Challenges and Opportunities in the Management of Cardiovascular Risk Factors in Youth With Type 1 Diabetes: Lifestyle and Beyond

The Effects of Exercise Training on Body Composition and Cardiometabolic Risk Factors in Type 1 Diabetes Mellitus: A Systematic Review and Meta-Analysis

INTRODUCTION AND AIM

We performed a systematic review and meta-analysis to investigate the effects of exercise training on body composition and cardiometabolic health in patients with Type 1 diabetes (T1D).

METHOD

A search in three main databases including PubMed, Web of Science, and Scopus was conducted from the inception of this review until June 2024 to identify randomized control trials investigating the effects of exercise training compared to a control on body composition and cardiometabolic risk factors in patients with T1D. The data were pooled using random effects models to calculate weighted mean differences (WMDs), standardized mean differences (SMDs), and 95% confidence intervals (CIs).

RESULTS

Overall, 25 studies involving 1120 patients with T1D were included in the meta-analysis. Exercise training decreased body mass index (BMI) [WMD: -0.18 kg.m2, p = 0.02], fasting glucose [WMD: -14.97 mg/dl, p = 0.01], and HbA1c [WMD: -0.49%, p = 0.003], and increased VO2max/peak [WMD: 2.76 mL/kg/min, p = 0.001] as compared with controls. Exercise training had no effect on body fat percentage or lean body mass, lipid profiles, or blood pressure. Subgroup analysis indicated that age, exercise mode, and intervention duration were the main moderators for the beneficial effects of exercise training.

CONCLUSIONS

In patients with T1D, exercise training is effective for decreasing body weight and cardiometabolic risk factors.

Adolescents and type 1 diabetes: A grounded theory on adolescents' experiences of adaptation to type 1 diabetes

PURPOSE

Type 1 diabetes influences adolescents' health status and therapeutic management. Adaptation for adolescents with type 1 diabetes is considered a significant issue for this cohort group and is based on many factors, including availability of resources, and family and community support. Thus, this study aimed to explore Palestinian adolescents' experiences of adaptation to type 1 diabetes in the West Bank.

DESIGN AND METHODS

A qualitative grounded theory approach was adopted. The purposive sample consisted of fourteen adolescents aged from 12 to 18 years and diagnosed with type 1 diabetes. The data were collected using semi-structured and face-to-face individual interviews during the period from March to June 2023. A constant comparative method was used to analyze data.

FINDINGS

The core category had emerged with categories and subcategories. There were three categories and ten subcategories including difficulties in the management of type 1 diabetes, for example, "insulin injections, dietary management, and control of HbA1c levels", burdens of type1 diabetes, for example, "burden regarding follow-up treatment, the burden of interaction and communication, emotional burden, and economic burden", and fears and worries of unexpected future life, for example, "worries about disease complications, worries regarding social relationships, and worries about marriage and parenthood".

CONCLUSION

Adolescents diagnosed with type 1 diabetes suffer from difficult experiences influencing their adaptation to this disease.

PRACTICE IMPLICATIONS

Counseling programs concerning self-care management for those adolescents need to be developed in addition to support programs. Health education programs are needed to develop their adaptation and coping skills to these experiences.

Exercise and Self-Management in Adults with Type 1 Diabetes

PURPOSE OF REVIEW

The purpose of this review paper is to examine the most recent evidence of exercise-related self-management in adults with type 1 diabetes (T1D).

RECENT FINDINGS

This paper reviews the benefits and barriers to exercise, diabetes self-management education, the role of the healthcare provider in assessment and counseling, the use of technology, and concerns for special populations with T1D. Adults with T1D may not exercise at sufficient levels. Assessing current levels of exercise, counseling during a clinical visit, and the use of technology may improve exercise in this population.

Caring for Young Adults With Diabetes in the Adult Care Setting: Summary of a Multidisciplinary Roundtable

Aims

A multidisciplinary team of clinicians and researchers, patients and family members, and representative from national advocacy groups and research organization met to review the literature, highlight gaps, and identify best practices to improve adult care delivery for young adults (YA) with diabetes.

