+ MODEL. Available online at Journal of Sport and Health Science xx (2012) 1e18. Review

Transcription

1 JSHS46_proof 4 Dcmbr / Q5 Q1 Rviw Physical activity, sdntary bhaviors, physical fitnss, and thir rlation to halth outcoms in youth with typ 1 and typ 2 diabts: A rviw of th pidmiologic litratur Angla D. Lis a, *, Xiaoguang Ma b, David M. Maahs c,d, Jnnifr L. Trilk a Cntr for Rsarch in Nutrition and Halth Disparitis, Dpartmnt of Epidmiology and Biostatistics, Arnold School of Public Halth, Univrsity of South Carolina, Columbia, SC 29208, USA b Dpartmnt of Epidmiology and Biostatistics, Arnold School of Public Halth, Univrsity of South Carolina, Columbia, SC 29208, USA c Barbara Davis Cntr for Childhood Diabts, Dpartmnt of Pdiatrics and School of Public Halth, Univrsity of Colorado Dnvr, Aurora, CO 80045, USA d Dpartmnt of Epidmiology, Univrsity of Colorado Dnvr, Aurora, CO 80045, USA Dpartmnt of Biomdical Scincs, Univrsity of South Carolina School of Mdicin Grnvill, Grnvill, SC 29605, USA Abstract Rcivd 27 Jun 2012; rvisd 15 Sptmbr 2012; accptd 16 Octobr 2012 Diabts is a lading chronic disas of childhood and adolscnc. In addition to th wll-known auto-immun, insulin-dpndnt diabts mllitus (typ 1 diabts (T1D)), th past two dcads hav witnssd th mrgnc of typ 2 diabts (T2D) in childrn and adolscnts, which prviously was only sn in middl-agd or oldr adults. On of th ky componnts of diabts managmnt is physical activity (PA). Th bnficial ffcts of incrasd PA and dcrasd sdntary bhavior ar xtrmly important in youth with diabts bcaus of th markdly incrasd long-trm risk of cardiovascular disas in this population compard to prsons without diabts. This rviw aims to comprhnsivly summariz th pidmiologic, obsrvational rsarch publishd and listd in PubMd btwn 1970 and 2012 on PA and sdntary bhaviors, as wll as physical fitnss in childrn and adolscnts with T1D and T2D. Additionally, w dscrib brifly th stat of knowldg on prcivd barrirs of PA in prsons with diabts, with a focus on hypoglycmia. Finally, w provid an ovrviw of th pidmiological litratur prtaining to halth bnfits of incrasd PA in youth with T1D and T2D and brifly discuss th topic of xrcis-rlatd hypoglycmia. Copyright Ó 2012, Shanghai Univrsity of Sport. Production and hosting by Elsvir B.V. All rights rsrvd. Kywords: Cardiovascular risk; Childrn; Exrcis; Glycmic control; Hypoglycmia; Physical activity; Physical fitnss; Sdntary bhavior; Typ 1 diabts mllitus; Typ 2 diabts mllitus; Youth * Corrsponding author. addrss: lis@sc.du (A.D. Lis) Pr rviw undr rsponsibility of Shanghai Univrsity of Sport Production and hosting by Elsvir Availabl onlin at Journal of Sport and Halth Scinc xx (2012) Introduction On of th lading chronic disass of childhood and adolscnc is auto-immun, insulin-dpndnt diabts mllitus, which now is commonly rfrrd to as typ 1 diabts (T1D). In T1D, th dstruction of pancratic bta clls lads to insulin dficincy and liflong dpndncy on insulin thrapy. Unfortunatly, th risk of T1D is incrasing worldwid at about 2%3% pr yar, which has rcntly bn confirmd for non-hispanic whit youth in th Unitd Stats (USA). 13 In 2001, mor than 140,000 youth undr th ag of 20 yars in /$ - s front mattr Copyright Ó 2012, Shanghai Univrsity of Sport. Production and hosting by Elsvir B.V. All rights rsrvd. Plas cit this articl in prss as: Lis AD, t al., Physical activity, sdntary bhaviors, physical fitnss, and thir rlation to halth outcoms in youth with typ 1 and typ 2 diabts: A rviw of th pidmiologic litratur, Journal of Sport and Halth Scinc (2012),

2 JSHS46_proof 4 Dcmbr /18 2 A.D. Lis t al th USA wr affctd by this incurabl disas 4 and likly about 3 million prsons of all ag groups in total. 5,6 Rcnt stimats from th SEARCH for diabts in youth study 7 suggst that th burdn has substantially incrasd from 2001 to ,9 Dspit improvmnts in tratmnt of T1D, th trnds for cardiovascular complications hav not improvd. 10 Prsons with T1D still xhibit a gratr than thr-fold highr risk of acut cardiovascular disas (CVD) compard to prsons without diabts, rsulting in approximatly 7 yars of lowr lif xpctancy Among youth with T1D, 14% hav two or mor CVD risk factors, 16 6% hav hyprtnsion, 17 and 19% prsnt with lipid abnormalitis. 18 Whil adiposity historically has not bn considrd a charactristic of T1D, th prvalnc of ovrwight (22%) in youth with T1D is highr than thir prs without diabts (16%), whil th prvalnc of obsity is lowr in T1D (13%) than in youth without diabts (17%). 19 Th incrass in adiposity in T1D may offst som of th improvmnts mad in T1D car in th past. 20 Furthrmor, th past two dcads hav witnssd th mrgnc of typ 2 diabts (T2D) in youth, formrly known as non-insulin dpndnt diabts mllitus, and prviously only sn in middl-agd or oldr adults In , th SEARCH for Diabts in Youth study publishd som of th first population-basd data on th prvalnc and incidnc of youth T2D in th USA and found that T2D was prsnt in all racial and thnic groups. 4,25 Mor rcnt stimats from SEARCH suggst that th prvalnc has incrasd by mor than 20% from 2001 to Ovrwight and obsity ar xtrmly common in T2D, affcting about 90% of youth 19 and 92% hav two or mor CVD risk factors. 16 Hyprtnsion affcts approximatly 23% of youth with diabts and lipid abnormalitis about 33%. 18 Youth with T1D hav bn dsignatd Tir 1 (high) risk for CVD by th Amrican Hart Association (AHA), as thy constitut a population for which thr is pathological and/or clinical vidnc for manifst coronary hart disas bfor 30 yars of ag. 27 Youth with T2D hav bn dsignatd as Tir 2 (modrat) risk for CVD, which is dfind as pathophysiological vidnc for artrial dysfunction indicativ of acclratd athrosclrosis bfor 30 yars of ag. 27 In this contxt, th importanc of physical activity (PA) is vidnt, as it is on of th fw bhavioral factors that hav bn shown to dcras th risk of CVD and many othr chronic conditions. 