Obesity in people living with type 1 diabetes

Lights and Shadows of Bariatric Surgery: Insights from a Nationwide Administrative Database of People Living with Type 1 Diabetes and Obesity

INTRODUCTION

The study aimed to describe the population of patients living with type 1 diabetes who had access to bariatric surgery (BS) in France, analyzing the changes in healthcare resource use and associated costs in the 3 years following this surgery.

METHODS

An observational longitudinal study based on the French national health insurance database was conducted on all adult patients that underwent a first BS from 2015 to 2020. Cost analyses were conducted on a sub-population who underwent BS from 2016 to 2017 for sufficient observation time using a pre-post methodology.

RESULTS

A total of 437 patients were identified as living with type 1 diabetes among the 234,077 patients who had undergone surgery over 6 years (2015-2020). The most frequently performed interventions were sleeve gastrectomy (n = 272; 62.2%) and gastric bypass (n = 154; 35.2%), with the majority of patients being women (77.8%) and an average age of 42.3 (± 12.0) years, consistent with the general population undergoing BS in France. While no significant differences were found in the overall healthcare costs when comparing the 3 years before and after BS, there was an increase in the frequency of biological measurements. Expenditures related to antidiabetic medications and insulin decreased significantly (p < 0.0001). The number of hospitalizations for severe hypoglycemia, coma, and ketoacidosis more than doubled in the 3 years following surgery compared with the period before (p = 0.04).

CONCLUSIONS

The risks of severe hypoglycemia or ketoacidosis in patients with type 1 diabetes undergoing BS remains a real concern and emphasizes the importance of involving the diabetologist in the operative decision with joint follow-up with the nutritionist.

Insulin Resistance in Type 1 Diabetes: Pathophysiological, Clinical, and Therapeutic Relevance

People with type 1 diabetes (T1D) are usually considered to exclusively exhibit β-cell failure, but they frequently also feature insulin resistance. This review discusses the mechanisms, clinical features, and therapeutic relevance of insulin resistance by focusing mainly on human studies using gold-standard techniques (euglycemic-hyperinsulinemic clamp). In T1D, tissue-specific insulin resistance can develop early and sustain throughout disease progression. The underlying pathophysiology is complex, involving both metabolic- and autoimmune-related factors operating synergistically. Insulin treatment may play an important pathogenic role in predisposing individuals with T1D to insulin resistance. However, the established lifestyle-related risk factors and peripheral insulin administration inducing glucolipotoxicity, hyperinsulinemia, hyperglucagonemia, inflammation, mitochondrial abnormalities, and oxidative stress cannot always fully explain insulin resistance in T1D, suggesting a phenotype distinct from type 2 diabetes. The mutual interaction between insulin resistance and impaired endothelial function further contributes to diabetes-related complications. Insulin resistance should therefore be considered a treatment target in T1D. Aside from lifestyle modifications, continuous subcutaneous insulin infusion can ameliorate insulin resistance and hyperinsulinemia, thereby improving glucose toxicity compared with multiple injection insulin treatment. Among other concepts, metformin, pioglitazone, incretin-based drugs such as GLP-1 receptor agonists, sodium-glucose cotransporter inhibitors, and pramlintide can improve insulin resistance, either directly or indirectly. However, considering the current issues of high cost, side effects, limited efficacy, and their off-label status, these agents in people with T1D are not widely used in routine clinical care at present.

Scaffold-free endocrine tissue engineering: role of islet organization and implications in type 1 diabetes

Type 1 diabetes (T1D) is a chronic hyperglycemia disorder emerging from beta-cell (insulin secreting cells of the pancreas) targeted autoimmunity. As the blood glucose levels significantly increase and the insulin secretion is gradually lost, the entire body suffers from the complications. Although various advances in the insulin analogs, blood glucose monitoring and insulin application practices have been achieved in the last few decades, a cure for the disease is not obtained. Alternatively, pancreas/islet transplantation is an attractive therapeutic approach based on the patient prognosis, yet this treatment is also limited mainly by donor shortage, life-long use of immunosuppressive drugs and risk of disease transmission. In research and clinics, such drawbacks are addressed by the endocrine tissue engineering of the pancreas. One arm of this engineering is scaffold-free models which often utilize highly developed cell-cell junctions, soluble factors and 3D arrangement of islets with the cellular heterogeneity to prepare the transplant formulations. In this review, taking T1D as a model autoimmune disease, techniques to produce so-called pseudoislets and their applications are studied in detail with the aim of understanding the role of mimicry and pointing out the promising efforts which can be translated from benchside to bedside to achieve exogenous insulin-free patient treatment. Likewise, these developments in the pseudoislet formation are tools for the research to elucidate underlying mechanisms in pancreas (patho)biology, as platforms to screen drugs and to introduce immunoisolation barrier-based hybrid strategies.

BMI matters: understanding the link between weight and severe psoriasis

This study aims to investigate the causal relationship between Body Mass Index (BMI) and the severity of Psoriasis (PsO) using bidirectional Mendelian Randomization (MR) and regression analyses. We conducted a multicenter study which combined bidirectional MR analyses with regression analyses. The MR analyses included 366,776 individuals from the largest up-to-date published BMI Genome-Wide Association Study (GWAS) data. Regression analyses were performed on 1,979 patients with psoriasis from 12 participating centers (from October 31, 2019, to May 31, 2022). We assessed the impact of BMI on PsO severity using odds ratios (ORs) and regression coefficients for three key measures: the Psoriasis Area and Severity Index (PASI), Body Surface Area (BSA), and Dermatology Life Quality Index (DLQI). Two independent MR analyses revealed a significant causal association between BMI and PsO development. The first MR1 analysis showed that an increased BMI is significantly associated with a higher risk of psoriasis, with odds ratios of 2.28 (95% CI 1.33-3.92; p = 0.003). A subsequent MR2 analysis yielded consistent results, presenting an odds ratio of 2.37 (95% CI 1.16-4.85; p = 0.018) using the inverse-variance weighted method. Logistic regression showed that for every 1-unit increase in BMI (unadjusted covariates), the risk of severe psoriasis (PASI ≥ 10, BSA ≥ 10%, DLQI ≥ 10) increased by 6%, 6%, and 3%, respectively. Linear regression analysis revealed that each unit increase in BMI (not standardised) was associated with an increase of 0.25 units in the mean PASI score (p < 0.001), 0.34 units in the BSA score (p = 0.001), and 0.14 units in the DLQI score (95% CI 0.05-0.23; p = 0.001). From both the genetic and clinical severity assessment perspectives, it has been verified that abnormal weight gain is correlated with the severity of the condition in psoriasis patients. Clinicians should prioritize weight management and nutritional balance in the management of psoriatic disease. Clinicaltrials.gov: ChiCTR1900024852, date of registration: 2019-07-31.

Triglyceride-glucose index in adolescents with type 1 diabetes mellitus

BACKGROUND AND AIM

Even though HbA1c can be obtained easily and accurately by blood test, the cost may limit its availability for some patients and their proper follow-up. The triglyceride-glucose index has been shown to have an association with HbA1c in other populations, but it hasn't been studied in adolescents with T1DM yet. The aim of this study is to assess the association of TyG index with glycaemic control in adolescents with T1DM.

METHODS

This cross-sectional study included a sample of 36 adolescents (50% female) from the paediatric unit of the San Juan Hospital in Alicante (Spain). Data on sociodemographics, growth parameters, glycaemic control, and blood tests results were collected after routine visits.

RESULTS

A higher TyG index was statistically associated with a higher BMI, percentile and z-score, a higher triglyceride, HbA1c and glucose levels and with the triglycerides/HDL, the total cholesterol/HDL, the TyG-BMI and the TyG-waist circumference indexes.

CONCLUSION

The TyG index is a simple and non-invasive biomarker that could serve as a valuable adjunct to HbA1c monitoring in adolescents with T1DM. It may have a potential utility as a screening tool for early identification of patients at risk for developing metabolic complications such as insulin resistance and dyslipidemia.

GLP-1 Receptor Agonists in Overweight and Obese Individuals With Type 1 Diabetes Using an Automated Insulin Delivery Device: A Real-World Study

INTRODUCTION

Automated insulin delivery (AID) systems have improved glycemic control in individuals with type 1 diabetes (T1D) but overweight and increased cardiovascular risk remain a challenge. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are associated with improved cardiometabolic profile but are currently not approved for the treatment of T1D.

MATERIAL AND METHODS

Individuals with T1D at Steno Diabetes Center Copenhagen, Denmark, treated with AID and off-label GLP-1 RA for at least six months between January 2017 and May 2024 were included in a retrospective chart review study.

RESULTS

Nineteen individuals with (median [range]) age 42 (24-60) years were included. At GLP-1 RA initiation, hemoglobin A1c (HbA1c) was 7.3% (6.1%-8.7%), HbA1c 56 (43-72) mmol/mol, body weight 91.5 (78.0-115.0) kg, and body mass index 35.4 (27.0-42.0) kg/m2. Time in range was 74% (29%-82%), time above range 25% (18%-71%) while time below range was 1% (0%-5%). After six months of treatment, body weight changed -11% (-22% to -3%; P = .001) and total daily insulin dose changed -15.1 (-32.5 to -8.2) IU (P = .004). There were no significant changes in HbA1c or other glucose measures. One person developed ketoacidosis caused by infusion set failure, but none reported severe hypoglycemia.

CONCLUSION

Glucagon-like peptide-1 receptor agonist as add-on therapy for six months in individuals with obesity and AID-treated T1D led to considerable weight loss and a reduction in insulin dose.

Cardiac autonomic neuropathy is associated with ectopic fat distribution in autoimmune but not in type 2 diabetes

BACKGROUND

Cardiac autonomic neuropathy (CAN) is a life-threatening complication of diabetes. While obesity is a well-known risk factor of dysautonomia, the association between CAN and body fat distribution has not been fully clarified, especially in autoimmune diabetes (AD).

AIM

To evaluate if the association between CAN and body fat distribution differs between AD and type 2 diabetes (T2D).

METHODS

Body fat distribution was evaluated by Dual X-Ray Absorptiometry in 143 people with diabetes (44 with ADand 99 with T2D) undergoing clinical screening for CAN. The association of CAN with markers of ectopic fat distribution was evaluated in multivariate regression models adjusting for confounders and testing for the interaction between diabetes type and CAN.