Methods

The participants prepared presentations in advance, rotated through sessions, and contributed to group discussions in three areas: physical health, mental health, and quality of life (QoL). Session moderators and scribes used thematic analysis to summarize discussions for each topic.

Results

Thematic analysis revealed four foci for addressing physical health, mental health and QoL: 1) best practices to facilitate the process of transfer; 2) age-specific curricula and guidelines for prevention and management of comorbidities and complications; 3) collaboration with behavioral health clinicians to address diabetes distress and mental health disorders; and 4) research on the impact of diabetes on QoL in YA.

Conclusion

There was substantial interest and need among adult clinicians to work in concert with pediatric and mental health professionals to identify best practices and future directions to improve healthcare process and diabetes-related outcome measures in YA with diabetes.

Too Much Dietary Flexibility May Hinder, Not Help: Could More Specific Targets for Daily Food Intake Distribution Promote Glycemic Management among Youth with Type 1 Diabetes?

Average glycemic levels among youth with type 1 diabetes (T1D) have worsened in some parts of the world over the past decade despite simultaneous increased uptake of diabetes technology, thereby highlighting the persistent need to identify effective behavioral strategies to manage glycemia during this life stage. Nutrition is fundamental to T1D management. We reviewed the evidence base of eating strategies tested to date to improve glycemic levels among youth with T1D in order to identify promising directions for future research. No eating strategy tested among youth with T1D since the advent of flexible insulin regimens—including widely promoted carbohydrate counting and low glycemic index strategies—is robustly supported by the existing evidence base, which is characterized by few prospective studies, small study sample sizes, and lack of replication of results due to marked differences in study design or eating strategy tested. Further, focus on macronutrients or food groups without consideration of food intake distribution throughout the day or day-to-day consistency may partially underlie the lack of glycemic benefits observed in studies to date. Increased attention paid to these factors by future observational and experimental studies may facilitate identification of behavioral targets that increase glycemic predictability and management among youth with T1D.

Multi-Faceted Influence of Obesity on Type 1 Diabetes in Children - From Disease Pathogenesis to Complications

The prevalence of overweight and obesity among youth patients with diabetes type 1 is increasing. It is estimated, that even up to 35% of young patients with this type of diabetes, considered so far to be characteristic for slim figure, are overweight or even obese. General increase of obesity in children's population complicates differential diagnosis of the type of diabetes in youths. Coexistence of obesity has clinical implications for all stages of diabetes course. It is confirmed that obesity is the risk factor for autoimmune diabetes, and is connected with the earlier onset of diabetes in predisposed patients. Many diabetic patients with obesity present additional risk factors for macroangiopathy, and are recognised to present metabolic syndrome, insulin resistance, and typical for diabetes type 2 - polycystic ovary syndrome, or non-alcoholic fatty liver disease. The prevalence of obesity rises dramatically in adolescence of diabetic child, more often in girls. It has negative impact on metabolic control, glycaemic variability and insulin demand. The risk for microangiopathic complications increases as well. The treatment is difficult and includes not only insulinotherapy and non-pharmacological trials. Recently treatment of insulin resistance with biguanids, and treatment with typical for type 2 new diabetes drugs like GLP-1 analogues, SGLT-2 receptor inhibitors, or even cases of bariatric surgery also has been reported.

Exercise, type 1 diabetes mellitus and blood glucose: The implications of exercise timing

The scientific literature shows that exercise has many benefits for individuals with type 1 diabetes. Yet, several barriers to exercise in this population exist, such as post-exercise hypoglycaemia or hyperglycaemia. Several studies suggest that the timing of exercise may be an important factor in preventing exercise-induced hypoglycaemia or hyperglycaemia. However, there is a paucity of evidence solely focused on summarising findings regarding exercise timing and the impact it has on glucose metabolism in type 1 diabetes. This report suggests that resistance or high-intensity interval exercise/training (often known as HIIT) may be best commenced at the time of day when an individual is most likely to experience a hypoglycaemic event (i.e., afternoon/evening) due to the superior blood glucose stability resistance and HIIT exercise provides. Continuous aerobic-based exercise is advised to be performed in the morning due to circadian elevations in blood glucose at this time, thereby providing added protection against a hypoglycaemic episode. Ultimately, the evidence concerning exercise timing and glycaemic control remains at an embryonic stage. Carefully designed investigations of this nexus are required, which could be harnessed to determine the most effective, and possibly safest, time to exercise for those with type 1 diabetes.