28,29 PA is dfind as any bodily movmnt producd by skltal muscls that rquirs nrgy xpnditur. 29 It is thrfor not surprising that PA is rcognizd as on of th four cornrstons of car for prsons with diabts, along with mdical nutritional thrapy (MNT), glucos monitoring, and mdication-basd (insulin-basd for T1D) managmnt for th achivmnt of good glycmic control. 30 car is highly advancd for insulin tratmnt, glucos monitoring and MNT. 31 Howvr, clinical guidlins for xrcis and PA, although largly basd on vidnc on th rlation of PA and T2D, ar still volving for T1D youth. In addition, physical fitnss, a broad concpt ncompassing svral spcific typs of fitnss including arobic powr, strngth, flxibility, and balanc 32 is important for prsons with diabts 33 and also is closly rlatd to all-caus mortality. 34,35 Thrfor, it is includd in our rviw. According to th 2008 Physical Activity Guidlins for Amricans, bing physically activ is on of th most important stps that Amricans of all ags can tak to improv thir halth. 28 Childrn and adolscnts should ngag in 60 min daily of modrat-to-vigorous PA (MVPA). Th rcommndations by th Amrican Acadmy for Pdiatric 36 and th World Halth Organization 37 ar ssntially idntical. A joint statmnt issud by th Amrican Diabts Association and th Amrican Collg of Sports Mdicin rcommnds 150 min/wk of modrat-to-vigorous activity for adults with T2D, sprad out during at last 3 days during th wk, with no mor than 2 conscutiv days btwn bouts of arobic activity. 38 Additionally,.prsons with typ 2 diabts should undrtak modrat-to-vigorous rsistanc training at last 23 days/wk. 38 Currnt data suggst that only 8% of U.S. youth mt th 60-min/day MVPA rcommndation, basd on acclromtr data, and that many youth xhibit sdntary bhavior and ar subsquntly largly physically inactiv. 39 Summarizing what is known about currnt PA in youth with T1D and T2D in th USA and worldwid is on of th ky aims of this rviw. Additionally, w also aim to summariz information on sdntary bhaviors, dfind as. any waking bhavior charactrizd by an nrgy xpnditur 1.5 METs whil in a sitting or rclining postur according to th Sdntary Bhaviour Rsarch Ntwork (SBRN). 40 W focus on th halth risks of sdntary bhavior bcaus physical inactivity has bn idntifid as th fourth lading risk factor for global mortality causing an stimatd 3.2 million daths globally. 29 Thrfor, it is ssntial that mor information b obtaind rgarding PA and sdntary bhaviors in T1D and T2D youth. Rcntly, Chimn t al. 41 publishd a comprhnsiv rviw on th halth bnfits of PA in T1D focusing on intrvntion studis. Whil intrvntion studis ar th gold standard to dtrmining causality, thy typically rflct vry spcific, controlld conditions. Obsrvational rsarch, on th othr hand, offrs insights into th actual bhavior of individuals in fr-living situations. Thus, this rviw will focus on pidmiologic rsarch on PA, and sdntary bhaviors and physical fitnss in childrn and adolscnts (hncforth rfrrd to as youth ) with T1D and T2D, with youth broadly considrd as prsons in th first two dcads of lif. Spcifically, this rviw will addrss th following: 1. What is known about PA, sdntary bhaviors, and physical fitnss in youth with T1D and T2D, including th most frqunt typs, intnsitis, and sttings of PA bhaviors in ral-lif sttings? 2. What is known about prcivd barrirs to PA, including far of hypoglycmia, in youth with T1D? 3. What can b larnd from obsrvational rsarch to dat about th halth bnfits of PA, sdntary bhaviors and physical fitnss in youth with T1D and T2D? Plas cit this articl in prss as: Lis AD, t al., Physical activity, sdntary bhaviors, physical fitnss, and thir rlation to halth outcoms in youth with typ 1 and typ 2 diabts: A rviw of th pidmiologic litratur, Journal of Sport and Halth Scinc (2012),

3 JSHS46_proof 4 Dcmbr /18 Physical activity and diabts in youth Mthods Epidmiological studis on PA and diabts mllitus in youth wr idntifid through Mdlin/PubMd (MSH) and ky word sarch trms wr typ 1 diabts mllitus, typ 2 diabts mllitus, insulin dpndnt diabts mllitus, IDDM, and NIDDM for diabts mllitus, PA, xrcis, physical fitnss for PA and fitnss, sdntary lifstyl, sdntary bhavior, sdntary bhaviour, tlvision, vido gam, intrnt, homwork, rading, physical inactivity, mdia us, sitting for sdntary bhavior, and childrn, youth, adolscnt, childrn, prschool for youth. Initially, 837 articls wr idntifid in PubMd with th combination of abov MSH and ky word sarch trms. W limitd our sarch to includ ntris from January 1, 1970 to August 31, 2012, writtn in English and prformd on human subjcts, which rducd th numbr of articls to 760. W thn usd th filtrs from PubMd to rmov clinical trials (124), mta-analysis studis and rviws (137), clinical guidlins (4), and ditorials (15). In th nd, 480 articls wr includd in th manual rviw procss. On mmbr of th rsarch tam (XM) rviwd ths articls (titls and abstracts) idntifid from PubMd in ordr to idntify thos that clarly focusd on PA (or physical fitnss) and diabts mllitus in youth and had bn conductd with an obsrvational study dsign (.g., cross-sctional studis, cas-control studis, cohort studis, follow-up studis, cas studis and rports). For articls without abstracts or without study dsign information in th abstract, w rqustd th full-lngth vrsion of th articl. Furthr rviw of ligibl obsrvational studis was conductd by rsarch tam mmbrs (ADL, XM) with th inclusion critria in mind. To mt out inclusion critria, studis had to prsnt original data and rsults on PA, sdntary bhaviors or physical fitnss in youth with T1D or T2D and had