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Ahola AJ, Parente EB, Harjutsalo V, Groop PH. Modifiable self-management practices impact nocturnal and morning glycaemia in type 1 diabetes. Prim Care Diabetes 2024:S1751-9918(24)00118-9. [PMID: 38852028 DOI: 10.1016/j.pcd.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/03/2024] [Accepted: 06/02/2024] [Indexed: 06/10/2024]
Abstract
AIMS To identify risk factors for nocturnal/morning hypo- and hyperglycaemia in type 1 diabetes. METHODS Data on self-management practices were obtained from 3-day records. We studied the associations between self-management practices on the first recording day and the self-reported blood glucose (BG) concentrations on the subsequent night/morning. RESULTS Of the 1025 participants (39 % men, median age 45 years), 4.4 % reported nocturnal hypoglycaemia (<3.9 mmol/l), 9.8 % morning hypoglycaemia, 51.5 % morning euglycaemia, and 34.3 % morning hyperglycaemia (≥8.9 mmol/l). Within hypoglycaemic range, insulin pump use was associated with higher nocturnal BG concentration (B=0.486 [95 % Confidence Interval=0.121-0.852], p=0.009). HbA1c was positively (0.046 [0.028-0.065], p<0.001), while antecedent fibre intake (-0.327 [-0.543 - -0.111], p=0.003) and physical activity (PA) (-0.042 [-0.075 - -0.010], p=0.010) were inversely associated with morning BG concentration. The odds of morning hypoglycaemia were increased by previous day hypoglycaemia (OR=2.058, p=0.002) and alcohol intake (1.031, p=0.001). Previous day PA (0.977, p=0.031) and fibre intake (0.848, p=0.017) were inversely, while HbA1c (1.027, p<0.001) was positively associated with the risk of morning hyperglycaemia. CONCLUSIONS Alcohol avoidance may prevent nocturnal hypoglycaemia, while PA and fibre intake may reduce hyperglycaemia risk. Avoidance of daytime hypoglycaemia and keeping HbA1c in control may help maintain normoglycaemia also at night-time.
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Affiliation(s)
- Aila J Ahola
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland; Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Finland
| | - Erika B Parente
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland; Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Finland
| | - Valma Harjutsalo
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland; Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Finland; National Institute for Health and Welfare, Helsinki, Finland
| | - Per-Henrik Groop
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland; Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Finland; Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia.
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Jafar A, Pasqua MR. Postprandial glucose-management strategies in type 1 diabetes: Current approaches and prospects with precision medicine and artificial intelligence. Diabetes Obes Metab 2024; 26:1555-1566. [PMID: 38263540 DOI: 10.1111/dom.15463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/01/2024] [Accepted: 01/05/2024] [Indexed: 01/25/2024]
Abstract
Postprandial glucose control can be challenging for individuals with type 1 diabetes, and this can be attributed to many factors, including suboptimal therapy parameters (carbohydrate ratios, correction factors, basal doses) because of physiological changes, meal macronutrients and engagement in postprandial physical activity. This narrative review aims to examine the current postprandial glucose-management strategies tested in clinical trials, including adjusting therapy settings, bolusing for meal macronutrients, adjusting pre-exercise and postexercise meal boluses for postprandial physical activity, and other therapeutic options, for individuals on open-loop and closed-loop therapies. Then we discuss their challenges and future avenues. Despite advancements in insulin delivery devices such as closed-loop systems and decision-support systems, many individuals with type 1 diabetes still struggle to manage their glucose levels. The main challenge is the lack of personalized recommendations, causing suboptimal postprandial glucose control. We suggest that postprandial glucose control can be improved by (i) providing personalized recommendations for meal macronutrients and postprandial activity; (ii) including behavioural recommendations; (iii) using other personalized therapeutic approaches (e.g. glucagon-like peptide-1 receptor agonists, sodium-glucose co-transporter inhibitors, amylin analogues, inhaled insulin) in addition to insulin therapy; and (iv) integrating an interpretability report to explain to individuals about changes in treatment therapy and behavioural recommendations. In addition, we suggest a future avenue to implement precision recommendations for individuals with type 1 diabetes utilizing the potential of deep reinforcement learning and foundation models (such as GPT and BERT), employing different modalities of data including diabetes-related and external background factors (i.e. behavioural, environmental, biological and abnormal events).
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Affiliation(s)
- Adnan Jafar
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Melissa-Rosina Pasqua
- Division of Endocrinology, Department of Medicine, McGill University, Montreal, Quebec, Canada
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3
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Gitsi E, Livadas S, Angelopoulos N, Paparodis RD, Raftopoulou M, Argyrakopoulou G. A Nutritional Approach to Optimizing Pump Therapy in Type 1 Diabetes Mellitus. Nutrients 2023; 15:4897. [PMID: 38068755 PMCID: PMC10707799 DOI: 10.3390/nu15234897] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 12/18/2023] Open
Abstract
Achieving optimal glucose control in individuals with type 1 diabetes (T1DM) continues to pose a significant challenge. While continuous insulin infusion systems have shown promise as an alternative to conventional insulin therapy, there remains a crucial need for greater awareness regarding the necessary adaptations for various special circumstances. Nutritional choices play an essential role in the efficacy of diabetes management and overall health status for patients with T1DM. Factors such as effective carbohydrate counting, assessment of the macronutrient composition of meals, and comprehending the concept of the glycemic index of foods are paramount in making informed pre-meal adjustments when utilizing insulin pumps. Furthermore, the ability to handle such situations as physical exercise, illness, pregnancy, and lactation by making appropriate adjustments in nutrition and pump settings should be cultivated within the patient-practitioner relationship. This review aims to provide healthcare practitioners with practical guidance on optimizing care for individuals living with T1DM. It includes recommendations on carbohydrate counting, managing mixed meals and the glycemic index, addressing exercise-related challenges, coping with illness, and managing nutritional needs during pregnancy and lactation. Additionally, considerations relating to closed-loop systems with regard to nutrition are addressed. By implementing these strategies, healthcare providers can better equip themselves to support individuals with T1DM in achieving improved diabetes management and enhanced quality of life.
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Affiliation(s)
- Evdoxia Gitsi
- Diabetes and Obesity Unit, Athens Medical Center, 15125 Athens, Greece; (E.G.); (M.R.)
| | | | | | - Rodis D. Paparodis
- Center for Diabetes and Endocrine Research, College of Medicine and Life Sciences, University of Toledo, Toledo, OH 43614, USA;
| | - Marina Raftopoulou
- Diabetes and Obesity Unit, Athens Medical Center, 15125 Athens, Greece; (E.G.); (M.R.)
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4
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Armstrong M, Colberg SR, Sigal RJ. Where to Start? Physical Assessment, Readiness, and Exercise Recommendations for People With Type 1 or Type 2 Diabetes. Diabetes Spectr 2023; 36:105-113. [PMID: 37193205 PMCID: PMC10182968 DOI: 10.2337/dsi22-0016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Exercise plays an important role in the management of diabetes and is associated with many benefits such as decreased morbidity and mortality. For people exhibiting signs and symptoms of cardiovascular disease, pre-exercise medical clearance is warranted; however, requiring broad screening requirements can lead to unnecessary barriers to initiating an exercise program. Robust evidence supports the promotion of both aerobic and resistance training, with evidence emerging on the importance of reducing sedentary time. For people with type 1 diabetes, there are special considerations, including hypoglycemia risk and prevention, exercise timing (including prandial status), and differences in glycemic responses based on biological sex.
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Affiliation(s)
- Marni Armstrong
- Medicine Strategic Clinical Network, Alberta Health Services, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sheri R. Colberg
- Human Movement Sciences Department, Old Dominion University, Norfolk, VA
| | - Ronald J. Sigal
- Departments of Medicine, Cardiac Sciences, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Abstract
Regular physical activity improves cardiometabolic and musculoskeletal health, helps with weight management, improves cognitive and psychosocial functioning, and is associated with reduced mortality related to cancer and diabetes mellitus. However, turnover rates of glucose in the blood increase dramatically during exercise, which often results in either hypoglycaemia or hyperglycaemia as well as increased glycaemic variability in individuals with type 1 diabetes mellitus (T1DM). A complex neuroendocrine response to an acute exercise session helps to maintain circulating levels of glucose in a fairly tight range in healthy individuals, while several abnormal physiological processes and limitations of insulin therapy limit the capacity of people with T1DM to exercise in a normoglycaemic state. Knowledge of the acute and chronic effects of exercise and regular physical activity is critical for the formulation of clinical strategies for the management of insulin and nutrition for active patients with T1DM. Emerging diabetes-related technologies, such as continuous glucose monitors, automated insulin delivery systems and the administration of solubilized glucagon, are demonstrating efficacy for preserving glucose homeostasis during and after exercise in this population of patients. This Review highlights the beneficial effects of regular exercise and details the complex endocrine and metabolic responses to different types of exercise for adults with T1DM. An overview of basic clinical strategies for the preservation of glucose homeostasis using emerging technologies is also provided.
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Affiliation(s)
- Michael C Riddell
- Muscle Health Research Centre, School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada.
- LMC Diabetes and Endocrinology, Toronto, Ontario, Canada.
| | - Anne L Peters
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Association of HbA1c with VO 2max in Individuals with Type 1 Diabetes: A Systematic Review and Meta-Analysis. Metabolites 2022; 12:metabo12111017. [PMID: 36355100 PMCID: PMC9697838 DOI: 10.3390/metabo12111017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/12/2022] [Accepted: 10/20/2022] [Indexed: 11/17/2022] Open
Abstract
The aim of this systematic review and meta-analysis was to evaluate the association between glycemic control (HbA1c) and functional capacity (VO2max) in individuals with type 1 diabetes (T1DM). A systematic literature search was conducted in EMBASE, PubMed, Cochrane Central Register of Controlled Trials, and ISI Web of Knowledge for publications from January 1950 until July 2020. Randomized and observational controlled trials with a minimum number of three participants were included if cardio-pulmonary exercise tests to determine VO2max and HbA1c measurement has been performed. Pooled mean values were estimated for VO2max and HbA1c and weighted Pearson correlation and meta-regression were performed to assess the association between these parameters. We included 187 studies with a total of 3278 individuals with T1DM. The pooled mean HbA1c value was 8.1% (95%CI; 7.9−8.3%), and relative VO2max was 38.5 mL/min/kg (37.3−39.6). The pooled mean VO2max was significantly lower (36.9 vs. 40.7, p = 0.001) in studies reporting a mean HbA1c > 7.5% compared to studies with a mean HbA1c ≤ 7.5%. Weighted Pearson correlation coefficient was r = −0.19 (p < 0.001) between VO2max and HbA1c. Meta-regression adjusted for age and sex showed a significant decrease of −0.94 mL/min/kg in VO2max per HbA1c increase of 1% (p = 0.024). In conclusion, we were able to determine a statistically significant correlation between HbA1c and VO2max in individuals with T1DM. However, as the correlation was only weak, the association of HbA1c and VO2max might not be of clinical relevance in individuals with T1DM.