Dyslipidaemia in Type 1 Diabetes: Molecular Mechanisms and Therapeutic Opportunities

Cardiovascular disease (CVD) is the leading cause of death in Type 1 Diabetes (T1D). The molecular basis for atherosclerosis in T1D is heavily influenced by hyperglycaemia and its atherogenic effects on LDL. Ongoing research into the distinct pathophysiology of atherosclerosis in T1D offers exciting opportunities for novel approaches to calculate CVD risk in patients with T1D and to manage this risk appropriately. Currently, despite the increased risk of CVD in the T1D population, there are few tools available for estimating the risk of CVD in younger patients. This poses significant challenges for clinicians in selecting which patients might benefit from lipid-lowering therapies over the long term. The current best practice guidance for the management of dyslipidaemia in T1D is generally based on evidence from patients with T2D and the opinion of experts in the field. In this review article, we explore the unique pathophysiology of atherosclerosis in T1D, with a specific focus on hyperglycaemia-induced damage and atherogenic LDL modifications. We also discuss the current clinical situation of managing these patients across paediatric and adult populations, focusing on the difficulties posed by a lack of strong evidence and various barriers to treatment.

Does Hashimoto's Thyroiditis Increase the Risk of Cardiovascular Disease in Young Type 1 Diabetic Patients?

Background: Immunological and hormonal disorders have undoubted influence on the development of atherosclerotic process. Autoimmune diseases accompanying type 1 diabetes (T1D) may additionally accelerate atherosclerosis progression and increase the risk of cardiovascular events in the future. The influence of subclinical hypothyroidism on the cardiovascular system, in particular, has recently aroused great interest. The aim of our study was to assess intima-media thickness (cIMT) of common carotid arteries and the occurrence of classical atherosclerosis risk factors together with selected new biomarkers of cardiovascular diseases in young patients with type 1 diabetes mellitus coexisting with Hashimoto's disease (HD). Patients and Methods: The study included 50 adolescents and young adults with T1D with mean age 17.1 ± 3 years, with mean diabetes duration of 10.5 ± 3.3 years, including 20 patients with diagnosed HD: T1D and HD(+), and 30 patients with no additional diseases: T1D and HD(-). Twenty-two healthy, age-matched volunteers formed control group (C). We analyzed mean HbA₁c value from all years of disease, BMI, blood pressure, lipids, new biomarkers of atherosclerosis (hsCRP, adiponectin, myeloperoxidase, NT-proBNP peptide, vitamin D), and cIMT of common carotid arteries. Results: In the group of patients with T1D and HD(+), significantly higher BMI was found: 23.3 ± 4.4 vs. 21.28 ± 2.9 in group HD(-) and 19.65 ± 2.4 kg/m² in group C (p = 0.003), and higher waist circumference: 79 ± 10.9 vs. 75.10 ± 7.6 in group HD(-) vs. 69.0 ± 7.4 cm in group C (p < 0.001). The mean value of HbA₁c was higher in group T1D and HD(+): 8.8% than in group HD(-): 8.1% (p = 0.04). Significantly higher concentration of hsCRP and lower vitamin D were observed in T1D and HD(+) in comparison to T1D and HD(-) and the control group. The IMT index in the HD(+) group was 0.46 ± 0.05 mm and was comparable to the HD(-) group but significantly higher than in healthy controls: 0.41 ± 0.03 mm (P < 0.05). Conclusions: Young patients with type 1 diabetes mellitus and with coexisting Hashimoto's thyroiditis have a higher BMI, a higher waist circumference, and a higher HbA₁c value, which altogether may cause faster development of macroangiopathy in the near future. Additional risk for cardiovascular disease may result from low vitamin D and increased hsCRP concentration in this group of patients. Coexistence of Hashimoto's thyroiditis did not significantly affect the cIMT value in the studied population.