to b obsrvational in natur. In th 480 studis, most studis wr prformd among adults, did not focus on PA or fitnss, or wr conductd with intrvntion dsigns (as th systmatic idntification of clinical trials as a publication typ in PubMd was only introducd in 2008 and applid rtrospctivly through 1991). In th nd, thr wr 38 studis mting our inclusion critria. Among ths, on lttr was includd bcaus th authors rportd original rsults. Th rfrnc list of ach ligibl publication was carfully rviwd to idntify additional studis (3 studis) which wr not idntifid in th PubMd sarch. If multipl publications originatd from th sam study, all wr includd as long as th rsults wr not duplicativ. W also includd on study focusing on nrgy xpnditur masurd using Armbands and two studis that wr in prss. In th nd, n ¼ 44 obsrvational studis on PA, sdntary bhaviors, or physical fitnss and diabts in youth wr includd. Furthrmor, sinc hypoglycmia can b a srious consqunc of PA in prsons with T1D and T2D, w also xamind ths 44 publications for studis xamining barrirs to physical activitis, spcifically far of hypoglycmia, and providd a brif ovrviw of th issu. Whil a comprhnsiv rviw of hypoglycmia is a topic onto itslf, 4245 our intrst hr was in how hypoglycmic far affcts PA and thrfor w focusd our papr accordingly. Lastly, w discussd th pidmiologic studis focusing on halth bnfits of PA or fitnss in youth with T1D or T2D in th intrst of supplmnting th intrvntion litratur, which has bn summarizd prviously Rsults 3.1. PA, sdntary bhaviors, and physical fitnss in youth with T1D and T2D Th litratur on PA and sdntary bhaviors in youth with diabts is still quit finit. PA rsarch for prsons with T1D has bn incrasing rapidly in th past dcad, whras for prsons with T2D it is still xtrmly limitd. In th following sction, w summariz th litratur with rspct to (1) th typ of instrumnts usd to assss PA and sdntary bhavior, (2) th amount and typ of activity and th amount of sdntary bhaviors obsrvd in youth with diabts, (3) how th amounts in youth with T1D and T2D compar to ach othr and to youth without diabts, and (4) what is known about fitnss lvls in youth with diabts. Tabl 1 provids a brif summary of all pidmiologic studis on PA, sdntary bhaviors and physical fitnss in youth with diabts that wr includd in this rviw. Paprs ar listd alphabtically by th first author s last nam and th citation numbr is includd in brackts Assssmnt mthods for PA and sdntary bhaviors Tabl 1 provids an ovrviw of th typs of instrumnts usd to assss PA and sdntary bhavior About half of th studis publishd to dat hav utilizd qustionnairs (ithr slf-rportd by th participants or thir parnts) with th othr half rlying on objctiv masurmnt of PA. Qustionnair-typs rangd from short scrnr instrumnts, 46,50,54,56,57,60,62,64,67,69 to longr structurd instrumnts such as th prvious day PA rcall (PDPAR), 59 3-day PA rcall (3DPAR), 58,61 7-day PA rcall, 51,52,68 th PA qustionnair (PAQ-A), 49,53 othr structurd instrumnts, 48,50,63 and th us of diaris. 65 Th vast majority of ths instrumnts hav bn validatd, and thr wr only four studis for which w could not confirm whthr validation had occurrd. 48,63,65,66 Objctiv assssmnt of PA or physical fitnss includd using hart rat monitoring, 73,74,80,84 xrcis/fitnss tsting, 70,71,78,88 pdomtrs (also known as stp countrs), 82 and acclromtrs (activity monitors that masur position and motion). 59,85,87 On study usd Armband tchnology. 53 Bfor considring what is known to dat about th amount and typ of activity obsrvd in youth with diabts, it is important to point out that a larg proportion of publishd dscriptiv paprs hav rlid on sampl sizs of lss than 100 youth, including (with a fw xcptions) 46,50,51,54,5658,60,6264,67,69,78,8082 th majority of studis that usd objctiv masurmnts. In rviwing th litratur, on nds to kp in mind that in gnral, slf-rport of PA is likly to b ovrstimatd. 90, Plas cit this articl in prss as: Lis AD, t al., Physical activity, sdntary bhaviors, physical fitnss, and thir rlation to halth outcoms in youth with typ 1 and typ 2 diabts: A rviw of th pidmiologic litratur, Journal of Sport and Halth Scinc (2012),

4 JSHS46_proof 4 Dcmbr /18 4 A.D. Lis t al Tabl 1 Summary of obsrvational studis on physical activity, sdntary bhavior, or physical fitnss in youth with diabts by instrumnt typ. Author a Plac & tim Qustionnairs/intrviws Aman t al. 46 Intrnational, 2009 Study dsign Ag rang (man SD) yars Sampl siz & composition Physical activity, fitnss, sdntary bhavior Instrumnt & rspondnt Cross-sctional T1D Qustionnair Bnvnto t al. 47,c Italy, 2010 Cross-sctional T1D Qustionnair Brnardini t al. 48 Italy, 2004 Cross-sctional T1D Qustionnair Chn t al. 49 Taiwan China, 2008 Cas-control T1D 107 controls Fainardi t al. 50 Italy, 2011 Cas-control T1D 214 controls Faulknr t al. 51,b USA, 2010 Cross-sctional T1D 42 T2D Faulknr t al. 52 USA, 2005 Cross-sctional T1D 27 T2D Fintini t al. 53,b Italy, 2012 Cas-control T1D 31 Controls PAQ-C qustionnair Participant Qustionnair Participant 7DPAR qustionnair Cycl rgomtr 7DPAR qustionnair PAQ qustionnair Tradmill Snswar armband Gallr t al. 54 Grmany, 2011 Cross-sctional T1D Qustionnair Guillory t al. 55 USA, 2012 Cross-sctional T2D GAQ qustionnair Typ of activity, fitnss or sdntary bhavior assssd Modratly physically activ (causing incrasd hart rat and/or brathlssnss) for 60 min, days in last wk; hours watching tlvision during 1 day Wkly hours spnt in sports; daily hours spnt on TV watching or computr us RPA, tim wkly spnt for physical activity and th typ of xrcis usually prformd in school and spar tim, min/wk Nin itms rfrring to physical activity during th past 7 days, physical activity lvl was dtrmind according to th man scal of th nin itms as low (2), modrat (23), and high activity (>3) RPA, occasions/wk, minuts/day, sssion tim in th day and 7 days bfor th qustionnair; TV watching and vidogams playing RPA, METs/day; VO 2pak (ml/kg/min) RPA, slp (1.0 METs), light (1.5 METs), modrat (4.0 METs), hard (6.0 METs), and vry hard (10 METs) Sdntary activity (h/day), physical activity (h/day), total daily nrgy xpnditur (cal/day), METs/day, VO 2max (ml/kg/min) RPA and mdia consumption, h/wk MVPA was calculatd basd on MET valus for youth for ach of 28 activitis, min/day Q Plas cit this articl in prss as: Lis AD, t al., Physical activity, sdntary bhaviors, physical fitnss, and thir rlation to halth outcoms in youth with typ 1 and typ 2 diabts: A rviw of th pidmiologic litratur, Journal of Sport and Halth Scinc (2012),

