Discussion
Our study results showed that 6.8% of the Spanish T1D population performed light PA, 20.9% moderate and 72.3% vigorous PA. These results described a higher performed PA intensity in T1D people than in the general Spanish population according to the Spanish Ministry of Health data using the same IPAQ questionnaire and similar population features (adults 15–69 y, mean age = 43 y,
n = 17,777): 35,3% light PA, 40,4% moderate and 24,3%, vigorous PA [
19]. This is an encouraging result, pointing to a higher motivation towards a healthy lifestyle in the T1D population, probably related to the effect of therapeutic education displayed in the last decades [
20].
Regarding the distribution of the total PA performed, 31.2% corresponds to vigorous activities, 38.8% to moderate and 30% to walking. Guidelines [
4] recommend that adults with T1D should engage in 150min or more of moderate-to vigorous-intensity physical activity, spread over at least three days/week, with no more than two consecutive days without activity. Attending to our results and attending exclusively to the leisure time, results indicate that the time used for moderate and vigorous activities (95.2 and 100.5min per week, respectively) could indicate that, in general, people with T1D are accomplishing this recommendation. However, reported PA presented a high inter-individual variability suggesting that an individual approach to the PA evaluation and management in this population is needed.
The data obtained regarding the vigorous activities on leisure time could indicate that the time used for sports (100.5min per week) is reduced compared with moderate and light PA (315,7min per week). For this reason, when clinical recommendations and guidelines are designed, it should be kept in mind to avoide focusing exclusively on sports or high-intensity practice.
Attending to our results of total MET minutes a week stratified by age, we observe that middle-age T1D people consumed more energy in PA than younger or older participants. Additionally, in the domestic and garden domain, the time spent in PA increased as people got older. Finn et al. [
21] data in 2021 indicated that, when stratified by age, the amount of moderate or vigorous PA decreased with age. Guidelines state that both young and adults with T1D can benefit from being physically active, and thus, activity should be recommended to all [
4,
11].
Our results showed that men generally spend more energy (METs) than women, except for the domestic and garden domain. These differences were more noticeable in vigorous METs (2865.80 in men vs 1352.12 in women). In agreement with these results, a Spanish population-based study reported a higher proportion of women performing lower energy expenditure in physical activities [
22]. The McCarthy et al. study (2017), showed that more women were in the sedentary category compared to men in adults with type 1 diabetes [
23]. Another recent publication demonstrated that more men than women met the PA guidelines [
21]. However, the time spent by women on the domestic and garden domain was clearly higher than in men (639.03 vs 344.39min/week,
p < 0.001). It supports the persistence of the traditional sex roles also in this population.
A correlation between overall glycemic control (HbA1c) and the METs performed by the participants was not observed. In a systematic review in people with T1D [
9], reductions of HbA1c by exercise intervention were observed. However, another literature review [
5] reported that studies investigating the effect of PA on glycemic control in T1D have largely failed to demonstrate a benefit. It should be mentioned that the Spanish RECORD guideline on clinical recommendations for the practice of sports in people with diabetes mellitus have reported that there is not sufficient evidence to conclude that sustained exercise consistently improves HbA1c levels in adults with T1D [
12]. The acute effect of PA on glycemic control after exercise remains unclear, probably depending on the duration, type and the insulin treatment management [
24]. However, PA should be recommended due to its other benefits to the cardiovascular system. In this line, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) [
25], even recognizing gaps in evidence on independent effects of PA on beta-cell function and HbA1c, included in its recent guideline on T1D management that people with T1D should be encouraged to engage in exercise because of improved fitness, increased insulin sensitivity, reduced insulin requirement, improved cardiovascular, and decreased mortality. Additionally, a more comprehensive description of glycemic control, including glycemic variability and glucometrics derived from continuous glucose monitoring, could be more precise to describe the effects of PA on glycemic dynamics in T1D people [
13,
24].
Several studies have reported outcomes where PA seems to be beneficial in people with T1D, playing, for instance, an important role in the prevention of cardiovascular disease [
5,
9,
26]. It is worth mentioning a longitudinal study [
27] that assessed the benefit of cycling in persons with diabetes whose results showed that cycling was associated with at least a 24% lower all-cause mortality when compared with noncyclists, independent of other physical activities and possible confounders. In Spain, low PA is rising, especially among women [
22]. In 2019, a meta-analysis revealed that exercise training might result in positive changes in biological cardiovascular risk factors, including aerobic fitness, HbA1c, insulin dosage, and lipids in persons living with T1D [
9]. However, in our study only the energy (METS) consumed in vigorous PA could positively affect the predicted 10-year cardiovascular risk.