RESULTS

A significant interaction between CAN and diabetes type was found with respect to markers of ectopic fat distribution. Specifically, people with CAN had significantly higher amount of visceral adipose tissue (530 [376-665]g versus 251[189-360]g, p = 0.001), total fat mass (22708[20200-27845]g versus 15434[12981-21879]g, p = 0,016), and trunk-to-leg ratio (0.88 [0.75-1.04] versus 0.70 [0.56-0.78], p = 0,023) compared to those without CAN only in participants with AD, but not in T2D (p-values for interaction < 0.05 for all comparisons).

CONCLUSION

Ectopic fat distribution is more strongly associated with CAN in AD than in T2D. This highlights the distinct role of fat distribution in the cardiometabolic health of people with AD, suggesting the need for further studies to better understand the pathophysiology and implications of overweight in this population.

Body-weight Cycling and Risk of Diabetic Kidney Disease in People With Type 1 Diabetes in the DCCT/EDIC Population

CONTEXT

Intraindividual body-weight variability or cycling is associated with increased risk of chronic kidney disease (CKD) in the general population.

OBJECTIVE

We conducted a retrospective analysis of data from the Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) studies to assess association between body-weight cycling and the risk of renal events in type 1 diabetes.

METHODS

Four indices of intraindividual body-weight variability were calculated for 1432 participants of DCCT/EDIC taking into account body-weight measurements during the DCCT follow-up (6 ± 2 years). Variability independent of the mean (VIM) was the main index. Six criteria of progression to CKD were studied during DCCT/EDIC follow-up (21 ± 4 years). Hazard ratio (HR) with 95% confidence interval (CI) were computed in Cox analyses for 1 SD of the indices expressed as Z-score.

RESULTS

A high VIM was significantly associated with the incidence of a 40% decline in eGFR from baseline values (HR, 1.25; 95% CI, 1.09-1.41; P = .001), doubling of baseline serum creatinine (HR, 1.34; 95% CI, 1.13-1.57; P = .001), CKD stage 3 (HR, 1.36; 95% CI, 1.12-1.63; P = .002), and with a decline in eGFR > 3 mL/min/m2 per year (all analyses adjusted for CKD risk factors at baseline and follow-up, and use of nephroprotective drugs). VIM was also associated with the incidence of moderately and severely increased albuminuria, but associations did not remain significant following adjustment for follow-up covariates. Similar results were observed for the other indices of body-weight cycling.

CONCLUSION

Body-weight cycling is significantly associated with an increased risk of kidney events in people with type 1 diabetes, regardless of body mass index and traditional risk factors.

Cost-Effectiveness of FreeStyle Libre for Glucose Self-Management Among People with Diabetes Mellitus: A Canadian Private Payer Perspective

INTRODUCTION

For people living with diabetes, effective glucose monitoring is a key component in diabetes care, helping to reduce disease burden, complications, and healthcare utilization. Sensor-based glucose monitoring systems, which can provide more comprehensive information about glucose levels than capillary-based self-monitoring of blood glucose (SMBG), are becoming established among people living with diabetes. The objective of this study was to assess the cost-effectiveness of glucose monitoring with FreeStyle Libre systems, compared with SMBG, from the perspective of a Canadian private payer.

METHODS

The analysis used the validated, person-level microsimulation model DEDUCE (Determination of Diabetes Utilities, Costs, and Effects). Analyses were conducted separately for populations of people with type 1 and type 2 diabetes mellitus (T1DM; T2DM), with time horizons of 40 and 25 years, respectively. T2DM treatment was assumed to be 84% non-insulin, 10% basal insulin, and 6% multiple daily injections of insulin. The effect of FreeStyle Libre was modeled as reductions versus SMBG in glycated hemoglobin level (T1DM, - 0.42%; insulin-treated T2DM, - 0.59%; non-insulin-treated T2DM, - 0.3%) and in acute diabetic events (hypoglycemia and diabetic ketoacidosis). Costs (in 2023 Canadian dollars (Can$)) and utilities were discounted at 1.5%. Outcomes were assessed as costs and quality-adjusted life years (QALYs).

RESULTS

In both populations, FreeStyle Libre was dominant to SMBG, providing more QALYs at a lower cost (T1DM: + 1.25 QALYs, - Can$32,287 costs; T2DM: + 0.48 QALYs, - Can$8091 costs). Reductions were seen in the cumulative incidence of all complications (except blindness in the T1DM analysis). FreeStyle Libre was dominant to SMBG in all scenarios tested. Probabilistic sensitivity analysis showed that FreeStyle Libre had a 100% probability of being dominant to SMBG for T1DM and a 91% probability of being dominant for T2DM.

CONCLUSION

This economic analysis shows that, from a Canadian private payer perspective, FreeStyle Libre is cost-effective compared with SMBG for all people living with diabetes.

Simplified meal announcement study (SMASH) using hybrid closed-loop insulin delivery in youth and young adults with type 1 diabetes: a randomised controlled two-centre crossover trial

AIMS/HYPOTHESIS

The majority of hybrid closed-loop systems still require carbohydrate counting (CC) but the evidence for its justification remains limited. Here, we evaluated glucose control with simplified meal announcement (SMA) vs CC in youth and young adults with type 1 diabetes using the mylife CamAPS FX system.

METHODS

We conducted a two-centre, randomised crossover, non-inferiority trial in two University Hospitals in Switzerland in 46 participants (aged 12-20 years) with type 1 diabetes using multiple daily injections (n=35), sensor-augmented pump (n=4) or hybrid closed-loop (n=7) therapy before enrolment. Participants underwent two 3 month periods with the mylife CamAPS FX system (YpsoPump, Dexcom G6) to compare SMA (individualised carbohydrate meal sizes) with CC, in a randomly assigned order using computer-generated sequences. The primary endpoint was the proportion of time glucose was in target range (3.9-10.0 mmol/l) with a non-inferiority margin of 5 percentage points. Secondary endpoints were other sensor glucose and insulin metrics, usability and safety endpoints.

RESULTS

Forty-three participants (18 women and girls) completed the trial. In the intention-to-treat analysis, time in range (mean±SD) was 69.9±12.4% with SMA and 70.7±13.0% with CC (estimated mean difference -0.6 percentage points [95% CI -2.4, 1.1], demonstrating non-inferiority). Time <3.9 mmol/l (median [IQR] 1.8 [1.2-2.2]% vs 1.9 [1.6-2.5]%) and >10.0 mmol/l (28.2±12.6% vs 27.2±13.4%) was similar between periods. Total daily insulin dose was higher with SMA (54.0±14.7 U vs 51.7±12.1 U, p=0.037). Three participants experienced serious adverse events, none of which were intervention-related.

CONCLUSIONS/INTERPRETATION

Glucose control using the CamAPS FX algorithm with SMA was non-inferior to its use with CC in youth and young adults with type 1 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05481034.

FUNDING

The study was supported by the Swiss Diabetes Foundation and by a YTCR grant from the Bangerter-Rhyner Foundation and the Swiss Academy of Medical Sciences. Dexcom and Ypsomed provided product support.

Body weight variability as a predictor of cardiovascular outcomes in type 1 diabetes: A nationwide cohort study

AIM

Intraindividual body weight variability (BWV), that is, the degree of weight fluctuations over time, is associated with an increased risk of cardiovascular diseases (CVDs) in multiple settings. The impact of BWV on cardiovascular risk in type 1 diabetes (T1D) remains unclear, despite the issues relative to weight management in individuals with this condition.

MATERIALS AND METHODS

Using data from the Swedish National Diabetes Register, we identified individuals with T1D and without CVD at baseline with at least three measurements of body weight taken over three consecutive years. We estimated BWV as quartiles of the standard deviation of weight measures and explored its longitudinal association with the incidence of CVD during a 12.7 ± 4.6 year follow-up through adjusted Cox regression models. The primary endpoint was the composite of nonfatal myocardial infarction, nonfatal stroke and all-cause mortality. We modelled the function of risk in relation to the magnitude of BWV, testing also whether weight trends, that is, increasing, stable or decreasing, age, sex and glycaemic control modified the association between BWV and the outcome.

RESULTS

Among the 36 333 individuals with T1D in the register, we identified 19 373 individuals with at least three measures of body weight and without CVD at baseline. Participants with the highest BWV had a 42% increased risk of reaching the primary endpoint compared to those with the lowest BWV (hazard ratio [HR] = 1.42, 95% confidence interval [CI]: 1.24-1.62). In addition, high BWV was significantly associated with a 51% increased risk of all-cause mortality (HR = 1.51, 95% CI: 1.28-1.78), a 37% increased risk of peripheral artery disease (HR = 1.37, 95% CI: 1.06-1.77) and a 55% increased risk of hospitalization for heart failure (HR = 1.55, 95% CI: 1.20-2.01). BWV showed a quasi-linear association with the primary endpoint. No interaction was observed when comparing subgroups for weight trends, sex or degree of glycaemic control. In the subgroup of elderly individuals, the association of BWV with the primary endpoint was no longer significant.

CONCLUSIONS

High BWV is associated with an increased risk of CVD and all-cause mortality in individuals with T1D, independently of canonical risk factors. Weight trends, sex and glycaemic control do not modify such association while older age attenuates it.

Managing obesity in adults with type 1 diabetes

As the prevalence of obesity has reached epidemic proportions, its prevalence has also increased among adults living with type 1 diabetes mellitus. Unlike the pathophysiologic relationship between obesity and type 2 diabetes mellitus, the relationship between obesity and type 1 diabetes mellitus, and management of obesity in the setting of type 1 diabetes mellitus, have not been well reviewed. In this article, we discuss the comprehensive management of obesity in adults with type 1 diabetes mellitus, focusing on medical nutrition therapy and adjunct therapies such as weight loss-promoting medications and metabolic/bariatric surgery.

Glucagon-like peptide-1 receptor agonists and type 1 diabetes: a potential game changer?

This mini review explores the increasing prevalence of obesity in type 1 diabetes (T1D) and the challenges patients face in achieving optimal glycemic control with current treatments. It discusses the evidence supporting the use of glucagon-like peptide-1 receptor agonists (GLP-1RA) as potential adjunctive therapy in T1D to reduce weight and improve insulin resistance. Potential benefits need to be weighed against the risk of hypoglycemia and lack of long-term data.