5 JSHS46_proof 4 Dcmbr /18 Physical activity and diabts in youth Tabl 1 (continud ) Author a Plac & tim Qustionnairs/intrviws Hrbst t al. 56 Grmany, Austria, 2007 Hrbst t al. 57 Grmany, Austria, 2006 Study dsign Ag rang (man SD) yars Sampl siz & composition Physical activity, fitnss, sdntary bhavior Instrumnt & rspondnt Cross-sctional ,251 T1D Qustionnair /parnt Cross-sctional ,143 T1D Qustionnair /parnt Loblo t al. 58 USA, 2010 Cas-control T1D 90 T2D 173 Controls 3DPAR qustionnair Participant Maahs t al. 59,b USA, 2012 Cross-sctional T1D PDPAR qustionnair acclrpatint Margirsdottir Norway, 2007 Cross-sctional T1D Intrviw t al. 60 /parnt Nadau t al. 61,b USA, 2009 Cas-control T2D 13 obs controls 12 lan controls 3DPAR qustionnair Cycl rgomtr Participant Ovrby t al. 62 Norway, 2009 Cross-sctional T1D Qustionnair Rail t al. 63 Grmany, 1999 Cas-control T1D 97 controls Qustionnair Typ of activity, fitnss or sdntary bhavior assssd RPA dfind as prformd rgularly for at last 30 min/wk, xclud school sports, RPA0 (non), RPA1 (12 tims/wk), RPA2 (3 tims/wk) RPA dfind as prformd rgularly for at last 30 min/wk, xclud school sports, RPA0 (non), RPA1 (12 tims/wk), RPA2 (3 tims/wk) About 80 activitis and EM us and tlvision us, 30-min tim incrmnt, VPA (>6 METs), MVPA (>3 METs), MPA (36 METs) Th rspondnt rportd th dominant activity and th approximat intnsity of that activity for that priod; sdntary, 50 counts/min; light, ; modrat, ; and vigorous, >2900 Daily tim spnt watching tlvision or using a computr (including tim spnt playing computr gams), h/day Habitual physical activity as a 3-day avrag of METs pr day; xrcis tsting (VO 2pak, rspiratory xchang ratio, pak work rat) Activity on wkdays and wknds and during and aftr school, VPA (>6 METs), MPA (36 METs) Tim spnt for physical activity and sports in school, in comptitiv sports, and in spar tim, h/wk (continud on nxt pag) Plas cit this articl in prss as: Lis AD, t al., Physical activity, sdntary bhaviors, physical fitnss, and thir rlation to halth outcoms in youth with typ 1 and typ 2 diabts: A rviw of th pidmiologic litratur, Journal of Sport and Halth Scinc (2012),

6 JSHS46_proof 4 Dcmbr /18 6 A.D. Lis t al Tabl 1 (continud) Author a Plac & tim Study dsign Ag rang (man SD) yars Sampl siz & composition Physical activity, fitnss, sdntary bhavior Instrumnt & rspondnt Qustionnairs/intrviws Rothman t al. 64 USA, 2008 Cross-sctional T2D Qustionnair Sacky t al. 65 UK, 1996 Cross-sctional T1D, T2D 6-day PA diary Salvatoni t al. 66 Italy, 2005 Follow-up T1D Qustionnair Schwigr t al. 67 USA, 2010 Cross-sctional T1D PACEþ girls qustionnair Shaibi t al. 68,b USA, 2009 Cross-sctional T2D 7DPAR qustionnair Cycl rgomtr Valrio t al. 69 Italy, 2007 Cas-control T1D Qustionnair Objctiv physical activity monitors Arslanian t al. 70 USA, 1990 Cas-control 27 T1D 10 controls Cycl rgomtr Participant Austin t al. 71 USA, 1993 Cas-control T1D Cycl rgomtr 18 Controls Participant Baraldi t al. 72 Italy, 1992 Cas-control T1D Tradmill 47 Controls Participant Edmunds t al. 73 UK, 2010 Cross-sctional T1D Hart rat monitoring Edmunds t al. 74 UK, 2007 Cross-sctional T1D Hart rat monitoring Gusso t al. 75 Nw Zaland, 2008 Cas-control T1D girls 8 T2D girls 20 controls Cycl rgomtr Hyman t al. 76 Franc, 2005 Cas-control T1D boys 18 controls Cycl rgomtr Hyman t al. 77 Franc, 2007 Cas-control T1D girls Cycl rgomtr 19 controls Huttunn t al. 78 Finland, 1984 Cas-control T1D PWC tst Kornhausr t al. 79 Mxico, 2011 Cross-sctional T1D Cycl rgomtr Typ of activity, fitnss or sdntary bhavior assssd Exrcis bhaviors: frquncy of xrcis for mor than 20 min (tims/wk), tlvision viwing (h/day) Daily activity from Friday to Wdnsday, ach activity was assignd a scor and activity scor was calculatd by th schm of th scoring RPA, hours of physical activity in past wk 60 min MVPA days/wk MVPA, VO 2pak (ml/kg/min) MVPA in spar tim and numbr and kind of sports playd in th last 12 months, numbr of 60 min MVPA days/wk VO 2max (ml/kg/min) VO 2max (ml/kg/min) VO 2max (ml/kg/min) Habitual physical activity: VPA (75% HRR), MVPA (50% HRR); VO 2pak Habitual physical activity: VPA (75% HRR), MVPA (50% HRR); VO 2pak VO 2max PWC 170 PWC 170,VO 2max Four succssiv sssions, 4 min VO 2max Plas cit this articl in prss as: Lis AD, t al., Physical activity, sdntary bhaviors, physical fitnss, and thir rlation to halth outcoms in youth with typ 1 and typ 2 diabts: A rviw of th pidmiologic litratur, Journal of Sport and Halth Scinc (2012),