Cardiovascular Risk Reduction in High-Risk Pediatric Patients: A Scientific Statement From the American Heart Association

This scientific statement presents considerations for clinical management regarding the assessment and risk reduction of select pediatric populations at high risk for premature cardiovascular disease, including acquired arteriosclerosis or atherosclerosis. For each topic, the evidence for accelerated acquired coronary artery disease and stroke in childhood and adolescence and the evidence for benefit of interventions in youth will be reviewed. Children and adolescents may be at higher risk for cardiovascular disease because of significant atherosclerotic or arteriosclerotic risk factors, high-risk conditions that promote atherosclerosis, or coronary artery or other cardiac or vascular abnormalities that make the individual more vulnerable to the adverse effects of traditional cardiovascular risk factors. Existing scientific statements and guidelines will be referenced when applicable, and suggestions for risk identification and reduction specific to each setting will be described. This statement is directed toward pediatric cardiologists, primary care providers, and subspecialists who provide clinical care for these young patients. The focus will be on management and justification for management, minimizing information on pathophysiology and epidemiology.

Alcohol consumption or cigarette smoking and cardiovascular disease risk in youth with type 1 diabetes

AIM

To assess the association between alcohol consumption and/or cigarette smoking with other unhealthy behaviors and clinical cardiovascular risk factors in youth with type 1 diabetes.

METHODS

Two hundred and twenty-eight youth with type 1 diabetes (age 13-19 years) were consecutively enrolled in three Regional Pediatric Diabetes Centers in Italy. Demographic, anthropometric, lifestyle (adherence to the Mediterranean diet pattern and sports participation) and laboratory parameters were compared among youth reporting isolated or combined alcohol consumption and/or cigarette smoking.

RESULTS

Ten percent of the youth reported alcohol consumption, 10% cigarette smoking and 6% both alcohol and cigarette use; 74% did not report alcohol or cigarette use. Compared to non-drinker non-smoker youth, smokers showed significantly higher percentages of each of the behavioral and clinical cardiovascular risk factors. Drinkers showed a significantly higher proportion of abdominal adiposity, dyslipidemia and poor adherence to the Mediterranean diet. Alcohol consumption was independently associated with both dyslipidemia and high glycosylated hemoglobin.

CONCLUSIONS

Our findings emphasize the need to increase the awareness of youth with T1D about the negative impact of alcohol drinking on cardiovascular risk, since the effects of alcohol might be underestimated with respect to the well-known detrimental effects of smoking. Clustering of unhealthy lifestyle should be discouraged in type 1 diabetes youth in order to promote cardiovascular protection.

Relationship of the Aggregation of Cardiovascular Risk Factors in the Parasympathetic Modulation of Young People with Type 1 Diabetes

Background and objectives: In healthy individuals, autonomic alterations are associated with the aggregation of cardiovascular risk factors. However, in individuals with type 1 diabetes, who are known to present autonomic alterations, mainly characterized by a reduction in parasympathetic modulation, these associations have not yet been investigated. We assess whether the aggregation of cardiovascular risk factors influences parasympathetic indices of heart rate variability in young people with type 1 diabetes. Materials and methods: This cross-sectional study included 39 individuals with type 1 diabetes (22.54 ± 4.31), evaluated in relation to the risk factors: blood pressure, fat percentage, and resting heart rate. For heart rate variability analysis, heart rate was recorded beat-to-beat using a cardio frequency meter (PolarS810i) for 30 min with the volunteers in dorsal decubitus. The parasympathetic heart rate variability indices were calculated: rMSSD, pNN50, high frequency (HF) n.u (normalized units), SD1, 2LV, and 2ULV. Data collection was carried out in 2014 and analyzed in 2017. Results: Individuals with two aggregate risk factors present a reduction in the values of the indices that reflect parasympathetic autonomic modulation compared to individuals without the risk factors analyzed, regardless of sex and age. Conclusion: In young people with type 1 diabetes, the aggregation of cardiovascular risk factors is associated with parasympathetic autonomic impairment.

Effect of Aerobic and Resistance Exercise on Glycemic Control in Adults With Type 1 Diabetes

OBJECTIVES

Physical exercise is recommended for individuals with type 1 diabetes, yet the effects of exercise on glycemic control are not well established. We evaluated the impact of different modes of exercise on glycemic control in people with type 1 diabetes.