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Tagougui S, Legault L, Heyman E, Messier V, Suppere C, Potter KJ, Pigny P, Berthoin S, Taleb N, Rabasa-Lhoret R. Anticipated Basal Insulin Reduction to Prevent Exercise-Induced Hypoglycemia in Adults and Adolescents Living with Type 1 Diabetes. Diabetes Technol Ther 2022; 24:307-315. [PMID: 35099281 DOI: 10.1089/dia.2021.0375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective: We investigated the effect of two key timings for basal insulin rate reduction on exercise-induced glucose changes and explored the association between circulating insulin concentrations and muscle vasoreactivity. Research Design and Methods: Twenty adults and adolescents performed 60-min exercise sessions (ergocycle) at 60% VO2peak, 240 min after a standardized lunch. In a randomized order, we compared an 80% basal insulin reduction applied 40 min (T-40) or 90 min (T-90) before exercise onset. Near-infrared spectroscopy was used to investigate muscle hemodynamics at vastus lateralis. Glucose and insulin plasma concentrations were measured. Results: Reduction in plasma glucose (PG) level during exercise was attenuated during T-90 versus T-40 strategy (-0.89 ± 1.89 mmol/L vs. -2.17 ± 2.49 mmol/L, respectively; P = 0.09). Linear mixed model analysis showed that PG dropped by an additional 0.01 mM per minute in T-40 versus T-90 (time × strategy interaction, P < 0.05). The absolute number of hypoglycemic events was not different between the two strategies, but they occurred later with T-90. Free insulin tends to decrease more during the pre-exercise period in the T-90 strategy (P = 0.08). Although local muscle vasodilatation (ΔTHb) was comparable between the two strategies, we found that PG dropped more in cases of higher exercise-induced skeletal muscle vasodilatation (ΔTHb × time interaction P < 0.005, e: -0.0086 mM/min and additional mM of ΔTHb). Conclusion: T-90 timing reduced exercise-induced drop in PG and delayed the occurrence of hypoglycemic episodes compared with T-40 timing without a significant reduction in the number of events requiring treatment. Trial registration: ClinicalTrials.gov identifier: NCT03349489.
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Affiliation(s)
- Sémah Tagougui
- Montreal Clinical Research Institute (IRCM), Montreal, Canada
- Département de nutrition, Université de Montréal, Montreal, Canada
- Univ. Lille, Univ. Artois, Univ. Littoral Côte d'Opale, ULR 7369 - URePSSS - Unité de Recherche Pluridisciplinaire Sport Santé Société, Lille, France
| | - Laurent Legault
- Montreal Clinical Research Institute (IRCM), Montreal, Canada
- McGill University Health Center (MUHC), Montreal Children's Hospital, Montreal, Canada
| | - Elsa Heyman
- Univ. Lille, Univ. Artois, Univ. Littoral Côte d'Opale, ULR 7369 - URePSSS - Unité de Recherche Pluridisciplinaire Sport Santé Société, Lille, France
| | | | - Corinne Suppere
- Montreal Clinical Research Institute (IRCM), Montreal, Canada
| | | | - Pascal Pigny
- Laboratoire de Biochimie-Hormonologie, CHU Lille, Centre de Biologie-Pathologie, Lille, France
| | - Serge Berthoin
- Univ. Lille, Univ. Artois, Univ. Littoral Côte d'Opale, ULR 7369 - URePSSS - Unité de Recherche Pluridisciplinaire Sport Santé Société, Lille, France
| | - Nadine Taleb
- Montreal Clinical Research Institute (IRCM), Montreal, Canada
- Division of Biomedical Sciences, Faculty of Medicine, Université de Montréal, Montréal, Canada
- Endocrinology Division, Montreal Diabetes Research Center (MDRC), Montreal University Hospital (CHUM), Montreal, Canada
| | - Rémi Rabasa-Lhoret
- Montreal Clinical Research Institute (IRCM), Montreal, Canada
- Département de nutrition, Université de Montréal, Montreal, Canada
- Endocrinology Division, Montreal Diabetes Research Center (MDRC), Montreal University Hospital (CHUM), Montreal, Canada
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Paiement K, Frenette V, Wu Z, Suppère C, Messier V, Lasalle-Vaillancourt A, Mathieu ME, Rabasa-Lhoret R. Is a better understanding of management strategies for type 1 diabetes associated with a lower risk of developing hypoglycemia during and after physical activity? Can J Diabetes 2022; 46:526-534. [DOI: 10.1016/j.jcjd.2022.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 02/08/2022] [Accepted: 02/20/2022] [Indexed: 11/29/2022]
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Pujalte G, Alhumaidi HM, Ligaray KPL, Vomer RP, Israni K, Abadin AA, Meek SE. Considerations in the Care of Athletes With Type 1 Diabetes Mellitus. Cureus 2022; 14:e22447. [PMID: 35345701 PMCID: PMC8942069 DOI: 10.7759/cureus.22447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 11/12/2022] Open
Abstract
Type 1 diabetes mellitus is an autoimmune disease caused by affected individuals’ autoimmune response to their own pancreatic beta-cell. It affects millions of people worldwide. Exercise has numerous health and social benefits for patients with type 1 diabetes mellitus; however, careful management of blood glucose is crucial to minimize the risk of hypoglycemia and hyperglycemia. Anaerobic and aerobic exercises cause different glycemic responses during and after exercise, each of which will affect athletes’ ability to reach their target blood glucose ranges. The optimization of the patient’s macronutrient consumption, especially carbohydrates, the dosage of basal and short-acting insulin, and the frequent monitoring of blood glucose, will enable athletes to perform at peak levels while reducing their risk of dysglycemia. Despite best efforts, hypoglycemia can occur. Recognition of symptoms and rapid treatment with either fast-acting carbohydrates or glucagon is important. Continuous glucose monitoring devices have become more widely used in preventing hypoglycemia.
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Thuillier P, Domun N, Sonnet E, Le Ven F, Roudaut C, Kergus A, Kerlan V, Roudaut N. Prevention of exercise-induced hypoglycemia in 12 patients with type 1 diabetes running the Paris Marathon using continuous glucose monitoring: a prospective, single-center observational study. DIABETES & METABOLISM 2022; 48:101321. [PMID: 35032674 DOI: 10.1016/j.diabet.2022.101321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/09/2021] [Accepted: 12/13/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To investigate the glycemic balance before, during and after the 2016 Paris Marathon using a real-time continuous glucose monitoring (RT-CGM) system in patients with type 1 diabetes mellitus in a prospective single-center observational study. METHODS Inclusion criteria were as follows: type 1 diabetes mellitus; age ≥18 years; HbA1c < 9%. Participants performed two 2h-preparatory races (PR) before the Marathon and were monitored with RT-CGM 24h before, during and 72h after each race. Hypoglycemic events were prevented via carbohydrate intake / insulin dose adjustments. The primary outcome was area under the curve (AUC) < 70 and > 200 mg/dl and percentage of time spent in euglycemia, hypoglycemia, and hyperglycemia during the races. RESULTS Twelve patients (2F/10M; median HbA1c=6.8%) were included and completed the study. Median AUC < 70 and time spent in hypoglycemia (< 70 mg/dl) during the PRs and Marathon were equal to 0. However, no hypoglycemic episodes occurred during Marathon, while two patients experienced hypoglycemia during PR1 and PR2. There was a significant increase in AUC > 200 mg/dl during races between PR2 and Marathon (P = 0.009) although the median time spent > 200mg/dl was not statistically different in Marathon versus PR2 (48.4% versus 18.4%; P = 0.09). Median time spent in euglycemia (70-200 mg/dl) was lower in Marathon versus PR2 (51.6 versus 58%; P = 0.03). CONCLUSION Our study proposes a medical support protocol for extreme endurance physical activity in patients with type 1 diabetes mellitus. Our results suggest that RT-CGM, coupled with adjustments in carbohydrate intake and insulin doses, appears to be effective to prevent hypoglycemia during and after exercise.
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Affiliation(s)
- Philippe Thuillier
- Department of Endocrinology, University Hospital of Brest, France; EA GETBO 3878, University Hospital of Brest, France.
| | - Nikhil Domun
- Department of Endocrinology, University Hospital of Brest, France; EA GETBO 3878, University Hospital of Brest, France
| | - Emmanuel Sonnet
- Department of Endocrinology, University Hospital of Brest, France; EA GETBO 3878, University Hospital of Brest, France
| | - Florent Le Ven
- Department of Endocrinology, University Hospital of Brest, France; Department of Cardiology, University Hospital of Brest, France
| | - Caroline Roudaut
- Department of Endocrinology, University Hospital of Brest, France
| | - Anne Kergus
- Department of Endocrinology, University Hospital of Brest, France
| | - Véronique Kerlan
- Department of Endocrinology, University Hospital of Brest, France; EA GETBO 3878, University Hospital of Brest, France
| | - Nathalie Roudaut
- Department of Endocrinology, University Hospital of Brest, France; EA GETBO 3878, University Hospital of Brest, France
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Molveau J, Rabasa-Lhoret R, Myette-Côté É, Messier V, Suppère C, J. Potter K, Heyman E, Tagougui S. Prevalence of nocturnal hypoglycemia in free-living conditions in adults with type 1 diabetes: What is the impact of daily physical activity? Front Endocrinol (Lausanne) 2022; 13:953879. [PMID: 36237197 PMCID: PMC9551602 DOI: 10.3389/fendo.2022.953879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/18/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Studies investigating strategies to limit the risk of nocturnal hypoglycemia associated with physical activity (PA) are scarce and have been conducted in standardized, controlled conditions in people with type 1 diabetes (T1D). This study sought to investigate the effect of daily PA level on nocturnal glucose management in free-living conditions while taking into consideration reported mitigation strategies to limit the risk of nocturnal hyoglycemia in people with T1D. METHODS Data from 25 adults (10 males, 15 females, HbA1c: 7.6 ± 0.8%), 20-60 years old, living with T1D, were collected. One week of continuous glucose monitoring and PA (assessed using an accelerometer) were collected in free-living conditions. Nocturnal glucose values (midnight-6:00 am) following an active day "ACT" and a less active day "L-ACT" were analyzed to assess the time spent within the different glycemic target zones (<3.9 mmol/L; 3.9 - 10.0 mmol/L and >10.0 mmol/L) between conditions. Self-reported data about mitigation strategies applied to reduce the risk of nocturnal hypoglycemia was also analyzed. RESULTS Only 44% of participants reported applying a carbohydrate- or insulin-based strategy to limit the risk of nocturnal hypoglycemia on ACT day. Nocturnal hypoglycemia occurrences were comparable on ACT night versus on L-ACT night. Additional post-meal carbohydrate intake was higher on evenings following ACT (27.7 ± 15.6 g, ACT vs. 19.5 ± 11.0 g, L-ACT; P=0.045), but was frequently associated with an insulin bolus (70% of participants). Nocturnal hypoglycemia the night following ACT occurred mostly in people who administrated an additional insulin bolus before midnight (3 out of 5 participants with nocturnal hypoglycemia). CONCLUSIONS Although people with T1D seem to be aware of the increased risk of nocturnal hypoglycemia associated with PA, the risk associated with additional insulin boluses may not be as clear. Most participants did not report using compensation strategies to reduce the risk of PA related late-onset hypoglycemia which may be because they did not consider habitual PA as something requiring treatment adjustments.
