A personalized approach to exercise promotion in adolescents with type 1 diabetes.

Pediatric type 1 diabetes (T1DM) is a complex disease with risks for multi-system failure (1), poor academic performance, lower life satisfaction (2–4), and early cardiovascular disease (CVD) (5–7). The risk of dying from CVD prior to age 40 yr is nearly 20-fold in persons with T1DM compared with non-diabetics (6). Declining physical activity during adolescence is problematic, particularly for those with T1DM who have an added risk for future CVD (8) and an increased incidence of hypertension (9). Regular exercise, a known intervention for combating premature heart disease (10), has multiple benefits including decreasing risk factors for macrovascular disease, increasing life expectancy (11–13), decreasing insulin requirements, lowering blood pressure, improving glucose control, CV fitness, and improving overall quality of life (QOL) (14–21). However, there are limited studies of exercise or physical activity interventions in children and adolescents with T1DM, with inconsistencies in the reported outcomes of glucose control and fitness levels (20). Most exercise programs for youths are school-or community-based (22–24). Although children and adolescents with diabetes can participate in competitive sports programs, earlier research indicates that some prefer to engage in individual exercise such as biking, swimming, or inline skating (11). Regardless of the type of involvement, 60 minutes of moderate-to-vigorous daily activity is recommended for optimal health (25, 26). The development of innovative interventions leading to healthy lifestyles during childhood, and adolescence is necessary to avert devastating CV and other associated complications of diabetes seen later in adult life. The transition to increasing autonomy with diabetes self-management for adolescents is particularly wrought with many challenges for balancing their treatment regime with school, family, and peer relationships. Research is required on individualized approaches to promoting healthy lifestyles for these adolescents that consider their unique preferences, cultural choices, and family and community resources. Thus, interventions for teens with diabetes may be more effective if focused on culturally appealing personalized exercise behaviors implemented in a setting of the teen’s own choosing. No studies have examined the effects of individualized exercise prescriptions for adolescents with T1DM that incorporate family support in a home or community setting. Therefore, we are testing such a program to determine how well adolescents adhere to their personalized exercise prescription (PEP) and to examine key behavioral factors that may influence their level of adherence, and physiological and psychosocial outcomes. To the best of our knowledge, this is the first study of youth with T1DM to incorporate longitudinal measures of adherence to an exercise study in community settings. We report the design of the intervention and methods of measurement of this ongoing study, which addresses the following research questions: What is the level of adherence to a personalized exercise intervention? Do perceptions of health, benefits or barriers to exercise, exercise self-efficacy, or family support relate to the level of adherence to a personalized exercise intervention? Are there changes in perceptions of benefits or barriers to exercise, exercise self-efficacy, family support, QOL, CV fitness or glycemic control following a personalized exercise intervention? Are changes in CV fitness and glycemic control related to the level of adherence to a personalized exercise intervention? Figure 1 illustrates the PEP intervention model. Individual characteristics (i.e., diagnosis with diabetes and current activity) and behavior-specific cognitions (i.e., preferences to exercise) are necessary components in planning individualized exercise programs with realistic goals. Physical activity is far more likely when there is a prescriptive program individualized to the specific needs of each person (27, 28). The dynamic intervention accommodates changing needs, desires, and conditions. Individualized communication and reinforcement strategies with each participant and a key family member (e.g., parent) are provided for ongoing support. Community resources are identified to establish natural supports for adherence to the exercise program, long-term maintenance, improved health status, and QOL of the adolescents with T1DM. Fig. 1 The personalized exercise prescription (PEP) intervention model modified for adolescents with diabetes.