METHODS

In a 3-week randomized crossover trial, 10 adults with type 1 diabetes (4 men and 6 women, aged 33±6 years; duration of diabetes, 18±10 years; glycated hemoglobin level, 7.4%±1%) were assigned to 3 weeks of intervention: aerobic exercise (treadmill at 60% of maximum volume of oxygen utilization), resistance training (8 to 12 repetitions of 5 upper and lower body exercises at 60% to 80% of 1 repetition maximum) or no exercise (control). During each exercise week, participants completed 2 monitored 45 min exercise sessions. For each week of the study, we analyzed participants' insulin pump data, sensor glucose data and meal intake using a custom smart-phone application. The primary outcome was the percentage of time in range (glucose >3.9 mmol/L and ≤10 mmol/L) for the 24 h after each bout of exercise or rest during the control week. The study was registered on ClinicalTrials.gov (NCT:02687893).

RESULTS

Aerobic exercise caused a mean glucose reduction during exercise of 3.94±2.67 mmol/L, whereas the reduction during resistance training was 1.33±1.78 mmol/L (p=0.007). The mean percentage time in range for the 24 h after resistance training was significantly greater than that during the control period (70% vs. 56%, p=0.013) but not after aerobic exercise (60%).

CONCLUSIONS

The results indicate that when various confounders are considered, resistance training could improve glycemic control in this population.

Metabolic risk factors in adolescent girls with type 1 diabetes

BACKGROUND

The incidence of pediatric metabolic syndrome (MS) has progressively increased. The incidence of type 1 diabetes mellitus (T1DM) has also increased. Thus, some children and adolescents with T1DM exhibit MS parameters. The aim of the study was to evaluate the presence of MS parameters in female adolescents with T1DM based on their nutritional status.

METHODS

We evaluated 44 adolescents with T1DM (consecutive non-randomized sample) aged between 14 and 18 years, who were on intensive therapy with insulin. Patients were subdivided according to their body mass index (BMI). Variables evaluated include: age, age at diagnosis, weight, height, BMI, abdominal circumference, blood pressure, glycated hemoglobin (HbA1c), abdominal and pelvic ultrasound and lipoprotein profile. Gynecological history data were also collected.

RESULTS

Lipid profile changes were identified in 32% of overweight or obese girls and in 23% of those with an adequate weight. Hypertension (HT) was observed in 19% of overweight or obese girls and in 14% of those with a BMI≥85th percentile (Pc). The only statistically significant difference between the groups was the presence of abdominal adiposity. All other features, including the presence of dyslipidemia, HT, abdominal adiposity, non-alcoholic steatohepatitis (NASH) and polycystic ovarian syndrome (PCOS), were present in both groups.

CONCLUSIONS

Although being overweight and/or obese aggravates the risk of cardiovascular disease, MS is already present in many young adolescents with T1DM of normal weight. It is necessary that MS risk factors are routinely evaluated in all diabetic adolescents, including those with an adequate BMI.

Intima-media thickness at different arterial segments in pediatric type 1 diabetes patients and its relationship with advanced glycation end products

BACKGROUND

Patients with type 1 diabetes mellitus (T1DM) are at risk for premature atherosclerosis (AS), which has its origin in childhood. Carotid intima-media thickness (IMT) is an established surrogate marker for subclinical AS in adults. The first macroscopically detectable AS changes, however, begin in the abdominal aorta. Advanced glycation end products (AGE) predict microvascular complications in diabetes.

OBJECTIVES

To assess the sensitivity for early macrovascular changes of brachial, femoral, and aortic IMT compared to conventional carotid IMT in pediatric T1DM patients ; and the relationship of IMT with AGE.

METHODS

Using high-resolution external ultrasound, carotid, brachial, femoral, and aortic IMT were prospectively analyzed in children and adolescents with established T1DM and in controls (Ctrls). AGE were estimated by skin intrinsic fluorescence (SIF). Other established cardiovascular risk factors were excluded.