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Affiliation(s)
- Joséphine Molveau
- Institut de recherches cliniques de Montréal, Montréal, QC, Canada
- Département de Nutrition, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
- Univ. Lille, Univ. Artois, Univ. Littoral Côte d’Opale, ULR 7369 - URePSSS - Unité de Recherche Pluridisciplinaire Sport Santé Société, Lille, France
| | - Rémi Rabasa-Lhoret
- Institut de recherches cliniques de Montréal, Montréal, QC, Canada
- Département de Nutrition, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
- Département des Sciences Biomédicales, Faculté de Médecine, Université de Montréal, Montreal, QC, Canada
- Endocrinology Division, Montreal Diabetes Research Center, Montréal, QC, Canada
- *Correspondence: Rémi Rabasa-Lhoret, ; Sémah Tagougui,
| | - Étienne Myette-Côté
- Institut de recherches cliniques de Montréal, Montréal, QC, Canada
- Department of Applied Human Sciences, Faculty of Science, University of Prince Edward Island, Charlottetown, PE, Canada
| | - Virginie Messier
- Institut de recherches cliniques de Montréal, Montréal, QC, Canada
| | - Corinne Suppère
- Institut de recherches cliniques de Montréal, Montréal, QC, Canada
| | | | - Elsa Heyman
- Univ. Lille, Univ. Artois, Univ. Littoral Côte d’Opale, ULR 7369 - URePSSS - Unité de Recherche Pluridisciplinaire Sport Santé Société, Lille, France
- Institut Universitaire de France (IUF), Paris, France
| | - Sémah Tagougui
- Institut de recherches cliniques de Montréal, Montréal, QC, Canada
- Département de Nutrition, Faculté de Médecine, Université de Montréal, Montréal, QC, Canada
- Univ. Lille, Univ. Artois, Univ. Littoral Côte d’Opale, ULR 7369 - URePSSS - Unité de Recherche Pluridisciplinaire Sport Santé Société, Lille, France
- *Correspondence: Rémi Rabasa-Lhoret, ; Sémah Tagougui,
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12
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Fitzpatrick R, Davison G, Wilson JJ, McMahon G, McClean C. Exercise, type 1 diabetes mellitus and blood glucose: The implications of exercise timing. Front Endocrinol (Lausanne) 2022; 13:1021800. [PMID: 36246914 PMCID: PMC9555792 DOI: 10.3389/fendo.2022.1021800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/12/2022] [Indexed: 11/25/2022] Open
Abstract
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.
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Rilstone S, Spurway P, Oliver N, Hill NE. Nutritional support for a person with type 1 diabetes undertaking endurance swimming. Front Endocrinol (Lausanne) 2022; 13:1038294. [PMID: 36425473 PMCID: PMC9679002 DOI: 10.3389/fendo.2022.1038294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022] Open
Abstract
Long distance and open water swimming have increased in popularity over recent years. Swimming a long distance in lakes, rivers and the sea present numerous challenges, including cold water exposure and maintaining adequate nutritional intake to fuel exercising muscles. Guidelines exist outlining issues to consider and potential solutions to overcome the difficulties in feeding athletes. Exercising with type 1 diabetes adds further complexity, mostly around matching insulin to the recommended high carbohydrate intake, but also because of the way in which higher circulating insulin levels affect glucose utilisation and fat oxidation. This paper describes the nutritional considerations for people with type 1 diabetes intending to undertake long distance open water events, and insulin management suggestions to trial alongside. In addition, we include personal testimony from a swimmer with type 1 diabetes describing the challenges and considerations he faced when undertaking marathon swimming.
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Affiliation(s)
- Siân Rilstone
- Department of Nutrition & Dietetics, Imperial College Healthcare National Health Service (NHS) Trust, London, United Kingdom
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
- *Correspondence: Siân Rilstone,
| | | | - Nick Oliver
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Neil E. Hill
- Department of Endocrinology & Diabetes, Imperial College Healthcare NHS Trust, London, United Kingdom
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14
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Physical Activity, Dietary Patterns, and Glycemic Management in Active Individuals with Type 1 Diabetes: An Online Survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18179332. [PMID: 34501920 PMCID: PMC8431360 DOI: 10.3390/ijerph18179332] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/18/2021] [Accepted: 08/31/2021] [Indexed: 12/19/2022]
Abstract
Individuals with type 1 diabetes (T1D) are able to balance their blood glucose levels while engaging in a wide variety of physical activities and sports. However, insulin use forces them to contend with many daily training and performance challenges involved with fine-tuning medication dosing, physical activity levels, and dietary patterns to optimize their participation and performance. The aim of this study was to ascertain which variables related to the diabetes management of physically active individuals with T1D have the greatest impact on overall blood glucose levels (reported as A1C) in a real-world setting. A total of 220 individuals with T1D completed an online survey to self-report information about their glycemic management, physical activity patterns, carbohydrate and dietary intake, use of diabetes technologies, and other variables that impact diabetes management and health. In analyzing many variables affecting glycemic management, the primary significant finding was that A1C values in lower, recommended ranges (<7%) were significantly predicted by a very-low carbohydrate intake dietary pattern, whereas the use of continuous glucose monitoring (CGM) devices had the greatest predictive ability when A1C was above recommended (≥7%). Various aspects of physical activity participation (including type, weekly time, frequency, and intensity) were not significantly associated with A1C for participants in this survey. In conclusion, when individuals with T1D are already physically active, dietary changes and more frequent monitoring of glucose may be most capable of further enhancing glycemic management.
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15
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Franc S, Benhamou P, Borot S, Chaillous L, Delemer B, Doron M, Guerci B, Hanaire H, Huneker E, Jeandidier N, Amadou C, Renard E, Reznik Y, Schaepelynck P, Simon C, Thivolet C, Thomas C, Hannaert P, Charpentier G. No more hypoglycaemia on days with physical activity and unrestricted diet when using a closed-loop system for 12 weeks: A post hoc secondary analysis of the multicentre, randomized controlled Diabeloop WP7 trial. Diabetes Obes Metab 2021; 23:2170-2176. [PMID: 34009725 PMCID: PMC8453744 DOI: 10.1111/dom.14442] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/06/2021] [Accepted: 05/16/2021] [Indexed: 12/15/2022]
Abstract
A post hoc analysis of the Diabeloop WP7 multicentre, randomized controlled trial was performed to investigate the efficacy of the Diabeloop Generation-1 (DBLG1) closed-loop system in controlling the hypoglycaemia induced by physical activity (PA) in real-life conditions. Glycaemic outcomes were compared between days with and without PA in 56 patients with type 1 diabetes (T1D) using DBLG1 for 12 weeks. After the patient announces a PA, DBLG1 reduces insulin delivery and, if necessary, calculates the amount of preventive carbohydrates (CHO). Daily time spent in the interstitial glucose range less than 70 mg/dL was not significantly different between days with and without PA (2.0% ± 1.5% vs. 2.2% ± 1.1%), regardless of the intensity or duration of the PA. Preventive CHO intake recommended by the system was significantly higher in days with PA (41.1 ± 35.5 vs. 21.8 ± 28.5 g/day; P < .0001), and insulin delivery was significantly lower (31.5 ± 10.5 vs. 34.0 ± 10.5 U/day; P < .0001). The time spent in hyperglycaemia and the glycaemic variation coefficient increased significantly on days with PA. In real-life conditions, the use of DBLG1 avoids PA-induced hypoglycaemia. Insulin adjustments and preventive CHO recommendation may explain this therapeutic benefit.
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Affiliation(s)
- Sylvia Franc
- Department of DiabetesSud‐Francilien HospitalCorbeil‐EssonnesFrance
- Centre d'Etude et de Recherche pour l'Intensification du Traitement du Diabète (CERITD)EvryFrance
- Laboratoire de Biologie de l'Exercice pour la Performance et la Santé, Université Evry Val d'Essonne, Institut de Recherches Biomédicales des Armées, Université Paris SaclayEvryFrance
| | | | - Sophie Borot
- Department of Endocrinology, Metabolism, Diabetes and NutritionCentre Hospitalier Universitaire Jean MinjozBesançonFrance
| | | | - Brigitte Delemer
- Department of Endocrinology, Diabetes and NutritionReims University HospitalReimsFrance
| | - Maeva Doron
- Université Grenoble Alpes, Commissariat à l'Energie Atomique, Laboratoire d'électronique et de technologie de l'information, Département micro Technologies pour la Biologie et la SantéGrenobleFrance
| | - Bruno Guerci
- Endocrinology‐Diabetes Care UnitUniversity of LorraineVandoeuvre Lès NancyFrance
| | - Hélène Hanaire
- Department of Diabetology, Metabolic Diseases and NutritionCHU Toulouse, University of ToulouseToulouseFrance
| | | | - Nathalie Jeandidier
- Department of Endocrinology, Diabetes and NutritionCHRU of Strasbourg (UDS)StrasbourgFrance
| | - Coralie Amadou
- Department of DiabetesSud‐Francilien HospitalCorbeil‐EssonnesFrance
- University Paris‐SaclayOrsayFrance
| | - Eric Renard
- Department of Endocrinology, Diabetes and NutritionMontpellier University Hospital, and Institute of Functional Genomics, CNRS, INSERM, University of MontpellierMontpellierFrance
| | - Yves Reznik
- Department of EndocrinologyUniversity of Caen Côte de Nacre Regional Hospital CenterCaenFrance
| | - Pauline Schaepelynck
- Department of Nutrition‐Endocrinology‐Metabolic DisordersMarseille University Hospital, Sainte Marguerite HospitalMarseilleFrance
| | - Chantal Simon
- Department of Endocrinology, Diabetes and NutritionCentre Hospitalier Lyon SudLyonFrance
| | | | - Claire Thomas
- Laboratoire de Biologie de l'Exercice pour la Performance et la Santé, Université Evry Val d'Essonne, Institut de Recherches Biomédicales des Armées, Université Paris SaclayEvryFrance
| | - Patrick Hannaert
- School of Medicine and Pharmacy of PoitiersIschémie Reperfusion en Transplantation d'Organes Mécanismes et Innovations Thérapeutiques, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1082PoitiersFrance
| | - Guillaume Charpentier
- Centre d'Etude et de Recherche pour l'Intensification du Traitement du Diabète (CERITD)EvryFrance
- Laboratoire de Biologie de l'Exercice pour la Performance et la Santé, Université Evry Val d'Essonne, Institut de Recherches Biomédicales des Armées, Université Paris SaclayEvryFrance
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16
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Grunberger G, Sherr J, Allende M, Blevins T, Bode B, Handelsman Y, Hellman R, Lajara R, Roberts VL, Rodbard D, Stec C, Unger J. American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons With Diabetes Mellitus. Endocr Pract 2021; 27:505-537. [PMID: 34116789 DOI: 10.1016/j.eprac.2021.04.008] [Citation(s) in RCA: 119] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations regarding the use of advanced technology in the management of persons with diabetes mellitus to clinicians, diabetes-care teams, health care professionals, and other stakeholders. METHODS The American Association of Clinical Endocrinology (AACE) conducted literature searches for relevant articles published from 2012 to 2021. A task force of medical experts developed evidence-based guideline recommendations based on a review of clinical evidence, expertise, and informal consensus, according to established AACE protocol for guideline development. MAIN OUTCOME MEASURES Primary outcomes of interest included hemoglobin A1C, rates and severity of hypoglycemia, time in range, time above range, and time below range. RESULTS This guideline includes 37 evidence-based clinical practice recommendations for advanced diabetes technology and contains 357 citations that inform the evidence base. RECOMMENDATIONS Evidence-based recommendations were developed regarding the efficacy and safety of devices for the management of persons with diabetes mellitus, metrics used to aide with the assessment of advanced diabetes technology, and standards for the implementation of this technology. CONCLUSIONS Advanced diabetes technology can assist persons with diabetes to safely and effectively achieve glycemic targets, improve quality of life, add greater convenience, potentially reduce burden of care, and offer a personalized approach to self-management. Furthermore, diabetes technology can improve the efficiency and effectiveness of clinical decision-making. Successful integration of these technologies into care requires knowledge about the functionality of devices in this rapidly changing field. This information will allow health care professionals to provide necessary education and training to persons accessing these treatments and have the required expertise to interpret data and make appropriate treatment adjustments.
