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EXercise for Type One Diabetes (EXTOD) is a programme of work that aims to explore the barriers and benefits of physical exercise for people with type 1 diabetes (T1D). Its overarching aim is to provide evidence-based support for people with T1D to undertake safe and effective exercise, and to enjoy its associated health benefits.1 Here we outline the origins of EXTOD, a summary of what has been achieved so far, and a brief overview of future plans. The first EXTOD study was a pilot study designed to explore whether the beta cell-preserving effects of exercise that have been demonstrated in people with type 2 diabetes and animal models of T1D also applied to patients with new-onset T1D.2,3 This study was funded by the National Institute of Health Research (NIHR) and has been recently published.4 Being a pilot study, its primary aims were to address the key uncertainties in designing a definitive trial to test whether regular exercise preserves beta cells in people newly diagnosed with T1D.4 Fifty-eight adults with newly diagnosed T1D who had evidence of residual beta cell function were randomised to usual care or usual care with support to increase their levels of exercise to at least 150 min of moderate intensity exercise per week. The study showed that it was possible to recruit and randomise people with newly diagnosed T1D to a trial of an exercise intervention, and to increase and maintain their exercise levels for 12 months. However, only two-thirds of the exercise arm reached the target of ≥150 min/week. Furthermore, trial retention was challenging and 30% of the participants did not complete the study. In addition, this study showed for the first time that beta cell function, when corrected for the changes in insulin sensitivity that accompany physical exercise, may be preserved in people with T1D (Figure 1). This finding is supported by a case-control study that we carried out in which the ‘honeymoon’ period appears to be five times longer in people who regularly exercise for more than 150 min per week.5 A home-based supervised exercise programme developed by collaborators in Liverpool has recently demonstrated adherence to exercise of over 90%. Furthermore, qualitative interviews with participants from the EXTOD study have been conducted to understand how to improve retention rates in lifestyle trials with adults with new-onset T1D.6 This information will now be used to support a funding application for a formal randomised controlled trial (RCT) to explore whether physical exercise preserves residual beta cell function in adults with new-onset T1D. Within this study there will be sub-studies to understand more about how exercise affects beta cell function and viability. The ‘EXTOD Mechanisms’ study was undertaken to explore the mechanisms through which physical exercise could preserve beta cell function in T1D. Early results suggest that exercise has the potential to modulate the behaviour of immune cells that target and destroy pancreatic beta cells (manuscripts in preparation). Peripheral blood samples were taken from people with T1D before and after a bout of vigorous exercise and the behaviour of immune cells in these samples was studied. Exercise modulated the ability of immune T cells to migrate across endothelial cells in T1D. Transendothelial migration of T cells is critical to the process by EDITORIAL

EXTOD: Exploring the barriers and benefits of physical exercise for people with type 1 diabetes