Overweight and obesity in patients with type 1 diabetes: associations with vascular complications and biomarkers of vascular remodeling

BACKGROUND: The prevalence of overweight and obesity in patients with type 1 diabetes (T1D) is increasing, which raises the issue of their impact on the development of complications.

AIM: to study the associations of overweight and obesity with vascular complications, cardiovascular risk factors and serum levels of vascular remodeling biomarkers in patients with T1D.

MATERIALS AND METHODS: The study included 547 patients, including 309 with body mass index (BMI) <25 kg/m2, 155 with BMI 25–29.9 kg/m2, and 83 with BMI ≥30 kg/m2. Insulin sensitivity was assessed by the estimated glucose disposal rate. In the serum of 130 patients and 30 individuals with normal weight and normal glucose tolerance, concentrations of advanced glycation end products (AGEs), endothelin-1, endothelial NO synthase (NOS3), adrenomedullin (ADM), endothelial cell-specific molecule-1 (ESM1), cell adhesion molecules (ICAM-1 and VCAM-1), integrin-associated protein-1 (IAP-1), integrin receptor subunit (ITGB1), heme oxygenase-1 (HO-1), GAS6, decorin, and transforming growth factor β1 (TGF-β1) were determined by ELISA.

RESULTS: Obesity in patients with T1D was independently associated with coronary artery disease, myocardial infarction, and chronic heart failure. Overweight was an independent predictor of chronic heart failure only. Patients with BMI ≥25 kg/m2, when compared with those with BMI <25 kg/m2, were older, had a reduced insulin sensitivity and increased levels of triglycerides, LDL-cholesterol, uric acid, and high-sensitivity C-reactive protein. Patients with T1D, as compared with controls, showed a significant increase in serum AGEs, endothelin-1, ICAM-1, VCAM-1, IAP-1, ESM1, HO-1, GAS6, and TGF-β1. Overweight patients, when compared with those with BMI <25 kg/m2, demonstrated higher levels of ICAM-1, IAP-1, ITGB1 and TGF-β1, while obese individuals had increased concentrations of AGEs, IAP-1 and HO-1.

CONCLUSION: In patients with T1D, overweight and obesity are associated with vascular complications, their risk factors and biomarkers of vascular remodeling.

Serological markers of exocrine pancreatic function are differentially informative for distinguishing individuals progressing to type 1 diabetes

INTRODUCTION

Altered serum levels of growth hormones, adipokines, and exocrine pancreas enzymes have been individually linked with type 1 diabetes (T1D). We collectively evaluated seven such biomarkers, combined with islet autoantibodies (AAb) and genetic risk score (GRS2), for their utility in predicting AAb/T1D status.

RESEARCH DESIGN AND METHODS

Cross-sectional serum samples (n=154 T1D, n=56 1AAb+, n=77 ≥2AAb+, n=256 AAb-) were assessed for IGF1, IGF2, adiponectin, leptin, amylase, lipase, and trypsinogen (n=543, age range 2.7-30.0 years) using random forest modeling.

RESULTS

GRS2, age, lipase, trypsinogen, and AAb against ZnT8, GAD65, and insulin were the most informative markers. Notably, these variables were differentially informative according to AAb/T1D status. Higher GRS2 (p<0.001) and lower lipase levels (p=0.002) favored ≥2AAb+ versus AAb- classification. AAb against ZnT8 (p<0.01), GAD65 (p=0.021), or insulin (p=0.01) each independently favored ≥2AAb+ versus 1AAb+ classification. Reduced trypsinogen (p<0.001) and increased lipase levels (p<0.001) favored recent-onset T1D versus ≥2AAb+ classification.

CONCLUSIONS

Among the serological markers tested, lipase and trypsinogen levels were the most informative for differentiating among clinical groups, with the utility of each enzyme varying according to GRS2 and AAb/T1D status. These data support exocrine pancreas enzymes as candidates for longitudinal follow-up.

Safety and Effectiveness of Glargine 300 U/ml After Switching from Basal Insulins in Patients with Type 1 Diabetes: COMET-T Study

INTRODUCTION

Appropriate glycemic control is paramount for people with type 1 diabetes (PwT1D) by the effective delivery of exogenous insulin. However, glycemic variability and the risk of severe hypoglycemia must be reliably controlled.

METHODS

COMET-T is a prospective, multicenter, observational study conducted in Germany, Austria, and Switzerland during 2021-2022 to assess the effectiveness and safety of insulin glargine 300 U/ml (Gla-300) after switching from other basal insulins. Out of 135 PwT1D, data of 94 patients were analyzed. The primary endpoint was the change in time in range (TIR) approximately 12 and 24 weeks after switching to Gla-300. Secondary endpoints were: change in HbA1c, fasting plasma glucose (FPG), coefficient of variation (CV%) of plasma glucose, body weight (BW) and insulin dose.

RESULTS

Patients had mean age of 48.6 ± 16.5 years, included 39.4% males and had 18.2 ± 15.5 years T1D duration. From baseline (54.3%), TIR changed at week 12 (mean change 0.3% [± 14.3]; p = 0.8383) and at week 24 (+ 4.5% [± 14.9], p = 0.078). At week 24, TIR significantly increased in patients with body mass index > 30 kg/m2 (8.4% [± 12.8] p = 0.0057) and patients who previously received insulin detemir (10.5%; [± 12.93]; p = 0.0005). At week 24, there was a significant reduction in the HbA1c value (8.1 ± 0.6% vs. 7.7 ± 0.9%; p < 0.001), a reduction in the CV% of plasma glucose (36.1 ± 12.4% vs. 32.8 ± 9.6%, p = 0.056), and increase in bolus insulin dose (26.5 ± 16.3 vs. 27.9 ± 16.6 U/day; p = 0.042). FPG, BW, and basal insulin doses were not significantly changed.

CONCLUSIONS

Although switching to Gla-300 in poorly controlled PwT1D did not significantly reduce TIR, it significantly decreased HbA1c values and glycemic variability without changes in BW and basal insulin dose.

Interventions Targeting Insulin Resistance in Patients with Type 1 Diabetes: A Narrative Review

Background and Objectives: Insulin resistance (IR) is the most important factor involved in the pathogenesis of type 2 diabetes but may also develop in type 1 diabetes (T1DM). Developing IR in patients with T1DM may generate a burden in achieving glycemic targets and may deteriorate the overall prognosis. This review aims to describe the pathogenesis of IR in T1DM, summarize the common associations of IR with other conditions in patients with T1DM, describe the consequences of developing IR in these patients, and present the interventions that target IR in people with T1DM. Results: The occurrence of IR in T1DM is multifactorial; however, it is frequently linked to overweight or obesity and sedentary lifestyle. Besides impairments in glycemic control and increased insulin requirements, the presence of IR is associated with an increased cardiovascular risk in patients with T1DM. Considering that patients with T1DM are insulin-treated, IR may be evaluated only using surrogate biomarkers, the most frequently used being the estimated glucose disposal rate. The most important interventions that are shown to be feasible in improving insulin sensitivity in patients with T1DM are lifestyle optimizations, including nutrition therapy or physical activity and pharmacotherapy with metformin, sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, and thiazolidinediones. Conclusions: Targeting the improvement of IR in patients with T1DM is a key element in achieving optimal glycemic control, as well as improving the overall patient's prognosis besides glycemic control.

Global Epidemiology and Characteristics of Metabolic Dysfunction-associated Steatotic Liver Disease in Type 1 Diabetes Mellitus: An Updated Systematic Review and Meta-analysis

BACKGROUND & AIMS

Metabolic dysfunction-associated steatotic liver disease (MASLD) is often overlooked in patients with type 1 diabetes mellitus (T1DM). Our study aims to provide a comprehensive overview of the burden of MASLD in T1DM by assessing the prevalence of MASLD and its advanced forms in individuals with T1DM.

METHODS

We systematically searched PubMed and Embase databases (from inception to May 5, 2024) for original articles on the prevalence or characteristics of MASLD (as detected by blood biomarkers/scores, imaging techniques, or liver biopsy) in adults with T1DM. Data were extracted, and we performed a meta-analysis of proportions using generalized linear mixed model, and pairwise meta-analysis using the DerSimonian-Laird method. Heterogeneity was investigated with further subgroup and meta-regression analyses, and publication bias was assessed.

RESULTS

We identified 23 studies for a total of 13,006 individuals with T1DM. Of these, 22.24% (95% confidence interval [CI], 15.62-30.66; I2 = 99.2%) had MASLD. Significant fibrosis (≥F2) and advanced fibrosis (≥F3) were found in 13.25% (95% CI, 11.15-15.67; I2 = 0%) and 5.12% (95% CI, 3.78-6.91; I2 = 0%) of patients with T1DM and MASLD, respectively. Patients with MASLD and T1DM were more likely to be older, overweight, male, have a longer duration of diabetes, require higher daily doses of insulin, have metabolic dysfunction, and were at a higher risk of microvascular complications.

CONCLUSION

MASLD is relatively common in T1DM. Patients with MASLD-T1DM have a distinct clinical profile compared with those with T1DM, with only a small proportion having significant or advanced fibrosis.

Effects of glucagon-like peptide-1 receptor agonists on glycated haemoglobin and continuous glucose monitoring metrics as adjunctive therapy to insulin in adults with type 1 diabetes: A meta-analysis of randomized controlled trials

AIMS

To conduct a meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of glucagon-like peptide-1 receptor agonists (GLP-1RAs) on glycated haemoglobin (HbA1c) and continuous glucose monitoring (CGM) metrics as an adjunct to insulin therapy in adults with type 1 diabetes mellitus (T1D).

METHODS

A systematic literature search was conducted through Medline (via PubMed), Cochrane Library, and Google Scholar up to 27 May 2024. Dual-independent study selection, data extraction, and quality assessment were performed. Results were summarized using random-effects meta-analysis.