Finally, we did not observe a correlation between the rest of the studied variables (therapeutic education, the types of insulin therapies, hypoglycemia and complications of the disease in patients diagnosed with T1D) with the PA performed by the participants.
One strength of our study is the representativity of the T1D population from the sample. Our study reports age (38.8 + 12.8years), BMI (25.2 + 4.2kg/m2), T1D evolution (19.1 ± 11.7years) and mean HbA1c (7.6 ± 1.1%[60 ± 12mmol/mol]), in concordance with other epidemiological studies in Spain [
28,
29] and other countries [
21,
26].
One limitation of this SED1 study is related to the cross-sectional study design, with no longitudinal data obtained that does not allow to determine the cause and effect. As a second limitation, the IPAQ scale is a self-report questionnaire, which may have led to overreporting of PA by participants with low capacity for PA. Finally, and also related to the IPAQ questionnaire itself, it is related to the validity of IPAQ in the elderly (age 65 and older), which has not yet been determined. However, this population group represented less than 4% of the sample.
In conclusion, the Spanish T1D population performed PA in a higher frequency and intensity than the general population and accomplished with general clinical recommendations. Nevertheless, a great interindividual variability is present. A relationship between PA and overall glycemic control could not be shown. However, the study's limitations should be kept in mind to discard a long-term positive influence. Some results offer opportunities to improve, such as the equity between sex in PA performance and the leisure time deserved for sports.
Acknowledgements
Sanofi provided logistical support for the research. Main authours would like to thank all participant physicians members of the SED for their dedication to participant care; and Anna de Prado and Neus Canal from IQVIA Information S.A Spain for conducting the study, medical writing the statistical analysis.
CONSORTIUM NAME
SED1 study Investigators
Isabel Serrano Olmedo6, Francisco Tinahones Madueño7, Florentino Carral San Laureano8, Martín López de la Torre9, Alberto Moreno Carazo10, Javier Acha Pérez Hospital11, Orosia Bandrés Nivela12, Edelmiro Menéndez2, Lluís Masmiquel Comas13, Francisca Payeras14, Ignacio Llorente Gómez15, Juan Angel Hernández Bayo16, Coral Montalbán17, Fernando Gómez-Peralta1, Daniel de Luis18, Gonzalo Díaz Soto18, Antonio López-Guzmán19, Estefania Santos Mazo20, Luz Mª López Jiménez21, Visitacion Alvarez22, Benito Blanco Samper23, Ana Chico Ballesteros24, Belen Dalama Gómez25, Ignacio Conget4, Manuel Pérez Maraver26, Berta Soldevila27, Ismael Capel Flores28, Marta Hernández García29, Wifredo Ricart30, Ana Megia Colet31, Elisenda Climent Biescas32, Francisco Javier Ampudia Blasco33, Antonio Hernández Mijares34, Carlos Sánchez Juan35, Antonio Picó36, José Ramón Domínguez Escribano37, Carmiña Fajardo Montañana38, Teresa Pedro39, Pablo Abellán40, Paolo Rossetti41, Francisco M. Morales-Pérez42, Fidel Enciso43, Alfonso Soto González44, Diego Bellido Guerrero45, Reyes Luna Cano46, José Manuel García López47, Víctor M. Andía Melero48, José Alfonso Arranz Martín49, Sharona Azriel Mira50, Marta Botella Serrano51, Miguel Brito Sanfiel52, Alfonso Calle Pascual53, Francisco Javier del Cañizo Gómez54, Manuel Ángel Gargallo Fernández54, Fátima Illán55, Antonio M. Hernández Martínez56, Lluis Forga Llenas57, Sonia Gaztambide58, Clara Rosario Fuentes Gómez59, Amelia Oleaga60, Mª Ángeles Martínez de Salinas Santamaría61, Juan Pedro López-Siguero62, Ana Lucía Gómez-Gila63, Alfonso María Lechuga Sancho64, Marta Ferrer Lozano65, Isolina Riaño Galán66, María Caimari67, Roque Cardona68, María Clemente León69, Gemma Carreras González70, Francisco Javier Arroyo Diez71, Paloma Cabanas Rodríguez47, Belén Roldán72, Noemí González Pérez de Villar73, Purificación Ros Pérez52, Itxaso Rica58, Ignacio Diez López.59