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Affiliation(s)
| | - Jennifer Sherr
- Yale University School of Medicine, New Haven, Connecticut
| | - Myriam Allende
- University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | | | - Bruce Bode
- Atlanta Diabetes Associates, Atlanta, Georgia
| | | | - Richard Hellman
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | | | | | - David Rodbard
- Biomedical Informatics Consultants, LLC, Potomac, Maryland
| | - Carla Stec
- American Association of Clinical Endocrinology, Jacksonville, Florida
| | - Jeff Unger
- Unger Primary Care Concierge Medical Group, Rancho Cucamonga, California
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17
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Mohammed MHH, Al-Qahtani MHH, Takken T. Effects of 12 weeks of recreational football (soccer) with caloric control on glycemia and cardiovascular health of adolescent boys with type 1 diabetes. Pediatr Diabetes 2021; 22:625-637. [PMID: 33745203 DOI: 10.1111/pedi.13203] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 02/09/2021] [Accepted: 03/11/2021] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To determine the effects of recreational football combined with caloric control on glycemia and cardiovascular health of adolescent boys with type 1 diabetes. BACKGROUND Though 12 weeks of physical activity alone improves the health of people with type 1 diabetes, there is little evidence that physical activity alone can improve glycemia in 12 weeks. RESEARCH DESIGN AND METHODS The participants were divided into four groups as follows: football with diet, football-only, diet-only, and the control groups. Each group consisted of 10 participants. The football with diet and the football-only groups had 1.5 h of football twice a week for 12 weeks. The following outcomes were measured before and after 12 weeks: Glycated hemoglobin, fasting blood glucose, total cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides, and resting blood pressures. Changes were considered significant when p ≤ 0.050 and common language effect size ≤42% or common language effect size ≥58%. RESULTS Glycated hemoglobin decreased in the football with diet group (mean change (standard deviation) = -0.9 (1.0) %, p = 0.019, and common language effect size = 31.5%) and was different from the control group (p = 2.4 × 10-4 and common language effect size = 95.5%.). However, none of the intervention groups showed a clear change in blood lipids nor blood pressure. CONCLUSIONS 12 weeks of combined football with diet intervention provides the greatest improvement in glycemia in adolescent boys with type 1 diabetes.
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Affiliation(s)
| | | | - Tim Takken
- Child Development and Exercise Center, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
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18
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Cigrovski Berkovic M, Bilic-Curcic I, La Grasta Sabolic L, Mrzljak A, Cigrovski V. Fear of hypoglycemia, a game changer during physical activity in type 1 diabetes mellitus patients. World J Diabetes 2021; 12:569-577. [PMID: 33995845 PMCID: PMC8107983 DOI: 10.4239/wjd.v12.i5.569] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/16/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023] Open
Abstract
Hypoglycemia limits optimal glycemic management of patients with type 1 diabetes mellitus (T1DM). Fear of hypoglycemia (FoH) is a significant psychosocial consequence that negatively impacts the willingness of T1DM patients to engage in and profit from the health benefits of regular physical activity (e.g., cardiometabolic health, improved body composition, cardiovascular fitness, quality of life). Technological advances, improved insulin regimens, and a better understanding of the physiology of various types of exercise could help ameliorate FoH. This narrative review summarizes the available literature on FoH in children and adults and tools to avoid it.
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Affiliation(s)
- Maja Cigrovski Berkovic
- Department of Endocrinology, Diabetes, Metabolism and Clinical Pharmacology, University Hospital Dubrava, Zagreb 10000, Croatia
| | - Ines Bilic-Curcic
- Department of Pharmacology, Faculty of Medicine, University of J. J. Strossmayer Osijek, Osijek 31000, Croatia
| | - Lavinia La Grasta Sabolic
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Hospital Centre Sestre Milosrdnice, Zagreb 10000, Croatia
| | - Anna Mrzljak
- Department of Medicine, Merkur University Hospital, Zagreb 10000, Croatia
- School of Medicine, University of Zagreb, Zagreb 10000, Croatia
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19
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Garcia-Tirado J, Brown SA, Laichuthai N, Colmegna P, Koravi CL, Ozaslan B, Corbett JP, Barnett CL, Pajewski M, Oliveri MC, Myers H, Breton MD. Anticipation of Historical Exercise Patterns by a Novel Artificial Pancreas System Reduces Hypoglycemia During and After Moderate-Intensity Physical Activity in People with Type 1 Diabetes. Diabetes Technol Ther 2021; 23:277-285. [PMID: 33270531 PMCID: PMC7994426 DOI: 10.1089/dia.2020.0516] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objective: Physical activity is a major challenge to glycemic control for people with type 1 diabetes. Moderate-intensity exercise often leads to steep decreases in blood glucose and hypoglycemia that closed-loop control systems have so far failed to protect against, despite improving glycemic control overall. Research Design and Methods: Fifteen adults with type 1 diabetes (42 ± 13.5 years old; hemoglobin A1c 6.6% ± 1.0%; 10F/5M) participated in a randomized crossover clinical trial comparing two hybrid closed-loop (HCL) systems, a state-of-the-art hybrid model predictive controller and a modified system designed to anticipate and detect unannounced exercise (APEX), during two 32-h supervised admissions with 45 min of planned moderate activity, following 4 weeks of data collection. Primary outcome was the number of hypoglycemic episodes during exercise. Continuous glucose monitor (CGM)-based metrics and hypoglycemia are also reported across the entire admissions. Results: The APEX system reduced hypoglycemic episodes overall (9 vs. 33; P = 0.02), during exercise (5 vs. 13; P = 0.04), and in the 4 h following (2 vs. 11; P = 0.02). Overall CGM median percent time <70 mg/dL decreased as well (0.3% vs. 1.6%; P = 0.004). This protection was obtained with no significant increase in time >180 mg/dL (18.5% vs. 16.6%, P = 0.15). Overnight control was notable for both systems with no hypoglycemia, median percent in time 70-180 mg/dL at 100% and median percent time 70-140 mg/dL at ∼96% for both. Conclusions: A new closed-loop system capable of anticipating and detecting exercise was proven to be safe and feasible and outperformed a state-of-the-art HCL, reducing participants' exposure to hypoglycemia during and after moderate-intensity physical activity. ClinicalTrials.gov NCT03859401.
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Affiliation(s)
- Jose Garcia-Tirado
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Sue A. Brown
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Nitchakarn Laichuthai
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
- Excellence Center in Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, and Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Patricio Colmegna
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Chaitanya L.K. Koravi
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Basak Ozaslan
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - John P. Corbett
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Charlotte L. Barnett
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Michael Pajewski
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Mary C. Oliveri
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Helen Myers
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Marc D. Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
- Address correspondence to: Marc D. Breton, PhD, Center for Diabetes Technology, University of Virginia, PO Box 400888, Charlottesville, VA 22904-4888, USA
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20
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McGaugh SM, Zaharieva DP, Pooni R, D'Souza NC, Vienneau T, Ly TT, Riddell MC. Carbohydrate Requirements for Prolonged, Fasted Exercise With and Without Basal Rate Reductions in Adults With Type 1 Diabetes on Continuous Subcutaneous Insulin Infusion. Diabetes Care 2021; 44:610-613. [PMID: 33328284 PMCID: PMC7818338 DOI: 10.2337/dc20-1554] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 11/16/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Exercising while fasted with type 1 diabetes facilitates weight loss; however, the best strategy to maintain glucose stability remains unclear. RESEARCH DESIGN AND METHODS Fifteen adults on continuous subcutaneous insulin infusion completed three sessions of fasted walking (120 min at 45% VO2max) in a randomized crossover design: 50% basal rate reduction, set 90 min pre-exercise (-90min50%BRR); usual basal rate with carbohydrate intake of 0.3 g/kg/h (CHO-only); and combined 50% basal rate reduction set at exercise onset with carbohydrate intake of 0.3 g/kg/h (Combo). RESULTS Combo had a smaller change in glucose (5 ± 47 mg/dL) versus CHO-only (-49 ± 61 mg/dL, P = 0.03) or -90min50%BRR (-34 ± 45 mg/dL). The -90min50%BRR strategy produced higher β-hydroxybutyrate levels (0.4 ± 0.3 vs. 0.1 ± 0.1 mmol/L) and greater fat oxidation (0.51 ± 0.2 vs. 0.39 ± 0.1 g/min) than CHO-only (both P < 0.05). CONCLUSIONS All strategies examined produced stable glycemia for fasted exercise, but a 50% basal rate reduction, set 90 min pre-exercise, eliminates carbohydrate needs and enhances fat oxidation better than carbohydrate feeding with or without a basal rate reduction set at exercise onset.
