) before and at about two weeks

For each subject the mean insulin dose and the average blood glucose concentrations were monitored in the morning, afternoon, and evening. Moreover, all incidents of hypo-and hyperglycemia were monitored and recorded and so was the time of their occurrence.

Food intake was recorded and compared to dietary recommendations for all study subjects

**GrR (n=28)**

**GrS (n=25)**

Age [yr] 11.5 (3.4) 12.2 (1.5) Body height [m] 1.67 (0.1) 1.55 (0.1) Body mass [kg] 56.0 (9.6) 45.0 (1.0) BMI [kg/m2] 19.8 (1.8) 18.9 (2.3) BMI Centiles[centiles] 51.1 (22.1) 54.5 (23.2) HgA1c [%] 7.16 (0.38) 7.02 (0.3)

**Table 1.** Anthropometric and physiologic features of the study population (mean, SD)

kcal/kg/day in boys and 9 kcal/kg/day in girls on most days within a week [83].

to their educational program and own lifestyle

tation summer camp.

**4. Biochemical assessments**

after the end of the study.

[32, 84].

**Variables**

with diabetes.

76 Glucose Homeostasis

Considering the aim of the study, PA measurements were conducted in two groups:

We studied the effects of energy intake and physical activity on glycaemic control in children and adolescents suffering from diabetes type 1. The variables associated with glucose homeo‐ stasis (e.g. daily insulin doses, energy intake, and glycated hemoglobin (HbA1c) were compared during daily activities and in response to exercise/sports participation in a sample of children and adolescents with T1DM.

The assessment of nutritional status of all children and adolescents who participated in the study showed normal body mass and normal BMI percentile values (57.5 ± 20.5 and 52.7 ± 24.9, respectively). Before the study all children had similar levels of hemoglobin A1c (HbA 1c). Anthropometric features of the two study groups (GrS vs. GrR) were similar for all subjects (Table 1.) Children from the GrS accumulated an average of 8904 ± 981 steps/day while the average activity-induced energy expenditure was 248 ± 40 kcal/day and the relative energy expenditure was 6.06 ± 0.86 kcal/kg/day. The mean number of steps per day during daily PA at school (GrS) was low compared to recommended values (Fig.1).

Analysis of variance revealed a significant effect of physical activity programme during diabetes camp on daily steps (F=44.0; p<0.001) and daily energy expenditure (F=21.0; p<0.001). The two-week adherence to a structured exercise programme increased children and adoles‐ cents physical activity. Diabetic children who participated in the camp (GrR) accumulated an average of 14378 ± 1699 steps/day, corresponding to 466 ± 48 kcal/day; the relative energy expenditure was 10.4 ± 0.85 kcal/kg/day. A comparison of the study subjects who took part in their daily PA at school according to their educational program (GrS) and participants of the camp for diabetics (GrR) revealed significant differences regarding steps per day (p<0.001) and daily energy expenditure (p<0.01) between these groups (Table 2).

T1DM children participated in the camp exhibited a higher tolerance of physical exercise on each day of the investigations (Fig. 1). The average daily dose of insulin (Ins/kg) was similar for all subjects, and no significant differences were observed in GrS compared to GrR. No differences were observed in mean daily serum glucose levels between GrS vs GrR groups (p>0.05) (Table 2). However, based on the measurements of blood glucose concentrations during the day, several incidents of hypo-and hyperglycemia were observed. Two-way ANOVA revealed a significant effect of physical activity levels on hyperglycemic but not hypoglycemic incidents (GrS vs GrR; F=1014.7 p<0.001). GrR exhibited a trend to higher number of hypoglycemic events between 10.00 to 12.00 hours compared to GrS (Fig. 2).The number of hyperglycemic events differed depending on the day of the study (F=442.0, p<0.001). Higher risk of hyperglycemia was noted in children with T1DM who participated in the sports camp. A significant increase in hyperglycemic incidents was diagnosed between 12.00 to 20.00 hours (Fig.3). This trend coincided with the distribution of physical activities carried out during the camp. In the morning we used low-intensity exercise of longer duration while the intensity of afternoon exercises was higher. This might suggest that intense exercise increased the rate of hyperglycemic episodes. A large number of episodes of hyperglycemia directly related to the high intensity exercise may suggest higher glucose levels as a defense mechanism against hypoglycemia.