1 Endocrinology and Nutrition Unit, Hospital General de Segovia, Segovia, Spain; 2 Endocrinology and Nutrition Service; Hospital Universitario Central Asturias, Oviedo, Spain; 3 Centro de Salud de Barbastro, Huesca, Spain; 4 Endocrinology and Nutrition Unit, Hospital Clínic, Barcelona, Spain; 5 SED1 study Investigators, Sociedad Española de Diabetes – SED, Madrid, Spain; 6 Hospital Virgen Macarena, Sevilla, Spain; 7 Hospital Univ. Virgen De La Victoria, Málaga, Spain; 8 Hospital Puerto Real, Cádiz, Spain;9 Hospital Univ. Virgen De Las Nieves, Granada, Spain; 10 Hospital de Jaén, Jaén, Spain; 11 Hospital Univ. Miguel Servet, Zaragoza, Spain; 12 Hospital Royo Vilanova, Zaragoza, Spain; 13 Hospital Son Llatzer, Mallorca, Spain; 14 Hospital Comarcal de Manacor, Manacor, Spain; 15 Hospital Univ. Nuestra Sra Candelaria, Tenerife, Spain; 16 Hospital General de La Palma, Breña Alta, Spain; 17 Hospital Univ. Marqués De Valdecilla, Santander, Spain; 18 Hospital Clínico Univ. Valladolid, Valladolid, Spain; 19 Complejo Asistencial De Ávila, Ávila, Spain; 20 Hospital Univ. Burgos, Burgos, Spain; 21 Complejo Hospitalario Univ. de Albacete, Albacete, Spain; 22 Hospital Univ. de Guadalajara, Guadalajara, Spain; 23 Hospital Nuestra Señora Del Prado,Talavera, Spain; 24 Hospital Sant Pau, Barcelona, Spain; 25 Hospital Univ. Vall Hebrón, Barcelona, Spain; 26 Hospital Univ. Bellvitge, Barcelona, Spain; 27 Hospital Germans Trias I Pujol, Barcelona, Spain; 28 Hospital Parc Tauli De Sabadell, Sabadell, Spain; 29 Hospital Arnau De Vilanova De Lleida, Lleida, Spain; 30 Hospital Josep Trueta, Girona, Spain; 31 Hospital JOAN XXIII, Tarragona, Spain; 32 Hospital de Mataró, Mataró, Spain; 33 Hospital Clinico Univ. De Valencia, Valencia, Spain; 34 Hospital Dr. Peset, Valencia, Spain; 35 Hospital General Univ. Valencia, Valencia, Spain; 36 Hospital General Univ. Alicante, Alicante, Spain; 37 Hospital San Juan De Alicante, Alicante, Spain; 38 Hospital De La Ribera Alzira, Valencia Spain; 39 Hospital Denia, Denia, Spain; 40 Complejo Hosp. Univ. Castellon, Castellon, Spain; 42 Hospital Gandía, Gandía, Spain; 42 Complejo Hospitalario Univ. Badajoz, Badajoz, Spain; 43 Complejo Hospitalario Univ. Cáceres, Cáceres, Spain; 44 Hospital A Coruña, A Coruña, Spain; 45 Hospital de Ferrol, Ferrol, Spain; 46 Hospital de Vigo, Vigo, Spain; 47 Hospital Clínico de Santiago (Hospital de Conxo), Santiago de Compostela, Spain; 48 Hospital Univ. Gregorio Marañon, Madrid, Spain; 49 Hospital Univ. La Princesa, Madrid, Spain; 50 Hospital Infanta Sofía, San Sebastián de los Reyes, Spain; 51 Hospital Univ. Príncipe de Asturias, Alcalá de Henares, Spain; 52 Hospital Univ. Puerta de Hierro, Madrid, Spain; 53 Hospital Clínico San Carlos, Madrid, Spain; 54 Hospital Infanta Leonor, Madrid, Spain; 55 Hospital Morales Messeguer, Murcia, Spain; 56 Hospital Virgen Arrixaca, Murcia, Spain; 57 Complejo Hospitalario Navarra, Pamplona, Spain; 58 Hospital de Cruces, Barakaldo, Spain; 59 Hospital Univ. Arava, Vitoria, Spain; 60 Hospital Basurto, Basurto, Spain; 61 Hospital San Pedro, Logroño, Spain; 62 Hospital Materno-Infantil—H. Regional Univ. de Málaga, Málaga, Spain; 63 Hospital Infantil Virgen del Rocío, Sevilla, Spain; 64 Hospital Univ. Puerta del Mar, Cádiz, Spain; 65 Hospital Miguel Servet, Zaragoza, Spain; 66 Hospital Univ. Central de Asturias, Oviedo, Spain; 67 Hospital Son Espases, Palma de Mallorca, Spain; 68 Hospital Sant Joan de Deu, Barcelona, Spain; 69 Hospital Vall Hebrón, Barcelona, Spain; 70 Hospital Sant Pau, Barcelona, Spain; 71 Hospital Perpetuo Socorro, Badajoz, Spain; 72 Hospital Univ. Ramón y Cajal, Madrid, Spain; 73 Hospital Univ. La Paz, Madrid, Spain.