7 Tabl 1 (continud ) Author a Plac & tim Study dsign Ag rang (man SD) yars With this cavat in mind, th following pictur mrgs on PA (Tabl 2) and sdntary bhavior pattrns (Tabl 3) in youth with diabts, ach of which will b discussd squntially by typ of diabts PA lvls in youth with T1D Studis using shortr qustionnairs or scrnr itms with mor global assssmnts of PA suggst that T1D youth ar not ntirly inactiv, as rsults rang from 22 to 76 min/day of slf-rportd PA, rcognizing that ths studis span a varity of sttings and ag groups. 47,48,50,54,56,57,63,66 According to th largst study of slf-rportd PA to dat publishd by Hrbst t al., 56,57 youth in Grmany and Austria rportd an avrag of 1.3 units of 30 min/wk of rgular PA that was conductd Sampl siz & composition Physical activity, fitnss, sdntary bhavior Instrumnt & rspondnt Qustionnairs/intrviws Massin t al. 80 Blgium, 2005 Cross-sctional T1D Hart rat monitoring Michaliszyn t al. 81 USA, 2009 Cross-sctional T1D Cycl rgomtr O Nill t al. 82 USA, 2012 Cas-control T1D Pdomtrs 49 T2D participant 127 Controls Poortmans t al. 83 Blgium, 1986 Cas-control T1D Cycl rgomtr 17 controls Roch t al. 84 UK, 2008 Cross-sctional T1D Hart rat monitoring Tradmill tst Särnblad t al. 85 Swdn, 2005 Cas-control T1D girls 49 controls Shaibi t al. 86 USA, 2008 Cas-control T1D boys 13 controls Trigona t al. 87 Switzrland, Cas-control T1D controls Williams t al. 88 Australia, 2011 Cas-control T1D 62 controls Wittmir t al. 89 Canada, 2012 Cas-control T2D 110 controls JSHS46_proof 4 Dcmbr /18 Physical activity and diabts in youth 7 Acclromtr Cycl rgomtr Acclromtr Tradmill tst Participant Submaximal stp tst Participant Cycl rgomtr Typ of activity, fitnss or sdntary bhavior assssd Light (20%40% HRR), modrat (40%50% HRR), vigorous (>50% HRR) VO 2pak Stps/day, 7 days PWC 170, VO 2max Habitual physical activity: VPA (75% HRR), MVPA (50% HRR); VO 2pak Acclromtr worn for 7 days, SLPA (<1952 counts/min), MVPA (>1952 counts/min) VO 2pak SLPA (<1999), MVPA (>2000); VO 2max Th hart rat rspons to stpping was rcordd bfor th tst, aftr 2 min of xrcis and 5 s aftr compltion of th tst Abbrviations: T1D ¼ typ 1 diabts; T2D ¼ typ 2 diabts; 3DPAR ¼ 3-day physical activity rcall; 7DPAR ¼ 7-day physical activity rcall; PDPAR ¼ prvious day physical activity rcall; PACEþ ¼patint-cntrd assssmnt and counsling for xrcis plus nutrition; PAQ-C ¼ physical activity qustionnair for childrn; PWC ¼ physical working capacity; EM ¼ lctronic mdia; RPA ¼ rgular physical activity; VPA ¼ vigorous physical activity; MVPA ¼ modrat/vigorous physical activity; MPA ¼ modrat physical activity; SLPA ¼ sdntary-to-light physical activity; MET ¼ mtabolic quivalnt; HRR ¼ hart rat rsrv; VO 2max ¼ maximal oxygn consumption; VO 2pak ¼ pak oxygn consumption. a Th studis wr sortd by th last nam of th first authors. b This study includd both qustionnair and objctiv activity tst for physical activity. c 56 of 86 participants wr schoolchildrn and 30 wr adults with a rgular mploymnt. VO 2pak outsid of school. About 45% wr not physically activ at all, 37% ngagd in 12 units of rgular PA pr wk, and 18% in 3 or mor units. Mor dtaild information can b obtaind from studis distinguishing diffrnt lvls of intnsity of activity basd on slf-rport, i.., vigorous PA (VPA), modrat PA (MPA), th aggrgatd catgory of MVPA (which is particularly important as it links to currnt guidlins), sdntary bhavior (SB), and light PA (LPA). Not that for th sak of comparability across studis, as bfor, w convrtd study-spcific masurmnt units to minuts pr day. According to studis rlying on slfrport, tim spnt in VPA by adolscnts with T1D (10 yars and oldr) rangd from 3 to 57 min/day. 58,62 Tim spnt in MVPA rangd from 65 to 156 min/day in adolscnt boys with Plas cit this articl in prss as: Lis AD, t al., Physical activity, sdntary bhaviors, physical fitnss, and thir rlation to halth outcoms in youth with typ 1 and typ 2 diabts: A rviw of th pidmiologic litratur, Journal of Sport and Halth Scinc (2012),

8 Tabl 2 Amount and typ of physical activity obsrvd in youth with diabts. Author All Mals Fmals Typ 1 diabts Studis with global masur of activity or sdntary bhavior Bnvnto t al. 47,b PA: min/day Exrcis: min/day Sports: min/day Spar tim: min/day Chn t al. 49 Low lvl: 29/93 ¼ 31.2% Modrat lvl: 45/93 ¼ 48.4% High lvl: 19/93 ¼ 20.4% Brnardini t al. 48 Exrcis: min/day Exrcis: min/day Fainardi t al. 50 PA: min/day Faulknr t al. 51 PA: METs/day Faulknr t al. 52 PA: METs/day Gallr t al. 54 PA: min/day Hrbst t al min RPA c : 1.29 tims/wk Not physically activ: 44.7% RPA c 12 tims/wk: 37.0% RPA c tims/wk: 18.3% Hrbst t al min RPA a : 1.30 tims/wk O Nill t al stps/day stps/day stps/day Rail t al. 63 PA: 58.3 min/day Salvatoni t al. 66 PA: min/day PA: min/day PA: min/day Studis masuring intnsity Aman t al min MVPA j (last wk): days 60 min MVPA j (typical wk): days Edmunds t al. 74 MVPA c : min/day MVPA d : min/day VPA c : min/day VPA d : min/day Fintini t al. 53 PAQ PA: min/day Armband PA 3 METs: min/day METs/day Total nrgy xpnditur: cal/day Activ nrgy xpnditur: cal/day Loblo t al. 58,a VPA :57 6 min/day MVPA : min/day MPA : min/day Mting VPA standard: % Mting MVPA standard: 82.3% 3.5% Maahs t al. 59 VPA f :69 min/day MPA f :911 min/day LPA f : min/day SPA f : min/day Massin t al. 80 Prschool childrn: VPA g : min/day MPA g : min/day LPA g : min/day School childrn: VPA g : min/day MPA g : min/day LPA g : min/day Tnagrs: VPA g : min/day MPA g : min/day LPA g : min/day JSHS46_proof 4 Dcmbr /18 8 A.D. Lis t al. 60 min MVPA j (last wk): days 60 min MVPA j (typical wk): days MVPA d : min/day VPA d : min/day VPA :366min/day MVPA : min/day MPA : min/day Mting VPA standard: 39.4% 4.2% Mting MVPA standard: 81.3% 3.4% Plas cit this articl in prss as: Lis AD, t al., Physical activity, sdntary bhaviors, physical fitnss, and thir rlation to halth outcoms in youth with typ 1 and typ 2 diabts: A rviw of th pidmiologic litratur, Journal of Sport and Halth Scinc (2012), Q