RESULTS

Seventy-six subjects (T1DM = 38; Ctrls = 38) with a mean age of 13.1 ± 4.0 years (6-19, median 13) qualified for analysis. Carotid, brachial, femoral, and aortic IMT analyses were feasible in 100%, 74%, 84%, and 92% of subjects, respectively. Aortic and femoral IMT were increased in T1DM patients (0.60 ± 0.11 vs 0.52 ± 0.10 mm, P < .001; and 0.41 ± 0.07 vs 0.36 ± 0.07 mm, P < .01, respectively) while carotid and brachial IMT were not. AGE levels were elevated in T1DM patients and correlated with aortic IMT only. The influence of AGE on aIMT did not remain significant after adjusting for T1DM and age in our small population.

CONCLUSION

We found aortic IMT-and to a lesser degree femoral IMT-to be more sensitive than carotid and brachial IMT for detecting early macrovascular changes in pediatric T1DM patients.

Saliva Proteomics Analysis Offers Insights on Type 1 Diabetes Pathology in a Pediatric Population

The composition of the salivary proteome is affected by pathological conditions. We analyzed by high resolution mass spectrometry approaches saliva samples collected from children and adolescents with type 1 diabetes and healthy controls. The list of more than 2000 high confidence protein identifications constitutes a comprehensive characterization of the salivary proteome. Patients with good glycemic regulation and healthy individuals have comparable proteomic profiles. In contrast, a significant number of differentially expressed proteins were identified in the saliva of patients with poor glycemic regulation compared to patients with good glycemic control and healthy children. These proteins are involved in biological processes relevant to diabetic pathology such as endothelial damage and inflammation. Moreover, a putative preventive therapeutic approach was identified based on bioinformatic analysis of the deregulated salivary proteins. Thus, thorough characterization of saliva proteins in diabetic pediatric patients established a connection between molecular changes and disease pathology. This proteomic and bioinformatic approach highlights the potential of salivary diagnostics in diabetes pathology and opens the way for preventive treatment of the disease.

Impaired flow-mediated dilation response and carotid intima-media thickness in patients with type 1 diabetes mellitus with a mean disease duration of 4.1 years

OBJECTIVE

This study aimed at assessing the endothelial function in patients with Type 1 diabetes (T1DM) using flow-mediated dilation (FMD) response and carotid artery intima-media thickness (CIMT).

MATERIALS AND METHODS

This study enrolled 32 T1DM patients (mean disease duration 4.1 years) and 28 age-matched controls (CTL Group). Endothelial function and CIMT were assessed with high-resolution ultrasound using standardized offline measurements.

RESULTS

FMD was significantly lower in patients in the T1DM Group (8.9 ± 3.2%) compared with those in the CTL Group (13.3 ± 4.3%; P-value < 0.0001). Similarly, CIMT differed significantly between T1DM patients (0.525 ± 0.03 mm) and controls (0.508 ± 0.03 mm; P-value = 0.041). Even though, the values are within the normal range for age.

CONCLUSIONS

Patients with T1DM have impaired endothelial function characterized by reduced FMD when compared to controls. However, vascular remodeling as seen by increases in CIMT was not found in this study.

HMGCS2 is a key ketogenic enzyme potentially involved in type 1 diabetes with high cardiovascular risk

Diabetes increases the risk of Cardio-vascular disease (CVD). CVD is more prevalent in type 2 diabetes (T2D) than type 1 diabetes (T1D), but the mortality risk is higher in T1D than in T2D. The pathophysiology of CVD in T1D is poorly defined. To learn more about biological pathways that are potentially involved in T1D with cardiac dysfunction, we sought to identify differentially expressed genes in the T1D heart. Our study used T1D mice with severe hyperglycemia along with significant deficits in echocardiographic measurements. Microarray analysis of heart tissue RNA revealed that the T1D mice differentially expressed 10 genes compared to control. Using Ingenuity Pathway Analysis (IPA), we showed that these genes were significantly involved in ketogenesis, cardiovascular disease, apoptosis and other toxicology functions. Of these 10 genes, the 3-Hydroxy-3-Methylglutaryl-CoA Synthase 2 (HMGCS2) was the highest upregulated gene in T1D heart. IPA analysis showed that HMGCS2 was center to many biological networks and pathways. Our data also suggested that apart from heart, the expression of HMGCS2 was also different in kidney and spleen between control and STZ treated mice. In conclusion, The HMGCS2 molecule may potentially be involved in T1D induced cardiac dysfunction.