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Affiliation(s)
- Sarah M McGaugh
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, Ontario, Canada
| | - Dessi P Zaharieva
- Department of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA
| | - Rubin Pooni
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, Ontario, Canada
| | - Ninoschka C D'Souza
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, Ontario, Canada
| | - Todd Vienneau
- Insulet Canada Corporation, Oakville, Ontario, Canada
| | | | - Michael C Riddell
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, Ontario, Canada .,LMC Diabetes & Endocrinology, Toronto, Ontario, Canada
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21
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Molveau J, Rabasa-Lhoret R, Taleb N, Heyman E, Myette-Côté É, Suppère C, Berthoin S, Tagougui S. Minimizing the Risk of Exercise-Induced Glucose Fluctuations in People Living With Type 1 Diabetes Using Continuous Subcutaneous Insulin Infusion: An Overview of Strategies. Can J Diabetes 2021; 45:666-676. [PMID: 33744123 DOI: 10.1016/j.jcjd.2021.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 01/11/2021] [Accepted: 01/11/2021] [Indexed: 12/16/2022]
Abstract
Physical activity (PA) is important for individuals living with type 1 diabetes (T1D) due to its various health benefits. Nonetheless, maintaining adequate glycemic control around PA remains a challenge for many individuals living with T1D because of the difficulty in properly managing circulating insulin levels around PA. Although the most common problem is increased incidence of hypoglycemia during and after most types of PA, hyperglycemia can also occur. Accordingly, a large proportion of people living with T1D are sedentary partly due to the fear of PA-associated hypoglycemia. Continuous subcutaneous insulin infusion (CSII) offers a higher precision and flexibility to adjust insulin basal rates and boluses according to the individual's specific needs around PA practice. Indeed, for physically active patients with T1D, CSII can be a preferred option to facilitate glucose regulation. To our knowledge, there are no guidelines to manage exercise-induced hypoglycemia during PA, specifically for individuals living with T1D and using CSII. In this review, we highlight the current state of knowledge on exercise-related glucose variations, especially hypoglycemic risk and its underlying physiology. We also detail the current recommendations for insulin modulations according to the different PA modalities (type, intensity, duration, frequency) in individuals living with T1D using CSII.
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Affiliation(s)
- Joséphine Molveau
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada; Département de Nutrition, Faculté de Médicine, Université de Montréal, Montreal, Québec, Canada
| | - Rémi Rabasa-Lhoret
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada; Département de Nutrition, Faculté de Médicine, Université de Montréal, Montreal, Québec, Canada; Département des Sciences Biomédicales, Faculté de Médicine, Université de Montréal, Montreal, Québec, Canada; Division of Endocrinology, McGill University, Montreal, Québec, Canada; Endocrinology Division, Montreal Diabetes Research Center, Montreal, Québec, Canada
| | - Nadine Taleb
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada; Département des Sciences Biomédicales, Faculté de Médicine, Université de Montréal, Montreal, Québec, Canada
| | - Elsa Heyman
- Université Lille, Unité de Recherche Pluridisciplinaire Sport Santé Société, Lille, France; Université Artois, Artois, France; Université Littoral Côte d'Opale, Dunkerque, France
| | - Étienne Myette-Côté
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada; Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Corinne Suppère
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
| | - Serge Berthoin
- Université Lille, Unité de Recherche Pluridisciplinaire Sport Santé Société, Lille, France; Université Artois, Artois, France; Université Littoral Côte d'Opale, Dunkerque, France
| | - Sémah Tagougui
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada; Département de Nutrition, Faculté de Médicine, Université de Montréal, Montreal, Québec, Canada; Université Lille, Unité de Recherche Pluridisciplinaire Sport Santé Société, Lille, France; Université Artois, Artois, France; Université Littoral Côte d'Opale, Dunkerque, France.
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22
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Francescato MP, Ajčević M, Accardo A. Carbohydrate Requirement for Exercise in Type 1 Diabetes: Effects of Insulin Concentration. J Diabetes Sci Technol 2020; 14:1116-1121. [PMID: 30767503 PMCID: PMC7645145 DOI: 10.1177/1932296819826962] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Physical activity is a keystone of a healthy lifestyle as well as of management of patients with type 1 diabetes. The risk of exercise-induced hypoglycemia, however, is a great challenge for these patients. The glycemic response to exercise depends upon several factors concerning the patient him/herself (eg, therapy, glycemic control, training level) and the characteristics of the exercise performed. Only in-depth knowledge of these factors will allow to develop individualized strategies minimizing the risk of hypoglycemia. The main factors affecting the exercise-induced hypoglycemia in patients with T1D have been analyzed, including the effects of insulin concentration. A model is discussed, which has the potential to become the basis for providing patients with individualized suggestions to keep constant glucose levels on each exercise occasion.
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Affiliation(s)
- Maria Pia Francescato
- Department of Medicine, University of Udine, Udine, Italy
- Maria Pia Francescato, MD, Department of Medicine, University of Udine, p. le M. Kolbe 4, 33100 Udine, Italy.
| | - Miloš Ajčević
- Department of Engineering and Architecture, University of Trieste, Trieste, Italy
| | - Agostino Accardo
- Department of Engineering and Architecture, University of Trieste, Trieste, Italy
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23
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Tagougui S, Taleb N, Legault L, Suppère C, Messier V, Boukabous I, Shohoudi A, Ladouceur M, Rabasa-Lhoret R. A single-blind, randomised, crossover study to reduce hypoglycaemia risk during postprandial exercise with closed-loop insulin delivery in adults with type 1 diabetes: announced (with or without bolus reduction) vs unannounced exercise strategies. Diabetologia 2020; 63:2282-2291. [PMID: 32740723 DOI: 10.1007/s00125-020-05244-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/15/2020] [Indexed: 12/17/2022]
Abstract
AIMS/HYPOTHESIS For individuals living with type 1 diabetes, closed-loop insulin delivery improves glycaemic control. Nonetheless, maintenance of glycaemic control during exercise while a prandial insulin bolus remains active is a challenge even to closed-loop systems. We investigated the effect of exercise announcement on the efficacy of a closed-loop system, to reduce hypoglycaemia during postprandial exercise. METHODS A single-blind randomised, crossover open-label trial was carried out to compare three strategies applied to a closed-loop system at mealtime in preparation for exercise taken 90 min after eating at a research testing centre: (1) announced exercise to the closed-loop system (increases target glucose levels) in addition to a 33% reduction in meal bolus (A-RB); (2) announced exercise to the closed-loop system and a full meal bolus (A-FB); (3) unannounced exercise and a full meal bolus (U-FB). Participants performed 60 min of exercise at 60% [Formula: see text] 90 min after eating breakfast. The investigators were not blinded to the interventions. However, the participants were blinded to the sensor glucose readings and to the insulin infusion rates throughout the intervention visits. RESULTS The trial was completed by 37 adults with type 1 diabetes, all using insulin pumps: mean±SD, 40.0 ± 15.0 years of age, HbA1c 57.1 ± 10.8 mmol/mol (7.3 ± 1.0%). Reported results were based on plasma glucose values. During exercise and the following 1 h recovery period, time spent in hypoglycaemia (<3.9 mmol/l; primary outcome) was reduced with A-RB (mean ± SD; 2.0 ± 6.2%) and A-FB (7.0 ± 12.6%) vs U-FB (13.0 ± 19.0%; p < 0.0001 and p = 0.005, respectively). During exercise, A-RB had the least drop in plasma glucose levels: A-RB -0.3 ± 2.8 mmol/l, A-FB -2.6 ± 2.9 mmol/l vs U-FB -2.4 ± 2.7 mmol/l (p < 0.0001 and p = 0.5, respectively). Comparison of A-RB vs U-FB revealed a decrease in the time spent in target (3.9-10 mmol/l) by 12.7% (p = 0.05) and an increase in the time spent in hyperglycaemia (>10 mmol/l) by 21% (p = 0.001). No side effects were reported during the applied strategies. CONCLUSIONS/INTERPRETATION Combining postprandial exercise announcement, which increases closed-loop system glucose target levels, with a 33% meal bolus reduction significantly reduced time spent in hypoglycaemia compared with the other two strategies, yet at the expense of more time spent in hyperglycaemia. TRIAL REGISTRATION ClinicalTrials.gov NCT0285530 FUNDING: JDRF (2-SRA-2016-210-A-N), the Canadian Institutes of Health Research (354024) and the Fondation J.-A. DeSève chair held by RR-L.
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Affiliation(s)
- Sémah Tagougui
- Montreal Clinical Research Institute (IRCM), 110 Pine Ave W, Montreal, QC, H2W 1R7, Canada
- Department of Nutrition, Université de Montréal, Montreal, QC, Canada
- Université de Lille, Université d'Artois, Université du Littoral Côte d'Opale, ULR 7369 - URePSSS - Unité de Recherche Pluridisciplinaire Sport, Santé, Société (URePSSS), Lille, France
| | - Nadine Taleb
- Montreal Clinical Research Institute (IRCM), 110 Pine Ave W, Montreal, QC, H2W 1R7, Canada
- Department of Biomedical Sciences, Université de Montréal, Montréal, QC, Canada
| | - Laurent Legault
- Montreal Clinical Research Institute (IRCM), 110 Pine Ave W, Montreal, QC, H2W 1R7, Canada
- Montreal Children's Hospital, McGill University Health Centre (MUHC), Montreal, QC, Canada
| | - Corinne Suppère
- Montreal Clinical Research Institute (IRCM), 110 Pine Ave W, Montreal, QC, H2W 1R7, Canada
| | - Virginie Messier
- Montreal Clinical Research Institute (IRCM), 110 Pine Ave W, Montreal, QC, H2W 1R7, Canada
| | - Inès Boukabous
- Montreal Clinical Research Institute (IRCM), 110 Pine Ave W, Montreal, QC, H2W 1R7, Canada
| | | | - Martin Ladouceur
- École de Santé Publique de l'Université de Montréal, Montreal, QC, Canada
| | - Rémi Rabasa-Lhoret
- Montreal Clinical Research Institute (IRCM), 110 Pine Ave W, Montreal, QC, H2W 1R7, Canada.
- Department of Nutrition, Université de Montréal, Montreal, QC, Canada.
- Montreal Diabetes Research Center, Montreal, QC, Canada.
- Endocrinology Division, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.
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24
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Jitschin A, Schleser-Mohr S, Stierling A, Meier JJ, Nauck MA. Risk of hypoglycaemia associated with professional, recreational, and traffic-related activities in patients with type 2 diabetes: a cross-sectional study by questionnaire. Acta Diabetol 2020; 57:965-972. [PMID: 32166401 DOI: 10.1007/s00592-020-01502-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/11/2020] [Indexed: 11/30/2022]
Abstract
AIMS We aimed to quantify the exposure to physical exercise associated with professional, recreational, or traffic-related activities in patients with type 2 diabetes, which may provoke or aggravate hypoglycaemic episodes, and to assess whether such risks determine the choice of medications minimizing the risk of hypoglycaemia. METHODS In total, 203 patients with type 2 diabetes (98 women, 105 men, age 65 [56;72; median, inter-quartile range] years, diabetes duration 10 [5;15] years) were recruited from a German diabetes practice. A questionnaire assessed their engagement in professional, recreational, or traffic-related activities. The prescription insulin or sulphonylureas was quantified in relation to the number of such activities. RESULTS 63.5% of the patients were treated with insulin, 7.4% with sulphonylureas, and 70.9% with either. Sixty-six patients (22.7%) were professionally active: 36 (54.4%) of those were professionally exposed to risky behaviour (14 [31.8%] patients with exposure to multiple risks and 20 (30.3%) who experienced hypoglycaemic episodes in the past year). In total, 194 (95.6%) patients were exposed to risky behaviour during recreational activities, 129 (63.6%) to multiple ones. All patients were exposed to traffic-related activities, 144 (70.9%) were exposed to more than being pedestrian, and 24 (11.8%) experienced hypoglycaemic episodes while in traffic. CONCLUSIONS Patients with type 2 diabetes are exposed to risks associated with professional, recreational, and traffic-related activities. We recommend a careful assessment of such risks before glucose-lowering medications with a potential for provoking hypoglycaemic episodes are prescribed.