RESULTS

Six RCTs were identified, involving a total of 378 individuals with T1D. The use of GLP-1RAs in addition to standard insulin therapy was associated with a significant reduction in HbA1c (mean difference [MD] -0.21%, 95% confidence interval [CI] -0.36 to -0.06; p = 0.007) and a similar time in range (TIR) compared to placebo (MD -0.22%, 95% CI -2.39 to 1.95; p = 0.84). GLP-1RA therapy resulted in a significantly higher time below range (MD 1.13%, 95% CI 0.50 to 1.76; p < 0.001) and a lower time above range compared with placebo (MD -1.83%, 95% CI -2.51 to -1.15; p < 0.001). Nonsignificant differences were noted for the secondary outcomes, including the mean amplitude of glucose excursion, continuous overall net glycaemic action for 60 min, mean daily glucose, coefficient of variation, and mean standard deviation of weekly glucose levels.

CONCLUSION

Our findings suggest that, in individuals with T1D, add-on therapy with GLP-1RAs does not confer significant benefits in terms of CGM metrics and is associated with a longer time below the target glycaemic range.

Metabolic health in people living with type 1 diabetes in Belgium: a repeated cross-sectional study

AIMS/HYPOTHESIS

Metabolic abnormalities such as central obesity, insulin resistance, dyslipidaemia and hypertension, often referred to as 'the metabolic syndrome' (or 'combined metabolic abnormalities'), are increasingly being identified in people living with type 1 diabetes, accelerating the risk for CVD. As a result, in recent years, treatment in people living with type 1 diabetes has shifted to improving overall metabolic health rather than glucose control alone. In Belgium, diabetes care for people living with type 1 diabetes is centrally organised. The Initiative for Quality Improvement and Epidemiology in Diabetes, imposed by the Belgian health insurance system, has systematically collected data from patients on intensive insulin therapy treated in all 101 diabetes clinics in Belgium since 2001. The aim of this real-world study is to describe the evolution of treatment and metabolic health, including the prevalence of obesity and combined metabolic abnormalities, in people living with type 1 diabetes over the past 20 years, and to compare the treatment and prevalence of complications between those with and without combined metabolic abnormalities.

METHODS

We analysed data on adults (≥16 years old) living with type 1 diabetes, who were diagnosed at age ≤45 years and who had a diabetes duration ≥1 year, collected between 2001 and 2022. The evolution of HbA1c, BMI, LDL-cholesterol, systolic BP, lipid-lowering therapy and antihypertensive therapy over time was analysed. The prevalence of individual and multiple metabolic abnormalities according to various definitions of the metabolic syndrome/combined metabolic abnormalities was analysed, and the association between combined metabolic abnormalities and metabolic health indicators, complications and treatment was investigated in the 2022 data.

RESULTS

The final dataset consisted of 26,791 registrations of adults living with type 1 diabetes collected between 2001 and 2022. Although glycaemic and lipid control generally improved over time, the prevalence of obesity strongly increased (12.1% in 2001 vs 21.7% in 2022, p<0.0001), as did the presence of combined metabolic abnormalities (WHO criteria: 26.9% in 2001 vs 42.9% in 2022 in women, p<0.0001; 30.4% in 2001 vs 52.1% in 2022 in men, p<0.0001; WHO criteria without albuminuria: 22.3% in 2001 vs 40.6% in 2022 in women, p<0.0001; 25.1% in 2001 vs 49.2% in 2022 in men, p<0.0001; NCEP-ATPIII criteria: 39.9% in 2005 vs 57.2% in 2022 in women, p<0.0001; 40.8% in 2005 vs 60.9% in 2022 in men, p<0.0001; IDF criteria: 43.9% in 2005 vs 59.3% in 2022 in women, p<0.001; 33.7% in 2005 vs 50.0% in 2022 in men, p<0.0001). People with combined metabolic abnormalities had higher glucose levels compared to those without combined metabolic abnormalities (HbA1c >58 mmol in men: 48.9% vs 36.9%; HbA1c >58 mmol in women: 53.3% vs 41.1%, p<0.0001). People with combined metabolic abnormalities were more often treated with adjunct therapies such as metformin, sodium-glucose transport protein 2 inhibitors and glucagon-like peptide-1 receptor agonists. In both men and women, the presence of combined metabolic abnormalities was strongly related to the presence of eye complications, peripheral neuropathy, chronic kidney disease and CVD, corrected for age, diabetes duration and HbA1c.

CONCLUSIONS/INTERPRETATION

Overweight, obesity and combined metabolic abnormalities are increasingly being identified in people living with type 1 diabetes, further accelerating the risk of microvascular and macrovascular complications. Early identification of the presence of combined metabolic abnormalities should enable therapeutic interventions to be modified towards multifactorial approaches, with attention to education on avoidance of overweight (e.g. dietary counselling) in addition to strict glycaemic control and intensification of use of antihypertensive agents and statins. Use of adjunct therapies in this population as a tool should be explored more thoroughly to reduce risk of complications.

Prevalence of obesity in people with and without type 1 diabetes across Belgium, Kuwait, and Mexico: an IMI2 SOPHIA study

Background

Individuals with type 1 diabetes (T1D) are traditionally perceived as lean, but recent evidence suggests an increasing trend of obesity. To provide global estimates, this study explored the prevalence of obesity among adults with and without T1D across three distinct global regions.

Methods

An observational, cross-sectional study was performed utilizing data from T1D registries and national health surveys to assess the prevalence of obesity (BMI ≥ 30 kg/m2) and the prevalence of overweight and obesity (BMI ≥ 25 kg/m2) across Belgium, Kuwait, and Mexico. Demographic and clinical characteristics of adults with and without T1D were assessed. Prevalence estimates were calculated through a binomial generalized linear mixed-effects model adjusting for age, sex, HbA1c, and survey year. As a sensitivity analysis, propensity score matching was performed for confounder adjustment of age and sex.

Findings

The study encompassed 3594 individuals with T1D (from 2003 to 2022) and 9898 without T1D (from 2014 to 2021). After model adjustment for confounders (age, sex, HbA1c% and data-collection year), individual obesity prevalence was lower in individuals with T1D in Kuwait and Mexico than among those without type 1 diabetes (Kuwait: 22% (CI: 18-26%) vs. 44% (CI: 41-48%); Mexico: 5% (CI: 3-7%) vs. 40% (CI: 38-42%)). In contrast, individuals with T1D in Belgium showed a more comparable proportions to those without T1D (12% (CI: 9-16%) vs. 16% (CI:11-22%)).

Interpretation

Our data reveal that obesity is prevalent among people with T1D. These findings underscore the need for targeted strategies in T1D care that address the growing concern of obesity.

Funding

This manuscript is part of the Stratification of Obesity Phenotypes to Optimize Future Obesity Therapy (SOPHIA) project (www.imisophia.eu). SOPHIA has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No. 875534. This Joint Undertaking support from the European Union's Horizon 2020 research and innovation program and EFPIA and type 1 diabetes Exchange, Breakthrough T1D, and Obesity Action Coalition.

Classification of longitudinal estimated glomerular filtration rate trajectories in Canadian adults with type 1 diabetes

AIMS

Type 1 diabetes (T1D) increases the risk of chronic kidney disease (CKD) development. The aims of this study were to classify trajectories of estimated glomerular filtration rate (eGFR) in a cohort of Canadian adults with T1D, and to describe the risk factors associated with declining eGFR trajectories.

METHODS

In this retrospective cohort of adults with T1D, data was collected between 1996 and 2020. CKD was defined as eGFR <60 mL/min/1.73 m2. Latent class mixed models were used to categorize eGFR trajectories. Multinomial logistic regression was used to identify factors associated with declining eGFR trajectories.

RESULTS

In this study, 304 adults were analyzed, with baseline measurements at a median duration of T1D of 15.3 (5.4-24.2) years. Eight percent of the cohort developed CKD over a median duration of 24.3 (13.7-34.8) years. Four classes of longitudinal eGFR trajectories were identified, broadly categorized as steeply declining (SD1, SD2) and gradual declining (GD1, GD2). Female sex, poor glycemic control, elevated body mass index, and albuminuria were associated with a steeply declining trajectory.

CONCLUSION

In this cohort, four distinctive eGFR trajectories were identified, including a subtype with steeply declining eGFR. Given the complex nature of CKD progression, further prospective study of this model for identification of individuals at risk for CKD based on their trajectory of kidney function may support clinicians in their decision-making.

Beyond the insulin pump: Unraveling diabetes tech dependency

The use of technology for Type 1 diabetes (T1D) has significantly developed in the last 20 years leading to several benefits in life-style management but also to potentially overreliance and addiction to such life changing devices. Insulin pumps (CSII) being small, discreet and sophisticated, offer features such as customizable basal rates, bolus calculators and integration with Continuous Glucose Monitoring (CGM) systems becoming a must have for diabetic patients. Indeed CGM, firstly introduced in the late 1990s and now being highly sophisticated provide trends and patterns hence allowing a better management of T1D. In this review we inquire the multifactorial aspects of dependency on diabetes technology, focusing not only on the benefits and the advancements these automations offer, but also the challenges, limits and possible risks associated with overreliance on them. Specifically, the impact that early introduction to technology had on patients, the dependency on CSII and CGM, the importance of learning and self-management skills and strategies for addressing unexpected events.

Health-related quality of life of people with type 1 diabetes: An IMI2 SOPHIA post hoc analysis of FUTURE and ADJUNCT-ONE

AIM

To characterize and stratify health-related quality of life in individuals with type 1 diabetes (T1D) using body mass index (BMI) and clustering analysis.

MATERIAL AND METHODS

Baseline data on individuals with T1D were pooled from two studies. A post hoc analysis of health-related quality of life, measured using the 36-item Short-Form questionnaire, was performed, referenced to the 2010 US general population. Descriptive statistics were presented for the pooled cohort and per BMI category. K-means clustering was performed. One-way analysis of variance was conducted to examine differences in clinical characteristics between clusters.

RESULTS

The pooled cohort consisted of 2256 individuals with T1D (age: 45.4 ± 15.0 years, BMI: 26.2 ± 4.6 kg/m2, diabetes duration: 22.7 ± 13.5 years). All quality-of-life domains were slightly lower than 50(the general population's mean), except for vitality. Individuals with a BMI ≥30 kg/m2 reported lower scores for bodily pain, physical functioning, general health, and vitality. A first cluster with a high and a second cluster with a low quality of life were identified, with significant differences in the mental (Cluster 1: 53.8 ± 6.8 vs. Cluster 2: 39.5 ± 10.7; p < 0.001) and physical component summary scores (Cluster 1: 49.6 ± 6.3 vs. Cluster 2: 35.2 ± 12.0; p < 0.001), which exceeded differences found between BMI categories.