The analysis of variance indicated a significant effect of the week day on the insulin dose (F=2.2; p<0.05) with significantly higher doses on Sunday compared to Saturday (p<0.05). The average daily glucose concentrations were similar in both groups with a tendency to higher differences in insulin doses in GrR compared to GrS. Sunday results showed an individualized decrease of daily steps, significant increase of insulin doses, and a tendency to hyperglycemia in all investigated diabetics.

**-60**

**0**

\*p<0.05 significant differences between GrS and GrR.

**Figure 2.** The number of hypoglycemic events at particular time of the day.

**1**

**2**

**incidents/day**

**3**

**4**

ces)

**-40**

**-20**

**0**

**steps/day [%]**

**M T W Th F S Sn**

**\*\* \***

The Effects of Energy Intake, Insulin Therapy and Physical Activity on Glucose Homeostasis in…

**\***

**\*\***

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79

**\*\*\* \*\*\***

\*p<0.05; \*\*p<0.01; \*\*\*p<0.001 significant differences between GrS and GrR.

**\***

**the days of the week**

**Figure 1.** The number of steps compared to the standards in GrS and GrR. (values presented as percentages differen‐

**6-8 8-10 10-12 12-14 14-16 16-18 18-20 20-22 time of the day [hour]**

**Hypoglycemia GrR Hypoglycemia GrS**

GrR GrS

**20**

**40**

**60**

Analysis of variance revealed a significant effect of daily energy expenditure during school and rehabilitation programme activities on glycated hemoglobin (HbA1c) concentrations (F=5.3; p<0.05). A tendency to increased HbA1c levels was observed in GrS after the two weeks of study while GrR subjects had slightly lower levels after the summer camp (Fig. 4).

Participation in a particular study group had a significant effect on fat consumption (F=15.1; p<0.001) and protein content of the diet (F=6.9; p<0.01). Children with T1DM from GrR group showed higher fat intakes (p<0.05) and lower protein intakes compared to GrS group (p<0.05) (Table 3). Protein consumption was higher compared to standard dietary guidelines for children in both GrS and GrR groups (4.7 % vs 2.6% above, respectively). The average values of fat consumption exceeded standard recommendations for children being higher in GrR compared to GrS (9% vs 3.5% above). Carbohydrates consumption was lower than recom‐ mended in all investigated diabetics (12% for GrS and 15.3% for GrR below the normal ingestion). Significant correlation was observed between total energy intake and insulin dose (r=0.57; p<0.01). Lower physical activity was associated with an individualized increase of daily insulin doses in all investigated subjects.


\*\*p<0.01; \*\*\*p<0.001 significant differences between GrS and GrR.

**Table 2.** Mean energy expenditure, average number of steps, mean daily dose of insulin, and glucose concentrations on successive week days in the GrS and GrR.

The Effects of Energy Intake, Insulin Therapy and Physical Activity on Glucose Homeostasis in… http://dx.doi.org/10.5772/57590 79

\*p<0.05; \*\*p<0.01; \*\*\*p<0.001 significant differences between GrS and GrR.

number of hypoglycemic events between 10.00 to 12.00 hours compared to GrS (Fig. 2).The number of hyperglycemic events differed depending on the day of the study (F=442.0, p<0.001). Higher risk of hyperglycemia was noted in children with T1DM who participated in the sports camp. A significant increase in hyperglycemic incidents was diagnosed between 12.00 to 20.00 hours (Fig.3). This trend coincided with the distribution of physical activities carried out during the camp. In the morning we used low-intensity exercise of longer duration while the intensity of afternoon exercises was higher. This might suggest that intense exercise increased the rate of hyperglycemic episodes. A large number of episodes of hyperglycemia directly related to the high intensity exercise may suggest higher glucose levels as a defense mechanism

The analysis of variance indicated a significant effect of the week day on the insulin dose (F=2.2; p<0.05) with significantly higher doses on Sunday compared to Saturday (p<0.05). The average daily glucose concentrations were similar in both groups with a tendency to higher differences in insulin doses in GrR compared to GrS. Sunday results showed an individualized decrease of daily steps, significant increase of insulin doses, and a tendency to hyperglycemia in all

Analysis of variance revealed a significant effect of daily energy expenditure during school and rehabilitation programme activities on glycated hemoglobin (HbA1c) concentrations (F=5.3; p<0.05). A tendency to increased HbA1c levels was observed in GrS after the two weeks