9 JSHS46_proof 4 Dcmbr / Tabl 2 (continud ) Author All Mals Fmals Ovrby t al yars old: VPA : min/day MPA :88 53 min/day 1119 yars old: VPA :8 24 min/day MPA :57 49 min/day 610 yars old: VPA : min/day MPA :70 51 min/day 1119 yars old: VPA :3 14 min/day MPA :47 42 min/day Roch t al. 84 MVPA c : min/day VPA c : min/day MVPA d : min/day VPA d : min/day MVPA d : min/day VPA d : min/day Särnblad t al. 85 MVPA h :56 20 min/day LPA h : min/day SPA h : min/day Schwigr t al min MVPA k (last wk): days 60 min MVPA k (typical wk): days Trigona t al. 87 MVPA i (95%CI): 53.3 ( ) min/day SLPA i (95%CI): ( ) min/day %MVPA i (95%CI) (% in total PA): 7.6 (5.99.3) N of subjcts with MVPA i > 60 min/day (%): 9 (35) Valrio t al min MVPA k : days/wk 60 min MVPA k : days/wk 60 min MVPA k : days/wk Typ 2 diabts Faulknr t al. 51 PA: METs/day Faulknr t al. 52 PA: METs/day Guillory t al. 55 MVPA: min/day MVPA: min/day MVPA: min/day Loblo t al. 58,a VPA :33 12 min/day MVPA : min/day MPA : min/day Mting VPA standard: 35.9% 9.7% Mting MVPA standard: 64.6% 7.8% Nadau t al. 61 Habitual PA: METs/day VPA :339min/day MVPA : min/day MPA : min/day Mting VPA standard: 32.9% 6.6% Mting MVPA standard: 71.3% 5.3% O Nill t al stps/day stps/day stps/day Rothman t al. 64 Excis frquncy (20 min): Non: 18% 13 tims/wk: 48% 4 tims/wk: 34% Shaibi t al. 68 MVPA: min/day MVPA: min/day Abbrviations: 3DPAR ¼ 3-day physical activity rcall; 7DPAR ¼ 7-day physical activity rcall; PACEþ¼patint-cntrd assssmnt and counsling for xrcis plus nutrition; PAQ-C ¼ physical activity qustionnair for childrn; RPA ¼ rgular physical activity; VPA ¼ vigorous physical activity; MVPA ¼ modrat/vigorous physical activity; MPA ¼ modrat physical activity; SLPA ¼ sdntary-to-light physical activity; LPA ¼ light physical activity; MET ¼ mtabolic quivalnt; HRR ¼ hart rat rsrv; PA ¼ physical activity. a Data wr collctd in 30 min blocks pr day and wr convrtd to minuts pr day for comparability to othr studis. b 56 of 86 patints wr schoolchildrn and 30 of 86 patints wr adults with a rgular mploymnt. c 30 min RPA was dfind as physical activity prformd rgularly at last onc a wk for at last 30 min (school sports wr xcludd). d Tim spnt abov 50% HRR was classifid as MVPA and abov 75% HRR was classifid as VPA. VPA, 6 METs; MVPA, 3 METs; MPA, 36 METs. f VPA was dfind as >2900 counts/min; MPA was dfind as counts/min; LPA was dfind as counts/min; SPA was dfind as <50 counts/min. g Light PA was dfind as 2040% HRR, modrat PA was dfind as 4050% HRR, and vigorous PA was dfind as >50% HRR. h MVPA was dfind as >1952 counts/min; LPA was dfind as counts/min; SPA was dfind as <100 counts/min. i MVPA was dfind as >1999 counts/min; SLPA was dfind as 1999 counts/min. j 60 min MVPA was dfind as an activity causing incrasd hart rat and/or brathlssnss for mor than 60 min. k 60 min MVPA was dfind as numbr of days in which subjcts had accumulatd 60 min of modrat/vigorous physical activity during th prvious days and for a typical wk. Plas cit this articl in prss as: Lis AD, t al., Physical activity, sdntary bhaviors, physical fitnss, and thir rlation to halth outcoms in youth with typ 1 and typ 2 diabts: A rviw of th pidmiologic litratur, Journal of Sport and Halth Scinc (2012),

10 Tabl 3 Amount and typ of sdntary bhavior obsrvd in youth with diabts. Author All Mals Fmals Typ 1 diabts Aman t al. 46 TV us wkday: min/day TV us wknd: min/day Computr us wkday: min/day Computr us wknd: min/day Bnvnto t al. 47,b TV watching: min/day Computr us: min/day Fainardi t al. 50 TV viwing: min/day Vidogams playing: min/day Fintini t al. 53 PAQ sdntary bhavior: min/day Armband: min/day T1D and from 50 to 156 min/day in adolscnt girls with T1D. 58,62 Monitor-basd studis suggst that th lowr nd of ths rangs may b mor ralistic, with studis ranging from 6 to 25 min of VPA 74,80,84 and 4670 min/day of MVPA. 74,80,84,85,87 Ths rathr wid rangs ar likly du to th wid ag rang xamind in th study populations. For th sak of comparison to a gnral population of youth, acclromtr data from th NHANES indicat that during ags 1215, adolscnt boys and girls obtain about 45 and 25 min/day of MVPA, rspctivly, whras 1619 yars old boys and girls spnd 33 and 20 min/day of MVPA, rspctivly. 39 Most studis suggst that boys with diabts tnd to b mor activ than girls with diabts. 46,48,58,62,66,69,74,84 On study rportd PA in trms of mtabolic quivalnts of a task (METs). 51,52 In trms of mting rcommndations, w focusd on youth raching at last 60 min of MVPA pr day, in lin with currnt rcommndations issud in th USA and by th World Halth Organization. 28,37 Data basd on 3DPAR suggst that about 81%82% of youth with T1D achiv 60 min of MVPA pr day, 58 which is likly a substantial ovrstimat givn that th TV us wkday: min/day TV us wknd: min/day Computr us wkday: min/day Computr us wknd: min/day Gallr t al. 54 Mdia consumption: min/day Loblo t al. 58,a TV us: min/day EM us: min/day Mting EM us standard: 34.8% 4.3% Mting TV us standard: 55.1% 4.6% TV us: min/day EM us: min/day Mting EM us standard: 49.1% 4.2% Mting TV us standard: 58.4% 4.2% Margirsdottir t al. 60 TV viwing: 114 min/day Ovrby t al yars old: TV viwing: min/day Computr us: min/day 1119 yars old: TV viwing: min/day Computr us: min/day Typ 2 diabts Loblo t al. 58,a TV us: min/day EM us: min/day Mting EM us standard: 29.5% 9.8% Mting TV us standard: 46.7% 9.7% Rothman t al. 64 TV viwing: 1 h/day: 32% 23 h/day: 39% 4 h/day: 29% Abbrviations: EM ¼ lctronic mdia, gnrally dfind as TV and computr us; TV ¼ tlvision. a Th studis wr sortd by th last nam of th first authors. b 56 of 86 participants wr schoolchildrn and 30 wr adults with a rgular mploymnt. JSHS46_proof 4 Dcmbr /18 10 A.D. Lis t al. 610 yars old: TV viwing: min/day Computr us: min/day 1119 yars old: TV viwing: min/day Computr us: min/day TV us: min/day EM us: min/day Mting EM us standard: 47.6% 6.6% Mting TV us standard: 56.9% 6.6% avrag of pdomtr-basd stps pr day (Girls: ; Boys: ) was substantially lowr than th rcommndd lvls (.g., school-ag boys: 13,00015,000, school-ag girls: 11,00012,000, and adolscnt boys and girls: 10,00011,700). 