CONCLUSIONS

In our population of people living with T1D, higher BMI may have adversely impacted physical domains of quality of life, but larger differences between the high- and low-quality-of-life cluster indicate that more factors play a role.

Physical activity and sedentary behaviour in relation to body composition, estimated insulin sensitivity and arterial stiffness in adults with type 1 diabetes

AIMS

To examine the association of daily PA levels and sedentary behaviour with body composition, estimated insulin sensitivity, and arterial stiffness in adults with type 1 diabetes (T1D).

METHODS

Cross-sectional study in adults with T1D (n = 54). PA levels (daily steps, and time in moderate-to-vigorous intensity PA (MVPA)) and sedentary behaviour were measured using accelerometry for 7 days (McRoberts® DynaPort MoveMonitor). Cardiopulmonary exercise test for VO2max. Anthropometrics were collected, and body composition (total and % of fat mass (FMtot, FM%), total and % of lean mass (LMtot, LM%), and estimated visceral adipose tissue (VAT)) volume was assessed with dual energy X-ray-absorptiometry (DXA). Estimates of insulin sensitivity were determined (estimated glucose disposal rate (eGDR) and total daily insulin dose). Arterial stiffness was assessed with carotid-femoral pulse wave velocity (cf-PWV (m/s); SphygmoCor®).

RESULTS

Lower 10-years HbA1c associated moderately with all PA measures. Favourable moderate associations were also found between PA measures and BMI, waist, VAT but not FM and LM. PA measures were favourably associated with a lower total daily insulin dose and higher eGDR. All PA parameters associated moderately with cf-PWV however not independent from traditional risk factors. VO2max was inversely associated with cf-PWV independent of age, T1D duration and 24-hour mean blood pressure.

CONCLUSIONS

Higher levels of PA, lower sedentary behaviour and greater exercise capacity are favourably associated with long-term glycaemic control, body composition, insulin dosage, estimated insulin sensitivity and arterial stiffness in adults with T1D. Therefore, regular PA and limiting sedentary time should be encouraged to improve metabolic and cardiovascular health in this population. Future longitudinal studies should explore mutual interactions and synergistic effects of PA on these outcomes.

Insulin Resistance and CGM-Derived Parameters in People With Type 1 Diabetes: Are They Associated?

BACKGROUND

Insulin resistance (IR) is increasingly more prevalent in people with type 1 diabetes (T1D).

OBJECTIVE

We investigated whether IR is associated with continuous glucose monitor (CGM)-derived parameters (glucometrics), such as time in range (TIR), time above range (TAR), time below range (TBR), and glycemic variability (CV).

METHODS

This is a retrospective analysis of 2 databases: IR was quantified according to the estimated glucose disposal rate (eGDR) (NCT04664036) and by performing a hyperinsulinemic-euglycemic clamp (HEC) (NCT04623320). All glucometrics were calculated over 28 days.

RESULTS

A total of 287 subjects were included. Mean age was 46 ± 17 years, 55% were male, TIR was 57% ± 14%, and eGDR was 7.6 (5.6-9.3) mg/kg/min. The tertile of people with the lowest eGDR (highest level of IR) had a higher TAR compared to the tertile with the highest eGDR (39% ± 15% vs 33% ± 14%, P = .043). Using logistic regression, a higher eGDR was associated with a higher chance to fall in a higher TIR-tertile (odds ratio [OR] 1.251, P < .001), a lower TAR-tertile (OR 1.281, P < .001), and a higher TBR-tertile (OR 0.893, P = .039), adjusted for age, sex, diabetes duration, smoking status, and alcohol intake. In the 48 people undergoing a HEC, no significant association between glucometrics and the HEC-determined glucose disposal rate (M-value) was observed.

CONCLUSION

In people with T1D, an association between IR, measured by eGDR, and worse CGM profiles was observed.

ADO09, a co-formulation of pramlintide and insulin A21G, lowers body weight versus insulin lispro in type 1 diabetes

AIM

To study safety, efficacy and weight loss with ADO09, a co-formulation of insulin A21G and pramlintide, in type 1 diabetes.

MATERIALS AND METHODS

A randomized, two-arm ambulatory 16-week study compared ADO09 with insulin lispro in 80 participants with type 1 diabetes. We compared changes of weight, glycated haemoglobin, glycaemic patterns during continuous glucose monitoring, and insulin doses at baseline and at the end of treatment.

RESULTS

A significant and continuing weight loss, the primary endpoint, was observed with ADO09 compared with lispro as prandial insulin. In the whole group, the weight loss with ADO09 relative to lispro was 2.1 kg. Glycaemic control was relatively good (7.7% mean glycated haemoglobin) in both groups and did not change during treatment. Prandial insulin doses were reduced by 21% in the ADO09 group, whereas basal insulin dosage was not modified. Gastrointestinal symptoms were more frequent with ADO09, but no clear difference in hypoglycaemia was observed.

CONCLUSIONS

These results extend previous observations on the efficacy and safety of this insulin/pramlintide co-formulation. They show a beneficial effect on weight, using less mealtime insulin and without increased hypoglycaemia.

Applying technologies to simplify strategies for exercise in type 1 diabetes

Challenges and fears related to managing glucose levels around planned and spontaneous exercise affect outcomes and quality of life in people living with type 1 diabetes. Advances in technology, including continuous glucose monitoring, open-loop insulin pump therapy and hybrid closed-loop (HCL) systems for exercise management in type 1 diabetes, address some of these challenges. In this review, three research or clinical experts, each living with type 1 diabetes, leverage published literature and clinical and personal experiences to translate research findings into simplified, patient-centred strategies. With an understanding of limitations in insulin pharmacokinetics, variable intra-individual responses to aerobic and anaerobic exercise, and the features of the technologies, six steps are proposed to guide clinicians in efficiently communicating simplified actions more effectively to individuals with type 1 diabetes. Fundamentally, the six steps centre on two aspects. First, regardless of insulin therapy type, and especially needed for spontaneous exercise, we provide an estimate of glucose disposal into active muscle meant to be consumed as extra carbohydrates for exercise ('ExCarbs'; a common example is 0.5 g/kg body mass per hour for adults and 1.0 g/kg body mass per hour for youth). Second, for planned exercise using open-loop pump therapy or HCL systems, we additionally recommend pre-emptive basal insulin reduction or using HCL exercise modes initiated 90 min (1-2 h) before the start of exercise until the end of exercise. Modifications for aerobic- and anaerobic-type exercise are discussed. The burden of pre-emptive basal insulin reductions and consumption of ExCarbs are the limitations of HCL systems, which may be overcome by future innovations but are unquestionably required for currently available systems.

Effectiveness of Mindfulness-Based Interventions with Respect to Psychological and Biomedical Outcomes in Young People with Type 1 Diabetes: A Systematic Review

BACKGROUND

Type 1 diabetes is a chronic disease especially affecting young people. Mindfulness-based psychological interventions might reduce emotional symptoms post-diagnosis, but the evidence is limited.

OBJECTIVES

This systematic review aimed to evaluate the effectiveness of mindfulness interventions on psychological well-being and biomedical variables in young people with type 1 diabetes.

METHODS

A systematic review of trials was conducted that involved a bibliographic search in electronic databases (Web of Science, MEDLINE, SciELO, Scopus, PsycINFO, and Cochrane Library) considering studies published between 2013 and 2024.

RESULTS

A total of 434 records were identified, of which 252 underwent selection according to title and abstract, leaving 32 that were evaluated for eligibility and 7 included in this review. From Google Scholar, six more studies were identified and evaluated, and two were selected. Finally, nine studies were subjected to full reading and a detailed analysis of the inclusion criteria. A total of 66.6% of the studies were evaluated as having a methodological quality of moderate or optimal, but the samples analysed tended to be small, and only two articles carried out short-term follow-up evaluations.

CONCLUSIONS

Mindfulness-based interventions, upon reviewing the preliminary results, may be posited as a viable strategy to enhance psychological (anxiety, diabetes distress, perceived stress, depression, self-efficacy, psychological well-being, and quality of life) and biomedical outcomes (glycaemic control, blood glucose levels, and diastolic blood pressure) for type 1 diabetes in young people. Although promising, further research is required to improve the quality, methodology, and design of studies.

Effect of Body Weight on Glycaemic Indices in People with Type 1 Diabetes Using Continuous Glucose Monitoring

Background/Objectives: Obesity and overweight have become increasingly prevalent in different populations of people with type 1 diabetes (PwT1D). This study aimed to assess the effect of body weight on glycaemic indices in PwT1D. Methods: Adult PwT1D using continuous glucose monitoring (CGM) and followed up at a regional academic diabetes centre were included. Body weight, body mass index (BMI), waist circumference, glycated haemoglobin (HbA1c), and standard CGM glycaemic indices were recorded. Glycaemic indices were compared according to BMI, and correlation and linear regression analysis were performed to estimate the association between measures of adiposity and glycaemic indices. Results: A total of 73 PwT1D were included (48% normal weight, 33% overweight, and 19% obese). HbA1c was 7.2% (5.6-10), glucose management indicator (GMI) 6.9% (5.7-8.9), coefficient of variation (CV) for glucose 39.5% ± 6.4, mean glucose 148 (101-235) mg/dL, TIR (time in range, glucose 70-180 mg/dL) 66% (25-94), TBR70 (time below range, 54-69 mg/dL) 4% (0-16), TBR54 (<54 mg/dL) 1% (0-11), TAR180 (time above range, 181-250 mg/dL) 20% ± 7, and TAR250 (>250 mg/dL) 6% (0-40). Glycaemic indices and achievement (%) of optimal glycaemic targets were similar between normal weight, overweight, and obese patients. BMI was associated negatively with GMI, mean glucose, TAR180, and TAR250 and positively with TIR; waist circumference was negatively associated with TAR250. Conclusions: CGM-derived glycaemic indices were similar in overweight/obese and normal weight PwT1D. Body weight and BMI were positively associated with better glycaemic control. PwT1D should receive appropriate ongoing support to achieve optimal glycaemic targets whilst maintaining a healthy body weight.