Participation in a particular study group had a significant effect on fat consumption (F=15.1; p<0.001) and protein content of the diet (F=6.9; p<0.01). Children with T1DM from GrR group showed higher fat intakes (p<0.05) and lower protein intakes compared to GrS group (p<0.05) (Table 3). Protein consumption was higher compared to standard dietary guidelines for children in both GrS and GrR groups (4.7 % vs 2.6% above, respectively). The average values of fat consumption exceeded standard recommendations for children being higher in GrR compared to GrS (9% vs 3.5% above). Carbohydrates consumption was lower than recom‐ mended in all investigated diabetics (12% for GrS and 15.3% for GrR below the normal ingestion). Significant correlation was observed between total energy intake and insulin dose (r=0.57; p<0.01). Lower physical activity was associated with an individualized increase of

> **GrS (n=25)**

**Table 2.** Mean energy expenditure, average number of steps, mean daily dose of insulin, and glucose concentrations

Energy expenditure [kcal/kg/day] 6.06 (0.86) 10.4 (0.85)\*\* Average number of steps [steps/day] 8904 (981) 14378 (1699)\*\*\* Dose of insulin [u/kg/day] 0.39 (0.03) 0.41 (0.03) Glucose concentration [ mg/dl] 125.1 (8.6) 129.8 (4.5)

**GrR (n=28)**

of study while GrR subjects had slightly lower levels after the summer camp (Fig. 4).

against hypoglycemia.

78 Glucose Homeostasis

investigated diabetics.

**Variables**

daily insulin doses in all investigated subjects.

\*\*p<0.01; \*\*\*p<0.001 significant differences between GrS and GrR.

on successive week days in the GrS and GrR.

**Figure 1.** The number of steps compared to the standards in GrS and GrR. (values presented as percentages differen‐ ces)

\*p<0.05 significant differences between GrS and GrR.

**Figure 2.** The number of hypoglycemic events at particular time of the day.

**Variables**

**GrS (n=25)**

The Effects of Energy Intake, Insulin Therapy and Physical Activity on Glucose Homeostasis in…

Energy supply with diet [kcal/kg/day] 38.8 (15.6) 35.6 (10.8)

Fat intake [g/kg/day] 1.4 (0.8) 1.7 (0.7)\*

Carbohydrate intake [g/kg/day] 3.5 (1.8) 3.2 (1.2)

Protein intake [g/kg/day] 2.1 (1.5) 1.9 (0.8)\*

protocols may increase the risk of hyperglycemic episodes [51, 57, 62, 89].

maintaining normoglycemia in children with type 1 diabetes.

**Table 3.** Mean energy supply with diet, mean daily fat, carbohydrate, and protein intake on successive days of the

Children and adolescents engage in different types of exercise, most frequently in unplanned and spontaneous physical activities, which can, of course, be associated with immediate and long-term health benefits [36, 62, 85-86]. Children with T1DM gain similar health benefits from physical exercise as their healthy peers; however, due to several consequences of the disease, some specific characteristics of their adaptation to exercise should be considered. Diabetic children and adolescents differ from the healthy pediatric population in their physiological responses to exercise. They are characterized by impaired utilization of exogenous glucose as an energy source during exercise despite hyperinsulinemia and higher rates of perceived exertion, which persist after glucose ingestion [60, 87]. In patients with diabetes, exercise may increases insulin sensitivity and insulin absorption from the site of administration. Plasma glucose levels decrease during and after low-and moderate intensity exercise in response to enhanced glucose utilization in skeletal muscle [88]. In contrast, high-intensity exercise

In the present study we analyzed the level of physical activity of children and adolescents with type 1 diabetes and the effect of exercise intensity to compensate blood glucose level depending on the insulin treatment and the diet. Furthermore the aim of the study was to determine the energy expenditure associated with the programmed physical activity which is effective for

The major findings of our study are that: 1) physical activity in children with type 1 diabetes was lower than the standards for the population of healthy children and recommendations for health training, 2) programmed physical activity significantly increased daily energy expen‐ diture; however, may also increase the risk of hyperglycemia, 3) greater physical activity

\*p<0.05 significant differences between GrS and GrR.

week in the GrS and GrR.

**7. Discussion**

**GrR (n=28)**

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81

**Figure 3.** The number of hyperglycemic events at particular time of the day. \*\*p<0.01; \*\*\*p<0.001 significant differen‐ ces between GrS and GrR.

**Figure 4.** Glycated hemoglobin concentrations (HbA1c%) in GrS and GrR before and after two weeks of study.


**Table 3.** Mean energy supply with diet, mean daily fat, carbohydrate, and protein intake on successive days of the week in the GrS and GrR.