82,92 Trigona t al. 87 rportd that 35% of youth with T1D spnt a minimum of 60 min pr day ngagd in MVPA. Schwigr t al. 67 rportd an avrag of 3.1 days for mting th rcommndations, with only 4.7% of youth mting th rcommndation of 60 min of PA ach day, and 35% on 5 or mor days, but 30% rportd only on or no days pr wk of 60 min of PA. Aman t al. 46 rportd 4.2 days of mting th 60-min rcommndation for boys and 3.6 days for girls with T1D in a typical wk. In comparison, acclromtr data from th U.S. national NHANES study suggst that only 11% of boys and 4% of girls agd 1219 participat in th rcommndd amount of PA. Acclromtry is currntly th gold standard for masurmnt of PA of all ags. 93,94 Nw masurmnt tools of PA and nrgy xpnditur ar continuously bing dvlopd. SnsWar armbands ar vrsatil monitors that allow for convnint collction and Plas cit this articl in prss as: Lis AD, t al., Physical activity, sdntary bhaviors, physical fitnss, and thir rlation to halth outcoms in youth with typ 1 and typ 2 diabts: A rviw of th pidmiologic litratur, Journal of Sport and Halth Scinc (2012),

11 JSHS46_proof 4 Dcmbr /18 Physical activity and diabts in youth analysis rgarding PA in th fr-living nvironmnt. Th instrumnt has shown rasonabl concordanc with doubly labld watr for masuring daily nrgy xpnditur in frliving. 95 A rcntly publishd study rportd that th amount of PA masurd by SnsWar armbands ( h/day) was highr than that assssd by slf-rportd qustionnair ( h/day) among childrn with T1D. 53 Th SnsWar armband has bn validatd in childrn. 94 Comparison of PA lvls in youth with and without T1D yildd inconsistnt rsults. In a fw studis, including our own, both groups xhibitd similar lvls of slf-rportd VPA, MVPA, lctronic mdia and TV us 49,50,53,58,61 and thr wr no statistically significant diffrncs in trms of stps pr day. 82 Howvr, othr studis hav found PA lvls of T1D youth to b lowr than in controls without diabts 69,87 including in two small acclromtr-basd studis 85,87 and on using SnsWar armbands. 53 On study rportd highr activity lvls in youth with T1D than in controls PA in youth with T2D With rspct to youth with T2D, vry littl pidmiologic rsarch has bn publishd. 51,52,55,58,61,64,68,82 Our own work suggsts a vry low numbr of stps pr day among girls and boys ( ; , rspctivly). 82 Slf-rportd amounts of MVPA obsrvd in youth with T2D rang from 7 to 153 min/day in boys and 6141 min pr day in girls. 55,58,68 Faulknr t al. 51,52 rportd an avrag of 34 METs pr day, whil Nadau t al. 61 rportd a markdly highr avrag of 64 METs pr day in youth with T2D. Th proportion of youth with T2D who mt th 60-min MVPA standard is about 65% for boys and 71% for girls basd on slf-rportd information, 58 yt th avrag of pdomtr-basd stps pr day is lss than half of th rcommndd lvls. 82,92 Compard to youth without diabts, T2D youth sm to ngag in markdly lss PA. 58,82 In trms of stps pr day, O Nill 82 suggst a stp diffrnc, dpnding on gndr. Th fw studis that hav compard activity lvls btwn youth with T1D and T2D sm to indicat that activity lvls ar lowr in T2D than in T1D. 51,52,58,82 This diffrnc may b as larg as 2000 stps pr day 82 and mor than on mtabolic quivalnt Sdntary bhavior lvls in youth with T1D and T2D Tabl 3 summarizs data on sdntary bhaviors in youth with T1D and T2D. With rspct to sdntary bhaviors in T1D youth, all studis to dat consistntly rport a larg amount of TV watching, ranging approximatly btwn 110 and 140 min/day for adolscnt boys and girls alik. 46,47,50,58,60,62 Tim spnt on computr us by youth with T1D rangs from 40 min to 255 min/day. 47,62 Total tim spnt on lctronic mdia us and computr us, howvr, sms gratr for boys than for girls, similar to that rportd in youth without diabts 39 (90 vs. 72 min daily of wkday computr us 46 ; 105 vs. 59 min daily avrag computr us 62 ; 207 vs. 147 min daily avrag lctronic mdia). 58 Total mdia us was stimatd by Gallr t al. 54 at 174 min/day. Wknd us of TV and lctronic mdia was gratr than wkday us. 46 With rspct to rcommndations prtaining to TV watching, rcnt data by Ovrby t al. 62 from Norway, Bnvnto t al. 47 and Gallr t al. 54 from Grmany, Rothman t al. 64 and Loblo t al. 58 from th USA 58 suggst that T1D youth markdly xcd th rcommndation of 2 h of TV pr day, whras an intrnational study by Aman t al. 46 rportd TV on wkday markdly blow th rcommndation. Elctronic mdia us in T2D youth sms to b vry high with on avrag 3.6 h for boys and 2.9 h/day for girls, of which th majority is spnt watching TV. 58 Rothman t al. 64 rportd that only 32% of thir population watchd on hour of TV or lss pr day, whil th rmaind watchd 2 or mor hours. Compard to youth without diabts, 96,97 youth with T2D sm to ngag in markdly mor sdntary bhaviors. 58, Physical fitnss in youth with T1D and T2D A notworthy numbr of studis also shd light on physical fitnss lvls in youth with T1D and T2D (Tabl 4). Physical fitnss can b catgorizd as cardiorspiratory fitnss, muscular strngth, flxibility, or balanc. For this rviw, physical fitnss is dfind as cardiorspiratory fitnss (as dtrmind by maximal oxygn consumption, VO 2max, or pak oxygn consumption, VO 2pak, dpnding on th study critria); or powr output during a standardizd hart rat (PWC170). 98 Four studis to dat rport vry consistnt fitnss lvls of VO 2pak of about 3441 ml/kg/min in youth with T1D, which is considrd in th low cardiorspiratory fitnss rang for youth 51,52,70,71,99 Fitnss lvls in youth with T2D ar lowr than in T1D youth (at about 25 ml/kg/ min). 