Glucose Variability in People with Type 1 Diabetes: Associations with Body Weight, Body Composition, and Insulin Sensitivity

The prevalence of overweight and obesity increases in people with type 1 diabetes (T1D). However, the impact of fat accumulation on glucose dynamics in T1D is poorly understood. We assessed continuous glucose monitoring (CGM) parameters in patients with T1D depending on their body weight, body composition, and insulin sensitivity. In 547 patients, including 238 overweight/obese individuals, CGM-derived time in range (TIR) and glucose variability (GV) were estimated. Body composition was assessed by DXA. Estimated glucose disposal rate (eGDR) was used as an indicator of insulin sensitivity. Overweight/obese patients, when compared to normal-weight ones, have a lower time below range (TBR) (<3 mmol/L), GV, and experienced fewer episodes of low glucose. In men, lower TIR, higher time above range (TAR), and GV reduction were associated with central adiposity assessed by total, trunk, and android fat mass. In women, gynoid fat mass only was associated with a lower TIR and higher TAR. The eGDR was a positive predictor of TIR and a negative predictor of TAR, TBR, and GV in men and women. In conclusion, adiposity in people with T1D is associated with a lower risk of CGM-confirmed hypoglycemia, higher TAR, and reduced GV. These features of daily glucose dynamics may be mediated by insulin resistance.

Blood glucose control and metabolic dysfunction-associated steatotic liver disease in people with type 1 diabetes

PURPOSE

Metabolic dysfunction-associated steatotic liver disease (MASLD) may have distinctive pathophysiological features in type 1 diabetes (T1D). We evaluated the independent role of blood glucose control on MASLD in T1D.

METHODS

In a cross-sectional study on 659 T1D adult patients, MASLD was assessed by the Fatty Liver Index (FLI) and the Hepatic Steatosis Index (HSI). Anthropometric, biochemical, and clinical parameters were retrieved from electronic records. Blood glucose control status was evaluated by dividing participants into subgroups according to the median value of HbA1c [7.6% (60 mmol/mol)], and this analysis was repeated excluding overweight/obese patients.

RESULTS

Patients with HbA1c above 7.6% (60 mmol/mol) showed significantly higher MASLD indices (HSI 38 ± 6 vs. 36 ± 5, p < 0.001; FLI 26 ± 26 vs.19 ± 19, p < 0.001), and higher proportions of MASLD identified by HSI (57 vs. 44%, p < 0.001) and FLI (14 vs. 7%, p < 0.001) than patients with HbA1c below 7.6% (60 mmol/mol). Similar results were obtained for HSI after the exclusion of overweight/obese patients. Stepwise linear regression analysis confirmed that HbA1c was independently associated with HSI (r = 0.496, p = 0.009) and FLI (r = 0.722, p = 0.007); waist circumference with HSI (r = 0.492, p < 0.001); and waist circumference (r = 0.700, p < 0.001), HDL cholesterol (r = 0.719, p < 0.001), and LDL cholesterol (r = 0.712, p < 0.001) with FLI.

CONCLUSIONS

Blood glucose control is a main factor associated with MASLD in adults with T1D, also independently of overweight and obesity. Appropriate therapeutic strategies focused on tight blood glucose control may also be needed for the prevention and treatment of MASLD in T1D.

Evaluation of Cardiovascular Risk in People with Type 1 Diabetes: A Comprehensive and Specific Proposed Practical Approach

People living with type 1 diabetes (T1D) have an increased risk of cardiovascular disease (CVD), and it is the leading cause of morbidity and mortality in this population. CVD risk increases with each uncontrolled risk factor, even in individuals with good glycaemic control. Recommendations for assessing CVD risk in the T1D population are extended from those for type 2 diabetes (T2D) even though the physiopathology and underlying mechanisms of atherosclerosis in T1D are poorly understood and differ from those in T2D. Unlike the assessment of microvascular complications, which is well established in T1D, this is far from being the case for the comorbidities and risk associated with CVD. Aside from classical cardiovascular comorbidities, carotid ultrasound can be useful to stratify CVD risk. The utilization of specific risk scales such as the Steno Type 1 Risk Engine can help to more accurately classify cardiovascular risk in these individuals. The cornerstones of the management of cardiovascular risk in T1D are the promotion of the Mediterranean diet, tight glycaemic control (glycated haemoglobin (HbA1c) < 7%), blood pressure < 130/80 mmHg in most patients, and low-density lipoprotein (LDL) cholesterol < 100 mg/dL in moderate-risk individuals, < 70 mg/dL in high-risk individuals, and < 55 mg/dL in very high-risk individuals. Conventional medical follow-up of patients with T1D should be individualized (approximately 2-3 visits per year), and a carotid ultrasound evaluation is recommended every 5 years in the absence of significant preclinical atherosclerosis or more often in those with severe preclinical atherosclerosis. Antithrombotic therapy is recommended in those receiving secondary prevention, those with stenosis > 50% in any arterial bed, and those with an impaired ankle-brachial index. This document is a proposal of a practical approach for the evaluation, classification, and management of CVD risk in individuals living with T1D.

Metformin beyond type 2 diabetes: Emerging and potential new indications

Metformin is best known as a foundational therapy for type 2 diabetes but is also used in other contexts in clinical medicine with a number of emerging and potential indications. Many of its beneficial effects may be mediated by modest effects on weight loss and insulin sensitivity, but it has multiple other known mechanisms of action. Current clinical uses beyond type 2 diabetes include: polycystic ovarian syndrome; diabetes in pregnancy/gestational diabetes; prevention of type 2 diabetes in prediabetes; and adjunct therapy in type 1 diabetes. As metformin has been in clinical use for almost 70 years, much of the underpinning evidence for its use in these conditions is, by definition, based on trials conducted before the advent of contemporary evidence-based medicine. As a result, some of the above-established uses are 'off-label' in many regulatory territories and their use varies accordingly in different countries. Going forward, several current 'repurposing' investigational uses of metformin are also being investigated: prevention of cancer (including in Li Fraumeni syndrome), renal protection, Alzheimer's disease, metabolic dysfunction-associated steatotic liver disease and promotion of healthy ageing. Despite the longevity of metformin and its important current roles beyond type 2 diabetes in clinical medicine, it has further potential and much research is ongoing.

Simple meal announcements and pramlintide delivery versus carbohydrate counting in type 1 diabetes with automated fast-acting insulin aspart delivery: a randomised crossover trial in Montreal, Canada

BACKGROUND

In type 1 diabetes, carbohydrate counting is the standard of care to determine prandial insulin needs, but it can negatively affect quality of life. We developed a novel insulin-and-pramlintide closed-loop system that replaces carbohydrate counting with simple meal announcements.

METHODS

We performed a randomised crossover trial assessing 14 days of (1) insulin-and-pramlintide closed-loop system with simple meal announcements, (2) insulin-and-placebo closed-loop system with carbohydrate counting, and (3) insulin-and-placebo closed-loop system with simple meal announcements. Participants were recruited at McGill University Health Centre (Montreal, QC, Canada). Eligible participants were adults (aged ≥18 years) and adolescents (aged 12-17 years) with type 1 diabetes for at least 1 year. Participants were randomly assigned in a 1:1:1:1:1:1 ratio to a sequence of the three interventions, with faster insulin aspart used in all interventions. Each intervention was separated by a 14-45-day wash-out period, during which participants reverted to their usual insulin. During simple meal announcement interventions, participants triggered a prandial bolus at mealtimes based on a programmed fixed meal size, whereas during carbohydrate counting interventions, participants manually entered the carbohydrate content of the meal and an algorithm calculated the prandial bolus based on insulin-to-carbohydrate ratio. Two primary comparisons were predefined: the percentage of time in range (glucose 3·9-10·0 mmol/L) with a non-inferiority margin of 6·25% (non-inferiority comparison); and the mean Emotional Burden subscale score of the Diabetes Distress Scale (superiority comparison), comparing the insulin-and-placebo system with carbohydrate counting minus the insulin-and-pramlintide system with simple meal announcements. Analyses were performed on a modified intention-to-treat basis, excluding participants who did not complete all interventions. Serious adverse events were assessed in all participants. This trial is registered on ClinicalTrials.gov, NCT04163874.

FINDINGS

32 participants were enrolled between Feb 14, 2020, and Oct 5, 2021; two participants withdrew before study completion. 30 participants were analysed, including 15 adults (nine female, mean age 39·4 years [SD 13·8]) and 15 adolescents (eight female, mean age 15·7 years [1·3]). Non-inferiority of the insulin-and-pramlintide system with simple meal announcements relative to the insulin-and-placebo system with carbohydrate counting was reached (difference -5% [95% CI -9·0 to -0·7], non-inferiority p<0·0001). No statistically significant difference was found in the mean Emotional Burden score between the insulin-and-pramlintide system with simple meal announcements and the insulin-and-placebo system with carbohydrate counting (difference 0·01 [SD 0·82], p=0·93). With the insulin-and-pramlintide system with simple meal announcements, 14 (47%) participants reported mild gastrointestinal symptoms and two (7%) reported moderate symptoms, compared with two (7%) participants reporting mild gastrointestinal symptoms on the insulin-and-placebo system with carbohydrate counting. No serious adverse events occurred.

INTERPRETATION

The insulin-and-pramlintide system with simple meal announcements alleviated carbohydrate counting without degrading glucose control, although quality of life as measured by the Emotional Burden score was not improved. Longer and larger studies with this novel approach are warranted.

FUNDING

Juvenile Diabetes Research Foundation.

Preterm delivery and maternal obesity remain common complications in pregnancies with type 1 diabetes-A nationwide study in Sweden

AIM

A primary goal of obstetric care of women with type 1 diabetes (T1D) is to reduce the risks of preterm birth (PTB). Besides hyperglycaemia, maternal obesity is an important risk factor for PTB in T1D. However, it's unclear if public health efforts decreased risks of maternal obesity and PTB in pregnancies with T1D. We examined time-trends over the last 20 years in the distribution of gestational ages at birth (GA) in offspring of women with T1D in Sweden, and in maternal BMI in the same mothers.