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Affiliation(s)
- Anne Jitschin
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany
| | | | - Almut Stierling
- Diabetes-Schwerpunktpraxis am Gauss-Wall, Göttingen, Germany
| | - Juris J Meier
- Diabetes Division, Katholisches Klinikum Bochum, St. Josef-Hospital (Ruhr-University Bochum), Gudrunstr. 56, 44791, Bochum, Germany
| | - Michael A Nauck
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany.
- Diabetes Division, Katholisches Klinikum Bochum, St. Josef-Hospital (Ruhr-University Bochum), Gudrunstr. 56, 44791, Bochum, Germany.
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25
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Eckstein ML, McCarthy O, Tripolt NJ, Müller A, Birnbaumer P, Pferschy PN, Hofmann P, Bracken RM, Sourij H, Moser O. Efficacy of Carbohydrate Supplementation Compared With Bolus Insulin Dose Reduction Around Exercise in Adults With Type 1 Diabetes: A Retrospective, Controlled Analysis. Can J Diabetes 2020; 44:697-700. [PMID: 32565070 DOI: 10.1016/j.jcjd.2020.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 03/10/2020] [Accepted: 03/10/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Individuals with type 1 diabetes try to manage the risk of exercise-induced hypoglycemia by either pre-exercise/pre-meal bolus insulin dose reductions and/or consuming additional carbohydrates during exercise. Both strategies have proven to be effective in offsetting hypoglycemia, but it remains unclear which one is more beneficial. The aim of this study was to assess the efficacy of carbohydrate supplementation vs bolus insulin dose reduction in prevention of hypoglycemia during moderate-intensity exercise in those with type 1 diabetes. METHODS This investigation was a retrospective, controlled analysis of 2 independent clinical trials. All participants performed continuous, moderate-intensity cycle ergometer exercise for ∼45 minutes. Two therapy management groups and a control group were compared. Group A was supplemented with 15 to 30 g carbohydrates at a glycemic threshold of 7.0 mmol/L during exercise, group B reduced their individual bolus insulin dose by 50% with their last meal before exercise and group C served as a control. RESULTS No hypoglycemic events occurred in group A, whereas 4 events were recorded in groups B (p=0.02) and C (p=0.02). CONCLUSIONS Carbohydrate supplementation was superior to bolus insulin reduction for prevention of hypoglycemia during exercise in people with type 1 diabetes.
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Affiliation(s)
- Max L Eckstein
- Cardiovascular Diabetology Research Group, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Olivia McCarthy
- Applied Sport, Technology, Exercise and Medicine Research Centre, Swansea University, Swansea, United Kingdom
| | - Norbert J Tripolt
- Cardiovascular Diabetology Research Group, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Alexander Müller
- Exercise Physiology, Training and Training Therapy Research Group, Institute of Sports Science, University of Graz, Graz, Austria
| | - Philipp Birnbaumer
- Exercise Physiology, Training and Training Therapy Research Group, Institute of Sports Science, University of Graz, Graz, Austria
| | - Peter N Pferschy
- Cardiovascular Diabetology Research Group, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Peter Hofmann
- Exercise Physiology, Training and Training Therapy Research Group, Institute of Sports Science, University of Graz, Graz, Austria
| | - Richard M Bracken
- Applied Sport, Technology, Exercise and Medicine Research Centre, Swansea University, Swansea, United Kingdom
| | - Harald Sourij
- Cardiovascular Diabetology Research Group, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria; Zayed Center for Health Sciences, United Arab Emirates University, United Arab Emirates
| | - Othmar Moser
- Cardiovascular Diabetology Research Group, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria.
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26
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Aronson R, Li A, Brown RE, McGaugh S, Riddell MC. Flexible insulin therapy with a hybrid regimen of insulin degludec and continuous subcutaneous insulin infusion with pump suspension before exercise in physically active adults with type 1 diabetes (FIT Untethered): a single-centre, open-label, proof-of-concept, randomised crossover trial. Lancet Diabetes Endocrinol 2020; 8:511-523. [PMID: 32445738 DOI: 10.1016/s2213-8587(20)30114-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND People with type 1 diabetes who use continuous subcutaneous insulin infusion (CSII, or insulin pump therapy) often remove their pump before extended periods of exercise, but this approach might result in reduced glycaemic control and increased risk of hyperglycaemia and ketogenesis. We aimed to assess the efficacy and safety of a hybrid approach, in which basal insulin delivery was divided between CSII and a daily injection of insulin degludec. METHODS In this single-centre, open-label, proof-of-concept, randomised crossover trial done at the LMC Diabetes & Endocrinology research centre, we recruited physically active and aerobically fit participants aged 18 years or older with type 1 diabetes who were using CSII. Participants were randomly assigned (1:1) by use of a computer-generated sequence to one of two sequences of either usual CSII, involving the continuation of the participant's usual CSII regimen, followed by crossover to hybrid CSII, in which the delivery of the participant's usual daily basal insulin dose was split (50% delivered by CSII and 50% delivered by a once-daily morning injection of 100 U/mL insulin degludec), or the opposite sequence (ie, hybrid CSII followed by crossover to usual CSII). Treatment was not masked to the investigators or participants. For each intervention, participants completed a moderate-intensity and a high-intensity in-clinic exercise session in the first week, followed by four high-intensity and two moderate-intensity home-based exercise sessions in the subsequent 3 weeks. Insulin pumps were suspended or disconnected 60 min before exercise and reconnected immediately after exercise during both treatment regimens. The coprimary outcomes were: (1) time spent in the target control range of 4·0-10·0 mmol/L blood glucose after high-intensity exercise, and (2) time spent in target control range of 4·0-10·0 mmol/L blood glucose after moderate-intensity exercise, measured by continuous glucose monitoring in the 6-h period from the start of the high-intensity and moderate-intensity in-clinic exercise sessions. Outcomes were assessed in a modified intention-to-treat population that included all participants who started both intervention phases and completed all of the in-clinic exercise visits. This trial is registered with ClinicalTrials.gov, NCT03838783, and is complete. FINDINGS Between May 15, 2018, and March 5, 2019, we assessed 43 patients for eligibility, of whom 31 were randomly assigned to receive the usual CSII regimen (n=14) or hybrid CSII regimen (n=17) in the first phase (before crossover). The analysis population consisted of 24 participants who completed both study phases. Compared with the usual CSII regimen, participants on the hybrid CSII regimen had a significantly longer time in blood glucose range of 4-10 mmol/L during the 6-h period from the start of both moderate-intensity (mean difference 86 min [95% CI 61-147], p=0·005; percentage time in range 64% [SD 35] vs 40% [35]) and high-intensity in-clinic exercise session (60 min [11-109], p=0·01; 66% [32] vs 50% [27]). Participants on the hybrid CSII regimen also showed a higher time in blood glucose range of 4-10 mmol/L during home-based exercise sessions (mean difference 23 min [95% CI -1 to 46], p=0·055), with significantly lower time spent in hyperglycaemia than participants on the usual CSII regimen (mean difference 25 min [2-48], p=0·04). These exploratory outcomes also showed no significant difference in the amount of time spent in hypoglycaemia, nor the number of hypoglycaemic events, between the two interventions. There were three study-related adverse events reported with the usual CSII regimen (two hypotension events and one nausea event) and four with the hybrid CSII regimen (two hypotension events and two nausea events). INTERPRETATION A hybrid regimen of injected insulin degludec and CSII (with pump removal during exercise) appears to be safe and effective in adults with type 1 diabetes who exercise regularly. This approach could offer improved glycaemic control immediately after exercise and should be further assessed in a larger-scale randomised trial. FUNDING Novo Nordisk.
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Affiliation(s)
| | - Aihua Li
- LMC Diabetes & Endocrinology, Toronto, ON, Canada
| | - Ruth E Brown
- LMC Diabetes & Endocrinology, Toronto, ON, Canada
| | | | - Michael C Riddell
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
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27
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Hanaire H, Franc S, Borot S, Penfornis A, Benhamou PY, Schaepelynck P, Renard E, Guerci B, Jeandidier N, Simon C, Hannaert P, Xhaard I, Doron M, Huneker E, Charpentier G, Reznik Y. Efficacy of the Diabeloop closed-loop system to improve glycaemic control in patients with type 1 diabetes exposed to gastronomic dinners or to sustained physical exercise. Diabetes Obes Metab 2020; 22:324-334. [PMID: 31621186 DOI: 10.1111/dom.13898] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/10/2019] [Accepted: 10/11/2019] [Indexed: 12/12/2022]
Abstract
AIMS To compare closed-loop (CL) and open-loop (OL) systems for glycaemic control in patients with type 1 diabetes (T1D) exposed to real-life challenging situations (gastronomic dinners or sustained physical exercise). METHODS Thirty-eight adult patients with T1D were included in a three-armed randomized pilot trial (Diabeloop WP6.2 trial) comparing glucose control using a CL system with use of an OL device during two crossover 72-hour periods in one of the three following situations: large (gastronomic) dinners; sustained and repeated bouts of physical exercise (with uncontrolled food intake); or control (rest conditions). Outcomes included time in spent in the glucose ranges of 4.4-7.8 mmol/L and 3.9-10.0 mmol/L, and time in hypo- and hyperglycaemia. RESULTS Time spent overnight in the tight range of 4.4 to 7.8 mmol/L was longer with CL (mean values: 63.2% vs 40.9% with OL; P ≤ .0001). Time spent during the day in the range of 3.9 to 10.0 mmol/L was also longer with CL (79.4% vs 64.1% with OL; P ≤ .0001). Participants using the CL system spent less time during the day with hyperglycaemic excursions (glucose >10.0 mmol/L) compared to those using an OL system (17.9% vs 31.9%; P ≤ .0001), and the proportions of time spent during the day with hyperglycaemic excursions of those using the CL system in the gastronomic dinner and physical exercise subgroups were of similar magnitude to those in the control subgroup (18.1 ± 6.3%, 17.2 ± 8.1% and 18.4 ± 12.5%, respectively). Finally, times spent in hypoglycaemia were short and not significantly different among the groups. CONCLUSIONS The Diabeloop CL system is superior to OL devices in reducing hyperglycaemic excursions in patients with T1D exposed to gastronomic dinners, or exposed to physical exercise followed by uncontrolled food and carbohydrate intake.