61,68,75,89 This study also compard VO 2pak and pak work rat for T2D youth compard to control youth and found markdly lowr lvls of fitnss in T2D youth. 61 In comparison, for cardiorspiratory fitnss lvls in youth, data from NHANES indicat that 1219 yars old boys hav an stimatd VO 2max rang of ml/kg/min, whil 1219 yars old girls hav an stimatd VO 2max rang of ml/kg/min, and that approximatly 65% of 1219 yars old boys and girls mt critrion-rfrncd standards (FITNESSGRAM Ò ) that ar linkd to halth outcoms. 100 Anothr masur of cardiorspiratory fitnss, th physical working capacity (PWC170) tst, is a cycl rgomtr tst that prdicts th powr output (watts) at a projctd hart rat of 170 bats pr minut (bpm). This tst is standardizd to dtrmin physical fitnss 98 and has bn usd to som succss to track physical fitnss from youth to adulthood. 101 Hyman t al. 76,77 found that 1318 yars old girls with diabts had a PWC170 ranging from 1.66 to 2.28 w/kg Far of hypoglycmia as a spcific barrir to PA in youth with diabts Whil thr ar many barrirs to PA bhaviors in gnral, far of hypoglycmia is an important additional and highly prvalnt concrn for prsons with diabts, as vidncd by svral xtnsiv rviws Th Hypoglycmia Far Plas cit this articl in prss as: Lis AD, t al., Physical activity, sdntary bhaviors, physical fitnss, and thir rlation to halth outcoms in youth with typ 1 and typ 2 diabts: A rviw of th pidmiologic litratur, Journal of Sport and Halth Scinc (2012),

12 Tabl 4 Physical fitnss in youth with diabts. Author Instrumnt Masurmnt Typ 1 diabts Arslanian t al. 70 Cycl rgomtr VO 2max : ml/kg/min Austin t al. 71 Cycl rgomtr VO 2max : ml/kg/min Baraldi t al. 72 Tradmill xrcis tst VO 2max : ml/kg/min Faulknr t al. 51 Cardiopulmonary mtabolic VO 2pak : ml/kg/min cart and cycl rgomtr Fintini t al. 53 Tradmill xrcis tst VO 2max : ml/kg/min Gusso t al. 75 Cycl rgomtr VO 2max : ml/kg/min Hyman t al. 76 Cycl rgomtr PWC 170 : W PWC 170 : w/kg Hyman t al. 77 Cycl rgomtr PWC 170 : W PWC 170 : w/kg VO 2max : ml/kg/min Kornhausr t al. 79 Cycl rgomtr VO 2max : ml/kg/min Michaliszyn t al. 81 Cycl rgomtr VO 2pak : ml/kg/min Poortmans t al. 83 Cycl rgomtr PWC 170 for HbA1 <8.5%: w/kg PWC 170 for HbA1 >8.5%: w/kg VO 2max for HbA1 <8.5%: ml/kg/min VO 2max for HbA1 >8.5%: ml/kg/min Roch t al. 84 Tradmill xrcis tst VO 2pak : ml/kg/min Shaibi t al. 86 Cycl rgomtr VO 2pak : L/min Trigona t al. 87 Tradmill xrcis tst VO 2max (95%CI): 45.5 ( ) ml/kg/min Williams t al. 88 Submaximal stp tst Rcovry hart rat: bats/min Typ 2 diabts Faulknr t al. 51 Cardiopulmonary mtabolic cart and cycl rgomtr JSHS46_proof 4 Dcmbr /18 12 A.D. Lis t al. VO 2pak : ml/kg/min Gusso t al. 75 Cycl rgomtr VO 2max : ml/kg/min Nadau t al. 61 Cycl rgomtr VO 2pak : ml/kg body mass/min VO 2pak : ml/kg lan body mass/min Shaibi t al. 68 Cycl rgomtr VO 2pak for boys: ml/kg/min VO 2pak for girls: ml/kg/min Wittmir t al. 89 Cycl rgomtr VO 2pak : ml/kg FFM/min Abbrviations: VO 2max ¼ maximal oxygn consumption; VO 2pak ¼ pak oxygn consumption. Survy is on of th most common instrumnts usd to assss this issu. 42,102 As rviwd by Barnard t al., 42 hypoglycmia avoidanc bhaviors by parnts of youth with T1D typically includ having fast-acting sugars on hand and frqunt fdings. 103 Two rcnt studis hav also shown that far of hypoglycmia is a concrt barrir to PA in adults and childrn. 104,105 Th Barrirs to PA in Diabts Qustionnair (BAPAD-1) was dvlopd and validatd by Dub t al. 105 in youth and young adults with T1D, ags 1120, with frquncy of hypoglycmia ranging from 0 to 12% and HbA 1c lvls ranging from 7.2% to10%. Constructs includ prcivd fars rlatd to diabts, physical abilitis, tim constraints, and nvironmnt. Participants indicat th dgr of liklihood that an issu will kp thm from participating in rgular PA. Th BAPAD-1 has bn shown to hav vry good psychomtric proprtis and tstrtst rliability. 105 Furthrmor, a rcnt study has shown that th BAPAD-1 has good prdictiv validity whn valuatd against acclromtr in prsons with T1D. 106 Non of th 44 studis mting th critria of this rviw rportd any data on far of hypoglycmia. Thus, to dat, thr sms to b a lack of larg, rprsntativ studis of T1D youth that hav addrssd th rlation btwn far of hypoglycmia and spcific typs of PA, including using slfrportd information on th typs of activity and objctiv information on th amount and intnsity of activity, at last within th studis abstractd in PubMd Halth bnfits of PA in youth with diabts A comprhnsiv rviw of publishd intrvntion rsarch focusing on th halth bnfits of PA in youth with T1D was rcntly publishd by Chimn t al. 41 Th authors concludd that PA (1).improvs insulin rquirmnts in typ 1 diabts but shows a limitd ffct on glycmic control, (2).improvs lipid lvls, ndothlial function and insulin rsistanc but not blood prssur, and (3).is associatd with rducd CVD and mortality in patints with typ 1 diabts. In this sction of th rviw, w provid a brif ovrviw of th currnt pidmiological studis which addrssd ths thr groups of rsarch qustions (Tabl 5) in fr-living populations. With rspct to insulin rquirmnts and glycmic control in T1D youth, thr is clarly a continuing nd to idntify ways to improv glycmic control in youth as various studis, including clinical trials, hav shown that intnsiv glycmic control prvnts or dlays th progrssion of microvascular complications of diabts and th risk of macrovascular disas Th SEARCH study has shown that 17% of T1D Plas cit this articl in prss as: Lis AD, t al., Physical activity, sdntary bhaviors, physical fitnss, and thir rlation to halth outcoms in youth with typ 1 and typ 2 diabts: A rviw of th pidmiologic litratur, Journal of Sport and Halth Scinc (2012),