METHODS

Population-based cohort study, using data from national registries in Sweden. To capture differences not only in the median values, we used quantile regression models to compare the whole distributions of GA's and early pregnancy BMI between deliveries in 1998-2007 (P1) and 2008-2016 (P2). Multivariable models were adjusted for differences in maternal age, smoking and education between periods 1 and 2.

RESULTS

The study included 7639 offspring of women with T1D between 1998 and 2016. The 10% percentile GA, increased with 0.09 days (95% CI: -0.11 to 0.35) between P1 and P2. The 90% percentile for BMI was 1.20 kg/m2 higher (95% CI: 0.57 to 1.83) in P2. Risks of PTB remained stable over time also when adjusting for maternal BMI.

CONCLUSION

Despite modern diabetes management, the distribution of GA, and consequently the risk of PTB in T1D, remained unchanged from 1998 to 2016. During the same time, maternal BMI increased, particularly in the already obese.

Drawing lines in the sand: The growing threat of obesity in type 1 diabetes

In this editorial, we comment on the article by Zeng et al published in the recent issue of the World Journal of Diabetes in 2024. We focus on the epidemiological, pathophysiological, and clinical interplay between obesity and type 1 diabetes mellitus (T1DM). Overweight and obesity represent a growing threat for modern societies and people with T1DM could not be an exception to this rule. Chronic exogenous insulin administration, genetic and epigenetic factors, and psy-chosocial and behavioral parameters, along with the modern way of life that incorporates unhealthy eating patterns and physical inactivity, set the stage for the increasing obesity rates in T1DM. As our knowledge of the underlying mechanisms that lead to the development of obesity and hyperglycemia expands, it becomes clear that there are overlap zones in the pathophysiology of the two main types of diabetes. Stereotypes regarding strict dividing lines between "autoimmune" and "metabolic" phenotypes increase the risk of trapping physicians into ineffective therapeutic approaches, instead of individualized diabetes care. In this context, the use of adjuncts to insulin therapy that have the potential to alleviate cardiorenal risk and decrease body weight can reduce the burden of obesity in patients with T1DM.

Soluble urokinase plasminogen activator receptor (suPAR) in children with obesity or type 1 diabetes as a marker of endothelial dysfunction: a cross-sectional study

Pediatric obesity and type 1 diabetes mellitus (T1DM) represent two common chronic diseases associated with chronic inflammation, endothelial dysfunction and long-term complications. The aim of the present study was to assess the possible diagnostic and prognostic value of soluble urokinase plasminogen activator receptor (suPAR), a marker of inflammation and impaired endothelial function, in children with the diseases. In this cross-sectional study, children and adolescents with T1DM (N = 41) or obesity (N = 37), aged < 18 years old, and without proteinuria were included, together with children of similar age and without evident morbidity that served as controls (N = 42). Serum samples were obtained during standard outpatient follow up and the urokinase-type plasminogen activator receptor (suPAR) concentrations were measured using a commercially available sandwich ELISA kit (DUP00, R&D systems). Clinical and biochemical indices that were also assessed include body mass index (BMI) z-score, Tanner stages, glycosylated haemoglobin (HbA1c), fasting lipid profile and serum creatinine. Mean serum suPAR levels were significantly higher in patients with obesity compared to patients with T1DM and controls, while children with T1DM had similar suPAR levels to controls. Also, serum suPAR levels showed a negative correlation with age (Spearman rho -0.359, p < 0.001) and serum creatinine levels (Spearman rho -0.334, p = 0.005), and a positive correlation with BMI z-score (Spearman rho 0.354, p = 0.009) in the whole cohort.  Conclusion: Serum suPAR may be a useful predictive marker of inflammation or endothelial dysfunction for children with obesity and T1DM, as well as a promising therapeutic target. Further studies are needed in order to clarify whether the reported differences in suPAR levels could reflect a greater impairment of the inflammation status and endothelial function in children with obesity compared to children with T1DM. What is Known: • Paediatric obesity and type 1 diabetes are characterised by chronic inflammation and metabolic dysregulation. • Urokinase plasminogen activator receptor (uPAR) has been proposed as a useful biomarker for chronic inflammation and cardiovascular risk in adults. What is New: • Serum suPAR levels were increased in children and adolescents with obesity compared to those with T1DM and healthy controls; thus, obesity may affect the inflammatory status and endothelial function to a higher degree than T1DM during childhood. • Serum suPAR may serve as a diagnostic and predictive marker of inflammation and endothelial dysfunction for children and adolescents with obesity and T1DM.

Clinical potential of fasting in type 1 diabetes

Most adults with type 1 diabetes (T1DM) are either overweight or obese. As such, dietary management is recommended as an adjunct to insulin treatment to improve glycemic control and facilitate weight loss in these patients. Time-restricted eating (TRE) is a form of intermittent fasting that offers a simplified approach to treating obesity in T1DM. TRE typically involves restricting eating to 6 to 10 h per day, with water and medications allowed outside the eating window. This review examines the efficacy of TRE and other fasting protocols in improving weight and glycemic control in patients with obesity and T1DM. This review will also evaluate the safety of these regimens and provide advice to clinicians on implementing intermittent fasting in T1DM.

Influence of obesity on blood glucose control using continuous glucose monitoring data among patients with type 1 diabetes

INTRODUCTION

The global increase in the prevalence rates of overweight or obesity has also affected patients with type 1 diabetes (T1D), where this disease had traditionally been associated with a lean phenotype. On the other hand, the effect of obesity on new glycemic control metrics obtained from continuous glucose monitoring (CGM) in T1D is poorly understood. We wanted to assess whether there is any relationship between BMI (body mass index) and the different CGM metrics or HbA1c.

METHODS

Two hundred and twenty-five patients with T1D (47.1% ♀, mean age 42.9±14.7 years) with a CGM for a minimum of 6 months were analysed by downloading their CGM and collecting clinical and anthropometric variables.

RESULTS

35.1% (79/225) of the T1D patients had overweight and 17.3% (39/225) lived with obesity, while the remaining 47.6% had a normal weight. A negative correlation was found between GMI (glucose management indicator) and BMI (-0.2; p=0.008) and HbA1c (-0.2; p=0.01). In contrast, a positive correlation was observed between the total dose of insulin and the BMI (0.3; p<0.0001). No significant correlations were found between BMI and other CGM metrics.

CONCLUSIONS

Overweight or obesity do not imply worse glycemic control in patients with T1D or less use of CGM. Possibly, and in order to achieve a good glycemic control, more units of insulin are necessary in these patients which, in turn, makes weight control more difficult.

People with type 1 diabetes exhibit lower exercise capacity compared to a control population with similar physical activity levels

AIMS

We aimed to assess physical activity (PA) levels, adherence to PA guidelines, and fitness capacity in individuals with type 1 diabetes (T1D) and control population.

METHODS

This cross-sectional study included 232 T1D and 248 controls. PA levels (IPAQ-SF questionnaire), adherence to guidelines (>150 min/week of moderate-to-vigorous PA), fitness capacity (VO2max, maximal incremental test on a cycle ergometer and 1RM test) were assessed, along with other clinical variables.

RESULTS

Total PA levels (T1D 2202 ± 1839 vs. controls 2357 ± 2189 METs/min/week), adherence (T1D 53.1 % vs controls 53.2 %), and sedentariness (T1D 27.3 % vs. controls 25.1 %) were similar between groups. However, participants with T1D exhibited significantly lower levels of VO2max (29.1 ± 10.5 vs. 32.5 ± 11.5 mlO2/kg/min, p < 0.001), work capacity (2.73 ± 1.03 vs. 3 ± 10 W/kg of body weight, p = 0.004) and strength capacity (2.29 ± 0.53 vs. 2.41 ± 0.79 kg/kg body weight in 1RM, p = 0.01) than controls, after adjusting for sex and age.

CONCLUSIONS

Individuals with T1D exhibit lower fitness capacity compared to a control population, regardless of age and sex, even when presenting similar levels of total physical activity and adherence to guidelines.

Subdermal Progestin Implant and an Oral Combined Hormonal Contraceptive in Youth with Type 1 Diabetes

STUDY OBJECTIVE

To determine the metabolic effects of the subcutaneous etonogestrel implant compared with an oral contraceptive in adolescents and young adults (AYAs) with type 1 diabetes (T1D) on body weight, body composition, glucose, lipids, and C-reactive protein levels.

METHODS

This was a non-randomized, interventional, prospective study. Thirty-nine AYAs with T1D participated; 20 used the implant (Implant-T1D), and 19 used an oral combined contraceptive (OC-T1D). Body composition, HbA1c, intermittent continuous glucose monitoring, lipids, and high-sensitivity C-reactive protein (hsCRP) levels were evaluated.

RESULTS

All participants were followed for at least 12 months, and 26 completed the 24-month follow-up. No women discontinued the intervention due to adverse effects. Body weight increased by 0.8 ± 3.5 and 1 ± 2.9 kg in the OC-T1D and the Implant-T1D group at 12 months and by 2.6 ± 3.9 and 3.3 ± 3.6 kg at 24 months, respectively. OC-T1D and Implant-T1D had similar HbA1c, mean interstitial glucose levels, and time in range throughout the study; no significant difference over time was observed. hsCRP levels increased in both groups and were associated with BMI and HbA1c (P < .001 for both variables). Women in the OC-T1D group had higher total cholesterol, HDL-C, and triglyceride levels compared with the Implant-T1D.

CONCLUSION

Glucose levels were similar in youth using the subdermal progestin implant and an OC. However, both AYA groups showed increased BMI, fat mass, and subclinical inflammation. Changes in lipid levels were associated with the OC method. These data highlight the importance of weight gain prevention in young women with T1D using hormonal contraception.

Effect of sodium-glucose cotransporter-2 inhibitors on continuous glucose monitoring metrics, as adjunctive to insulin in adults with type 1 diabetes mellitus: a meta-analysis of randomized controlled trials

AIMS

This meta-analysis of randomized controlled trials (RCTs) aimed to evaluate the effect of sodium-glucose cotransporter-2 inhibitors (SGLT2is) on continuous glucose monitoring metrics as adjunctive to insulin in adults with type 1 diabetes mellitus (T1D).

METHODS

A systematic literature search was conducted through Medline (via PubMed), Cochrane Library and Google Scholar until October 25, 2023. Dual-independent study selection, data extraction and quality assessment were conducted. Results were summarized with random effects meta-analysis.