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Affiliation(s)
- Hélène Hanaire
- Department of Diabetology, Metabolic Diseases and Nutrition, CHU Toulouse, University of Toulouse, Toulouse, France
| | - Sylvia Franc
- Department of Diabetes, Sud-Francilien Hospital, Corbeil-Essonnes, and Centre d'Etude et de Recherche pour l'Intensification du Traitement du Diabete, Evry, France
| | - Sophie Borot
- Department of Endocrinology, Metabolism, Diabetes and Nutrition, Centre Hospitalier Universitaire Jean Minjoz, Besançon, France
| | - Alfred Penfornis
- Department of Diabetes, Sud-Francilien Hospital, Corbeil-Essonnes, and Centre d'Etude et de Recherche pour l'Intensification du Traitement du Diabete, Evry, France
- University Paris-Sud, Orsay, France
| | | | - Pauline Schaepelynck
- Department of Nutrition-Endocrinology-Metabolic Disorders, Marseille University Hospital, Sainte Marguerite Hospital, Marseille, France
| | - Eric Renard
- Department of Endocrinology, Diabetes and Nutrition, Montpellier University Hospital, and Institute of Functional Genomics, CNRS, INSERM, University of Montpellier, Montpellier, France
| | - Bruno Guerci
- Endocrinology-Diabetes Care Unit, University of Lorraine, Vandoeuvre Lès Nancy, France
| | - Nathalie Jeandidier
- Department of Endocrinology, Diabetes and Nutrition, CHU of Strasbourg, Strasbourg, France
| | - Chantal Simon
- Department of Endocrinology, Diabetes and Nutrition, Centre Hospitalier Lyon Sud, Lyon, France
| | - Patrick Hannaert
- School of Medicine and Pharmacy of Poitiers, IRTOMIT, INSERM UMR 1082, Poitiers, France
| | - Ilham Xhaard
- Centre d'Etudes et de Recherches pour l'Intensification du Traitement du Diabète, Evry, France
| | - Maeva Doron
- University Grenoble Alpes, Grenoble, France
- CEA LETI MlNATEC Campus, Grenoble, France
| | | | - Guillaume Charpentier
- Department of Diabetes, Sud-Francilien Hospital, Corbeil-Essonnes, and Centre d'Etude et de Recherche pour l'Intensification du Traitement du Diabete, Evry, France
| | - Yves Reznik
- Department of Endocrinology, University of Caen Côte de Nacre Regional Hospital Centre, Caen, France
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28
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Abstract
Advances in technologies such as glucose monitors, exercise wearables, closed-loop systems, and various smartphone applications are helping many people with diabetes to be more physically active. These technologies are designed to overcome the challenges associated with exercise duration, mode, relative intensity, and absolute intensity, all of which affect glucose homeostasis in people living with diabetes. At present, optimal use of these technologies depends largely on motivation, competence, and adherence to daily diabetes care requirements. This article discusses recent technologies designed to help patients with diabetes to be more physically active, while also trying to improve glucose control around exercise.
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Affiliation(s)
- Michael C Riddell
- School of Kinesiology and Health Science, York University, Toronto, ON M3J 1P3, Canada; LMC Diabetes & Endocrinology, 1929 Bayview Avenue, Toronto, ON M4G 3E8, Canada; York University, 347 Bethune College, North York, Ontario M3J 1P3, Canada.
| | - Rubin Pooni
- School of Kinesiology and Health Science, York University, Toronto, ON M3J 1P3, Canada; York University, 347 Bethune College, North York, Ontario M3J 1P3, Canada
| | - Federico Y Fontana
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Via Casorati, 43, 37121 Verona, Italy; Team Novo Nordisk Professional Cycling Team, 2144 Hills Avenue NW, Atlanta, 30318 GA, USA. https://twitter.com/FeedYourFlock
| | - Sam N Scott
- Team Novo Nordisk Professional Cycling Team, 2144 Hills Avenue NW, Atlanta, 30318 GA, USA; Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland. https://twitter.com/SamNathanScott
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29
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Yardley JE. The Athlete with Type 1 Diabetes: Transition from Case Reports to General Therapy Recommendations. Open Access J Sports Med 2019; 10:199-207. [PMID: 31827338 PMCID: PMC6902845 DOI: 10.2147/oajsm.s149257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 11/27/2019] [Indexed: 12/03/2022] Open
Abstract
Fear of hypoglycemia is a common barrier to exercise and physical activity for individuals with type 1 diabetes. While some of the earliest studies in this area involved only one or two participants, the link between exercise, exogenous insulin, and hypoglycemia was already clear, with the only suggested management strategies being to decrease insulin dosage and/or consume carbohydrates before and after exercise. Over the past 50 years, a great deal of knowledge has been developed around the impact of different types and intensities of exercise on blood glucose levels in this population. Recent decades have also seen the development of technologies such as continuous glucose monitors, faster-acting insulins and commercially available insulin pumps to allow for the real-time observation of interstitial glucose levels, and more precise adjustments to insulin dosage before, during and after activity. As such, there are now evidence-based exercise and physical activity guidelines for individuals with type 1 diabetes. While the risk of hypoglycemia has not been completely eliminated, therapy recommendations have evolved considerably. This review discusses the evolution of the knowledge and the technology related to type 1 diabetes and exercise that have allowed this evolution to take place.
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Affiliation(s)
- Jane E Yardley
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Canada.,Alberta Diabetes Institute, Edmonton, Canada.,Augustana Faculty, University of Alberta, Camrose, Canada.,Women's and Children's Research Institute, Edmonton, Canada
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30
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Carbohydrate Intake in the Context of Exercise in People with Type 1 Diabetes. Nutrients 2019; 11:nu11123017. [PMID: 31835538 PMCID: PMC6950062 DOI: 10.3390/nu11123017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/02/2019] [Accepted: 12/06/2019] [Indexed: 02/06/2023] Open
Abstract
Although the benefits of regular exercise on cardiovascular risk factors are well established for people with type 1 diabetes (T1D), glycemic control remains a challenge during exercise. Carbohydrate consumption to fuel the exercise bout and/or for hypoglycemia prevention is an important cornerstone to maintain performance and avoid hypoglycemia. The main strategies pertinent to carbohydrate supplementation in the context of exercise cover three aspects: the amount of carbohydrates ingested (i.e., quantity in relation to demands to fuel exercise and avoid hypoglycemia), the timing of the intake (before, during and after the exercise, as well as circadian factors), and the quality of the carbohydrates (encompassing differing carbohydrate types, as well as the context within a meal and the associated macronutrients). The aim of this review is to comprehensively summarize the literature on carbohydrate intake in the context of exercise in people with T1D.
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31
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Tagougui S, Taleb N, Molvau J, Nguyen É, Raffray M, Rabasa-Lhoret R. Artificial Pancreas Systems and Physical Activity in Patients with Type 1 Diabetes: Challenges, Adopted Approaches, and Future Perspectives. J Diabetes Sci Technol 2019; 13:1077-1090. [PMID: 31409125 PMCID: PMC6835182 DOI: 10.1177/1932296819869310] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Physical activity is important for patients living with type 1 diabetes (T1D) but limited by the challenges associated with physical activity induced glucose variability. Optimizing glycemic control without increasing the risk of hypoglycemia is still a hurdle despite many advances in insulin formulations, delivery methods, and continuous glucose monitoring systems. In this respect, the artificial pancreas (AP) system is a promising therapeutic option for a safer practice of physical activity in the context of T1D. It is important that healthcare professionals as well as patients acquire the necessary knowledge about how the AP system works, its limits, and how glucose control is regulated during physical activity. This review aims to examine the current state of knowledge on exercise-related glucose variations especially hypoglycemic risk in T1D and to discuss their effects on the use and development of AP systems. Though effective and highly promising, these systems warrant further research for an optimized use around exercise.
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Affiliation(s)
- Sémah Tagougui
- Montreal Clinical Research Institute, Montreal, Quebec, Canada
- Department of Nutrition, Faculty of Medicine, Montreal, Quebec, Canada
- Univ. Lille, Univ. Artois, Univ. Littoral Côte d’Opale, EA 7369 - URePSSS - Unité de Recherche Pluridisciplinaire Sport Santé Société, Lille, France
| | - Nadine Taleb
- Montreal Clinical Research Institute, Montreal, Quebec, Canada
- Department of Biomedical Sciences, Faculty of Medicine, Édouard-Montpetit, Montreal, Quebec, Canada
| | | | - Élisabeth Nguyen
- Montreal Clinical Research Institute, Montreal, Quebec, Canada
- Department of Nutrition, Faculty of Medicine, Montreal, Quebec, Canada
| | - Marie Raffray
- Montreal Clinical Research Institute, Montreal, Quebec, Canada
| | - Rémi Rabasa-Lhoret
- Montreal Clinical Research Institute, Montreal, Quebec, Canada
- Department of Nutrition, Faculty of Medicine, Montreal, Quebec, Canada
- Division of Endocrinology, Centre Hospitalier de l’université de Montréal, Montreal, Quebec, Canada
- Montreal Diabetes Research Center & Endocrinology division, Quebec, Canada
- Rémi Rabasa-Lhoret, Montreal Clinical Research Institute, 110, avenue des Pins Ouest, Montreal, Quebec, Canada H2W 1R7.
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32
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Mao Y, Wen S, Zhou M, Zhu S, Zhou L. The hypoglycemia associated autonomic failure triggered by exercise in the patients with "brittle" diabetes and the strategy for prevention. Endocr J 2019; 66:753-762. [PMID: 31406090 DOI: 10.1507/endocrj.ej19-0153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Exercise is a fundamental component of diabetes management. However, choosing inappropriate type or timing of exercise is associated with mild or severe hypoglycemia either during exercise or several hours after exercise. Several studies have shown that impaired counterregulatory responses triggers hypoglycemia. Therefore, in this investigation, we explored the appropriate intensity and time of exercise in patients with diabetes. The mechanisms of counterregulatory responses and hypoglycemia associated autonomic failure (HAAF), as well as the strategies for preventing episodes of hypoglycemia after exercise were also investigated. In this study, we obtained the following results: 1) High intensity interval exercise is more suitable for diabetic patients. 2) Morning exercise reduces nocturnal hypoglycemia risks compared with midday, afternoon and evening exercise. 3) Hypoglycemia can be prevented by dietary approach, reduction or suspension of insulin dose, use of mini dose glucagon, caffeine, mitigation methods, prediction algorithm, autonomic feedback controlled close-loop insulin delivery, real time continuous glucose monitoring. Based on these results we concluded that exercise may cause severe hypoglycemia or induce blunted response in patients with diabetes. For Diabetes Mellitus (DM) patients, the intensity and time of exercise influence the occurrence of hypoglycemia. This review summarizes the clinical characteristics of different types of exercises and time of exercise that can be potentially used to educate and guide patients regarding the role of exercise in standard of care.