Exercise management in type 1 diabetes: a consensus statement

Type 1 diabetes is a challenging condition to manage for various physiological and behavioural reasons. Regular exercise is important, but management of different forms of physical activity is particularly difficult for both the individual with type 1 diabetes and the health-care provider. People with type 1 diabetes tend to be at least as inactive as the general population, with a large percentage of individuals not maintaining a healthy body mass nor achieving the minimum amount of moderate to vigorous aerobic activity per week. Regular exercise can improve health and wellbeing, and can help individuals to achieve their target lipid profile, body composition, and fitness and glycaemic goals. However, several additional barriers to exercise can exist for a person with diabetes, including fear of hypoglycaemia, loss of glycaemic control, and inadequate knowledge around exercise management. This Review provides an up-to-date consensus on exercise management for individuals with type 1 diabetes who exercise regularly, including glucose targets for safe and effective exercise, and nutritional and insulin dose adjustments to protect against exercise-related glucose excursions.

The changes of subtypes in pediatric diabetes and their clinical and laboratory characteristics over the last 20 years

PURPOSE

We studied the changes in subtypes of diabetes mellitus (DM) in children and evaluated the characteristics of each group over the past 20 years. In addition, we also examined the correlation between the glycated hemoglobin (HbA1c) values at the time of diagnosis and lipid profiles.

METHODS

The patients were divided into 2 groups: there were a total of 190 patients under 20 years of age firstly diagnosed with DM in Ajou University Hospital. The patients in groups I and II were diagnosed from September 1995 to December 2004 and from January 2005 to April 2014, respectively.

RESULTS

The characteristics were compared between the 2 groups of patients. The result showed an increase in percentage of type 2 diabetes and maturity onset diabetes of the young (MODY) patients between the 2 groups. HbA1c and total cholesterol level had statistical significances to explain increasing the low-density lipoprotein cholesterol level among age, HbA1c, total cholesterol level, and z-scores of weight and body mass index (BMI) in type 2 diabetes. R-square was 0.074. However, z-score of BMI and total cholesterol level, not HbA1c, had statistical significances in type 1 diabetic patients. R-square was 0.323.

CONCLUSION

The increase in the proportions of both type 2 diabetes and MODY in the last 10 years needed to be reminded when diagnosing the subtypes of DM, and the dyslipidemia should be attended more as a common problem of pediatric diabetic patients.

Role of growth hormone-releasing hormone in dyslipidemia associated with experimental type 1 diabetes

Dyslipidemia associated with triglyceride-rich lipoproteins (TRLs) represents an important residual risk factor for cardiovascular and chronic kidney disease in patients with type 1 diabetes (T1D). Levels of growth hormone (GH) are elevated in T1D, which aggravates both hyperglycemia and dyslipidemia. The hypothalamic growth hormone-releasing hormone (GHRH) regulates the release of GH by the pituitary but also exerts separate actions on peripheral GHRH receptors, the functional role of which remains elusive in T1D. In a rat model of streptozotocin (STZ)-induced T1D, GHRH receptor expression was found to be up-regulated in the distal small intestine, a tissue involved in chylomicron synthesis. Treatment of T1D rats with a GHRH antagonist, MIA-602, at a dose that did not affect plasma GH levels, significantly reduced TRL, as well as markers of renal injury, and improved endothelial-dependent vasorelaxation. Glucagon-like peptide 1 (GLP-1) reduces hyperglucagonemia and postprandial TRL, the latter in part through a decreased synthesis of apolipoprotein B-48 (ApoB-48) by intestinal cells. Although plasma GLP-1 levels were elevated in diabetic animals, this was accompanied by increased rather than reduced glucagon levels, suggesting impaired GLP-1 signaling. Treatment with MIA-602 normalized GLP-1 and glucagon to control levels in T1D rats. MIA-602 also decreased secretion of ApoB-48 from rat intestinal epithelial cells in response to oleic acid stimulation in vitro, in part through a GLP-1-dependent mechanism. Our findings support the hypothesis that antagonizing the signaling of GHRH in T1D may improve GLP-1 function in the small intestine, which, in turn, diminishes TRL and reduces renal and vascular complications.