RESULTS

Eight RCTs were identified, involving a total of 2310 T1D patients. The use of SGLT2is on top of standard insulin therapy was associated with a significantly higher time in range (TIR) compared to placebo (mean difference (MD) 9.7 %; 95 % confidence interval (CI) [8.3, 1.11]; P < 0.001). The time above range was significantly lower in patients receiving SGLT2is (MD -8.71 %; 95 % CI [-11.62, -5.79]; P < 0.001), whereas no difference was observed regarding the time below range (TBR) (MD 0.34 %; 95 % CI [-0.17, 0.85]; P = 0.19). A significantly lower sensor-recorded mean daily glucose was noted in the group receiving SGLT2is (MD -16.55 mg/dL; 95 % CI [-19.82, -13.29]; P < 0.001). When considering the metrics of glucose variability, SGLT2is demonstrated a significant favorable effect on the mean amplitude of glucose excursions (MD -16.92 mg/dL; 95 % CI [-25.31, -8.13]; P < 0.001) and the mean standard deviation of weekly glucose levels (MD -7.67 mg/dL; 95 % CI [-11, -4.35]; P < 0.001). No significant effect was observed concerning the coefficient of variation (MD -1 %; 95 % CI [-2.39, 0.4]; P = 0.16). Regarding safety outcomes, SGLT2is were significantly linked to higher odds of diabetic ketoacidosis compared to insulin alone (OR 3.18; 95 % CI [1.79, 5.66]; P < 0.001), with no significant impact on severe hypoglycemia events (OR 1; 95 % CI [0.54, 1.85]; P = 0.1).

CONCLUSION

Our findings suggest that in individuals with T1D, adjunct therapy with SGLT2is provides a significant benefit in terms of TIR and reduced glucose variability, without an increase in TBR.

The emergence of obesity in type 1 diabetes

Obesity, a chronic low-grade inflammatory disease represented by multifactorial metabolic dysfunctions, is a significant global health threat for adults and children. The once-held belief that type 1 diabetes is a disease of people who are lean no longer holds. The mounting epidemiological data now establishes the connection between type 1 diabetes and the subsequent development of obesity, or vice versa. Beyond the consequences of the influx of an obesogenic environment, type 1 diabetes-specific biopsychosocial burden further exacerbates obesity. In the course of obesity management discussions, recurring challenges surfaced. The interplay between weight gain and escalating insulin dependence creates a vicious cycle from which patients struggle to break free. In the absence of weight management guidelines and regulatory approval for this population, healthcare professionals must navigate the delicate balance between benefits and risks. The gravity of this circumstance highlights the importance of bringing these topics to the forefront. In this Review, we discuss the changing trends and the biopsychosocial aspects of the intersection between type 1 diabetes and obesity. We highlight the evidence supporting the therapeutic means (i.e., exercise therapy, nutritional therapy, adjunct pharmacotherapy, and bariatric surgery) and directions for establishing a more robust and safer evidence-based approach.

Weight Gain and Glycemic Control in Adults with Type 1 Diabetes in the T1D Exchange Registry

Aim: The impact of weight gain on insulin dosage and glycemic control in adults with type 1 diabetes (T1D) aged 25 years and older was investigated in the T1D Exchange Registry participants. Methods: Participants were categorized into four groups based on their change in weight from T1D Exchange registry enrollment to year 5: stable weight (-5 to <5 lb), gained 5 to <10 lb, gained 10 to <20 lb, or gained ≥20 lb. Those who lost >5 lb were excluded. The primary outcomes were glucose control, as measured by glycosylated hemoglobin (HbA1c), and total daily insulin dose (TDD) at year 5. Linear regression models were used to evaluate the association between weight gain, HbA1c, and TDD. Results: There were 1969 participants included in the analyses. The mean ± standard deviation age was 45 ± 13 years, 57% were female, and 92% were White non-Hispanic. For those with an enrollment HbA1c <8.0%, the mean HbA1c at year 5 was higher for those who gained ≥20 lb compared to those with a stable weight of -5 to <5 lb (7.4% ± 1.1% vs. 7.2% ± 0.8%, respectively; P = 0.005). For this cohort, the mean TDD at year 5 increased from 49 ± 25 to 61 ± 29 U for those who gained ≥20 lb, while decreased from 45 ± 27 to 44 ± 25 U for those with stable weight of -5 to <5 lb (P < 0.001). Among participants with an enrollment HbA1c ≥9.0%, the mean HbA1c at year 5 was statistically insignificant at 8.4% ± 1.3% for those who gained ≥20 lb compared to 9.2% ± 1.7% for those with a stable weight of -5 to <5 lb (P = 0.09). Conclusion: Significant weight gain in adults with T1D who had good to adequate glycemic control was associated with modest deterioration in glucose control despite an increase in TDD. Worsening glucose control may indicate insulin resistance related to weight gain despite significantly increased insulin dosage which was insufficient to maintain adequate glycemic control.

Lower left atrial function in young individuals with type 1 diabetes mellitus compared to healthy controls: an echocardiographic study

In adulthood, individuals with type 1 diabetes mellitus may develop a condition of heart failure with preserved ejection fraction. However, subclinical changes to the heart in diabetes are likely to occur prior to the clinical presentation. This cross-sectional study aimed to compare left atrial function by echocardiography between 43 individuals with type 1 diabetes and 43 healthy controls, aged 10-30 years. All participants underwent echocardiography and 2D speckle tracking measurements for left atrial phase function parameters. Physical capacity was assessed by exercise test on a bicycle. Results showed that participants with type 1 diabetes had significantly lower left atrial function parameters than healthy controls (p < 0.05). There was a significant negative correlation between HbA1c means and reservoir and conduit strain (p < 0.05) and individuals with BMI < 30 showed a lower left atrial stiffness (p < 0.05). Individuals with type 1 diabetes and a higher physical capacity did not differ from their healthy peers. Results indicate that lower HbA1c levels, BMI < 30 and a higher physical capacity are favourable in terms of left atrial function in children and young adults with type 1 diabetes mellitus. Left atrial strain by echocardiography might become a new important tool in assessing heart function in T1DM.

Accurate construction of NIR probe for visualizing HClO fluctuations in type I, type II diabetes and diabetic liver disease assisted by theoretical calculation

Hypochlorous acid (HClO) is a key signaling molecule which involved in various pathological and physiological processes and the immune system. It had been proved that excess HClO in the organisms was closely associated with diabetes. In this paper, we constructed a series of BODIPY-based fluorophores modified with olefinic bond. With the assistance of theoretical calculations, the optimized near-infrared (NIR) dye BDP-ENE-S-Me, which possessed the longest wavelength (690 nm) and the best stability, was screened and synthesized. Based on BDP-ENE-S-Me, we further introduced N, N-dimethylcarbamate group to construct a NIR fluorescent probe BDP-ENE-ClO. BDP-ENE-ClO displayed excellent selectivity and sensitivity with a low detection limit (49 nM) towards HClO. Besides, the probe was successfully applied in monitoring concentration fluctuations of HClO in vitro and in vivo caused by various stimuli. Most importantly, the over-production of HClO in the type I, type II diabetes and diabetic liver disease mice models could be visualized and assessed precisely with the assistance of BDP-ENE-ClO. By comparing fluorescent intensity of diabetic mice models with that of diabetic liver disease mice models, the probe was competent to assess the progression of diabetes.

Beneficial effects of automated insulin delivery over one-year follow-up in real life for youths and adults with type 1 diabetes irrespective of patient characteristics

AIM

To investigate glycaemic outcomes in youths and adults with type 1 diabetes with either MiniMed™ 780G or Tandem t:slim X2™ control-IQ automated insulin delivery (AID) systems and to evaluate clinical factors that migrate, mitigate the achievement of therapeutic goals.

MATERIALS AND METHODS

This retrospective, real-world, observational study was conducted in a specialized university type 1 diabetes centre with patients observed for 3-12 months post-initiation of an AID system. Primary outcomes were the percentage time in the target glucose range [TIR70-180 mg/dl (3.9-10 mmol/L)] as measured by continuous glucose monitoring, mean glucose management indicator (GMI) and glycated haemoglobin (HbA1c) levels.

RESULTS

Our study cohort consisted of 48 adolescents and 183 adults (55% females) aged 10-77 years. The mean (95% confidence interval) TIR70-180 mg/dl after 30 days was higher than baseline and by 14% points after 360 days with 71.33% (69.4-73.2) (n = 123, p < .001). HbA1c levels decreased by 0.7% and GMI by 0.6% after 360 days. The proportion of time spent <70 mg/dl (3.9 mmol/L) was not significantly different from baseline. During follow-up, 780G users had better continuous glucose monitoring results than control-IQ users but similar HbA1c levels, and an increased risk of weight gain. Age at onset influenced TIR70-180 mg/dl in univariate analysis but there was no significant relationship after adjusting on explanatory variables. Baseline body mass index did not influence the performance of AID systems.

CONCLUSIONS

This analysis showed the beneficial effects of two AID systems for people with type 1 diabetes across a broad spectrum of participant characteristics. Only half of the participants achieved international recommendations for glucose control with TIR70-180 mg/dl >70%, HbA1c levels or GMI <7%, which outlines the need to maintain strong educational and individual strategies.

Rational Engineering of Islet Tolerance via Biomaterial-Mediated Immune Modulation

Type 1 diabetes (T1D) onset is characterized by an autoimmune attack on β islet cells within the pancreas, preventing the insulin secretion required to maintain glucose homeostasis. Targeted modulation of key immunoregulatory cell populations is a promising strategy to restore tolerance to β cells. This strategy can be used to prevent T1D onset or reverse T1D with transplanted islets. To this end, drug delivery systems can be employed to transport immunomodulatory cargo to specific cell populations that inhibit autoreactive T cell-mediated destruction of the β cell mass. The rational engineering of biomaterials into nanoscale and microscale drug carriers can facilitate targeted interactions with immune cells. The physicochemical properties of the biomaterial, the delivered immunomodulatory agent, and the target cell populations are critical variables in the design of these delivery systems. In this review, we discuss recent biomaterials-based drug delivery approaches to induce islet tolerance and the need to consider both immune and metabolic markers of disease progression.