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Affiliation(s)
- Yilun Mao
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai 201399, China
| | - Song Wen
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai 201399, China
| | - Mingyue Zhou
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
| | - Shifei Zhu
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai 201399, China
| | - Ligang Zhou
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai 201399, China
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Reddy R, Resalat N, Wilson LM, Castle JR, El Youssef J, Jacobs PG. Prediction of Hypoglycemia During Aerobic Exercise in Adults With Type 1 Diabetes. J Diabetes Sci Technol 2019; 13:919-927. [PMID: 30650997 PMCID: PMC6955453 DOI: 10.1177/1932296818823792] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Fear of exercise related hypoglycemia is a major reason why people with type 1 diabetes (T1D) do not exercise. There is no validated prediction algorithm that can predict hypoglycemia at the start of aerobic exercise. METHODS We have developed and evaluated two separate algorithms to predict hypoglycemia at the start of exercise. Model 1 is a decision tree and model 2 is a random forest model. Both models were trained using a meta-data set based on 154 observations of in-clinic aerobic exercise in 43 adults with T1D from 3 different studies that included participants using sensor augmented pump therapy, automated insulin delivery therapy, and automated insulin and glucagon therapy. Both models were validated using an entirely new validation data set with 90 exercise observations collected from 12 new adults with T1D. RESULTS Model 1 identified two critical features predictive of hypoglycemia during exercise: heart rate and glucose at the start of exercise. If heart rate was greater than 121 bpm during the first 5 min of exercise and glucose at the start of exercise was less than 182 mg/dL, it predicted hypoglycemia with 79.55% accuracy. Model 2 achieved a higher accuracy of 86.7% using additional features and higher complexity. CONCLUSIONS Models presented here can assist people with T1D to avoid exercise related hypoglycemia. The simple model 1 heuristic can be easily remembered (the 180/120 rule) and model 2 is more complex requiring computational resources, making it suitable for automated artificial pancreas or decision support systems.
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Affiliation(s)
- Ravi Reddy
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Navid Resalat
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Leah M. Wilson
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon, Health & Science University, Portland, OR, USA
| | - Jessica R. Castle
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon, Health & Science University, Portland, OR, USA
| | - Joseph El Youssef
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon, Health & Science University, Portland, OR, USA
| | - Peter G. Jacobs
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
- Peter G. Jacobs, PhD, Department of Biomedical Engineering, Oregon Health & Science University, 3303 SW Bond Ave, Mailstop: 13B, Portland, OR 97239, USA.
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Piotrowicz AK, McGill MJ, Overland J, Molyneaux L, Johnson NA, Twigg SM. An on-line support tool to reduce exercise-related hypoglycaemia and improve confidence to exercise in type 1 diabetes. J Diabetes Complications 2019; 33:682-689. [PMID: 31253489 DOI: 10.1016/j.jdiacomp.2019.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 05/05/2019] [Accepted: 05/15/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Hypoglycaemia related to exercise and lack of confidence to exercise, are common in T1DM. An online educational exercise tool (ExT1D) was tested to determine whether these parameters can be improved. RESEARCH DESIGN AND METHODS Thirty two adults with T1DM (50%M, age 35.8 ± 9.5 yr diabetes duration 12.3 ± 9.9 yr, median HbA1c 7.1%[ICR 6.4-7.7] NGSPU) exercising ≥ 60 min/week enrolled in a RCT utilising ExT1D, with partial cross-over design. The primary end-point was Exercise-related hypoglycaemia (ErH) number corrected for exercise session number, with ErH defined as CGM episodes < 4.0 mM occurring within 24 h of exercise. Secondary RCT endpoints were total ErH duration, and ErH duration/episode. A pre-defined longitudinal analysis with each subject compared with their baseline was also undertaken, for the three ErH parameters, and using fear of hypoglycaemia questionnaires. RESEARCH In the RCT a 50% lower median ErH number (P = 0.6) (37% lower ErH number per exercise session (P = 0.06, NS primary endpoint) occurred in the Intervention vs Control group. A 49% lower ErH duration per episode (P = 0.2), and 80% less ErH duration (P = 0.3), were also observed in the Intervention vs Control group. In the longitudinal study, ErH number reduced by 43% (P = 0.088), ErH duration per episode by 52% (P = 0.157) and total duration of ErH fell by 71% (P = 0.015). Confidence to prevent glucose lowering by exercise also improved (P = 0.039). Post-hoc analysis showed those with the greatest ErH events at baseline benefited most. Fructosamine and HbA1c levels were unchanged from baseline. CONCLUSIONS ExT1D can reduce exercise-related hypoglycaemia and provide greater confidence to exercise.
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Affiliation(s)
- Agata K Piotrowicz
- Diabetes Centre, Department of Endocrinology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
| | - Margaret J McGill
- Diabetes Centre, Department of Endocrinology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Jane Overland
- Diabetes Centre, Department of Endocrinology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Lynda Molyneaux
- Diabetes Centre, Department of Endocrinology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Nathan A Johnson
- Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia; Faculty of Health Sciences, The University of Sydney, Sydney, NSW 2006, Australia
| | - Stephen M Twigg
- Diabetes Centre, Department of Endocrinology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia.
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Roy-Fleming A, Taleb N, Messier V, Suppère C, Cameli C, Elbekri S, Smaoui MR, Ladouceur M, Legault L, Rabasa-Lhoret R. Timing of insulin basal rate reduction to reduce hypoglycemia during late post-prandial exercise in adults with type 1 diabetes using insulin pump therapy: A randomized crossover trial. DIABETES & METABOLISM 2019; 45:294-300. [PMID: 30165156 DOI: 10.1016/j.diabet.2018.08.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 06/23/2018] [Accepted: 08/11/2018] [Indexed: 02/07/2023]
Abstract
AIMS To compare the efficacy of three timings to decrease basal insulin infusion rate to reduce exercise-induced hypoglycaemia in patients with type 1 diabetes (T1D) using pump therapy. METHODS A single-blinded, randomized, 3-way crossover study in 22 adults that had T1D > 1 year and using insulin pump > 3 months (age, 40 ± 15 years; HbA1c, 56.3 ± 10.2 mmol/mol). Participants practiced three 45-min exercise sessions (ergocyle) at 60% VO2peak 3 hours after lunch comparing an 80% reduction of basal insulin applied 40 minutes before (T-40), 20 minutes before (T-20) or at exercise onset (T0). RESULTS No significant difference was observed for percentage of time spent < 4.0 mmol/L (T-40: 16 ± 25%; T-20: 26 ± 27%; T0: 24 ± 29%) (main outcome) and time spent in target range 4.0-10.0 mmol/L (T-40: 63 ± 37%; T-20: 66 ± 25%; T0: 65 ± 31%). With T-40 strategy, although not significant, starting blood glucose (BG) was higher (T-40: 8.6 ± 3.6 mmol/L; T-20: 7.4 ± 2.5 mmol/L ; T0: 7.4 ± 2.7 mmol/L), fewer patients needed extra carbohydrates consumption prior to exercise for BG < 5.0 mmol/L (T-40: n = 3; T-20: n = 5; T0: n = 6) as well as during exercise for BG < 3.3 mmol/L [T-40: n = 6 (27%); T-20: n = 12 (55%); T0: n = 11 (50%)] while time to first hypoglycaemic episode was delayed (T-40: 28 ± 14 min; T-20: 24 ± 10 min; T0: 22 ± 11 min). CONCLUSION Decreasing basal insulin infusion rate by 80% up to 40 minutes before exercise onset is insufficient to reduce exercise-induced hypoglycaemia.
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Affiliation(s)
- A Roy-Fleming
- Institut de recherches cliniques de Montréal, 110, avenue des Pins Ouest, Montréal, Québec, Canada; Nutrition department, faculty of medicine, universite de Montréal, 1204-2405, chemin de la Côte-Sainte-Catherine, Montréal, Québec H3T 1A8, Canada
| | - N Taleb
- Institut de recherches cliniques de Montréal, 110, avenue des Pins Ouest, Montréal, Québec, Canada; Division of biomedical sciences, faculty of medicine, université de Montréal, C.P.6128 Succ. Centre-Ville, Montréal, Québec H3C 3J7, Canada
| | - V Messier
- Institut de recherches cliniques de Montréal, 110, avenue des Pins Ouest, Montréal, Québec, Canada
| | - C Suppère
- Institut de recherches cliniques de Montréal, 110, avenue des Pins Ouest, Montréal, Québec, Canada
| | - C Cameli
- Institut de recherches cliniques de Montréal, 110, avenue des Pins Ouest, Montréal, Québec, Canada
| | - S Elbekri
- Institut de recherches cliniques de Montréal, 110, avenue des Pins Ouest, Montréal, Québec, Canada
| | - M R Smaoui
- School of computer science, McGill university, Montreal, Québec, Canada
| | - M Ladouceur
- School of public health, social and preventive medicine department, université de Montréal, C.P.6128 Succ. Centre-Ville, Montréal, Québec, H3C 3J7, Canada
| | - L Legault
- Institut de recherches cliniques de Montréal, 110, avenue des Pins Ouest, Montréal, Québec, Canada; Montreal children's hospital, McGill university health centre, 1001 Boul Décarie, Montreal, Québec H4A 3J1, Canada
| | - R Rabasa-Lhoret
- Institut de recherches cliniques de Montréal, 110, avenue des Pins Ouest, Montréal, Québec, Canada; Nutrition department, faculty of medicine, universite de Montréal, 1204-2405, chemin de la Côte-Sainte-Catherine, Montréal, Québec H3T 1A8, Canada; Centre de recherche du centre hospitalier de l'université de Montréal (CRCHUM), R-900 Saint-Denis, Montreal, Québec H2X 0A9, Canada; Montreal diabetes research centre, R-900 Saint-Denis, Montreal, Québec H2X 0A9, Canada.
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Zaharieva DP, McGaugh S, Pooni R, Vienneau T, Ly T, Riddell MC. Improved Open-Loop Glucose Control With Basal Insulin Reduction 90 Minutes Before Aerobic Exercise in Patients With Type 1 Diabetes on Continuous Subcutaneous Insulin Infusion. Diabetes Care 2019; 42:824-831. [PMID: 30796112 DOI: 10.2337/dc18-2204] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/29/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To reduce exercise-associated hypoglycemia, individuals with type 1 diabetes on continuous subcutaneous insulin infusion typically perform basal rate reductions (BRRs) and/or carbohydrate feeding, although the timing and amount of BRRs necessary to prevent hypoglycemia are unclear. The goal of this study was to determine if BRRs set 90 min pre-exercise better attenuate hypoglycemia versus pump suspension (PS) at exercise onset. RESEARCH DESIGN AND METHODS Seventeen individuals completed three 60-min treadmill exercise (∼50% of VO2peak) visits in a randomized crossover design. The insulin strategies included 1) PS at exercise onset, 2) 80% BRR set 90 min pre-exercise, and 3) 50% BRR set 90 min pre-exercise. RESULTS Blood glucose level at exercise onset was higher with 50% BRR (191 ± 49 mg/dL) vs. 80% BRR (164 ± 41 mg/dL; P < 0.001) and PS (164 ± 45 mg/dL; P < 0.001). By exercise end, 80% BRR showed the smallest drop (-31 ± 58 mg/dL) vs. 50% BRR (-47 ± 50 mg/dL; P = 0.04) and PS (-67 ± 41 mg/dL; P < 0.001). With PS, 7 out of 17 participants developed hypoglycemia versus 1 out of 17 in both BRR conditions (P < 0.05). Following a standardized meal postexercise, glucose rose with PS and 50% BRR (both P < 0.05), but failed to rise with 80% BRR (P = 0.16). Based on interstitial glucose, overnight mean percent time in range was 83%, 83%, and 78%, and time in hypoglycemia was 2%, 1%, and 5% with 80% BRR, 50% BRR, and PS, respectively (all P > 0.05). CONCLUSIONS Overall, a 50-80% BRR set 90 min pre-exercise improves glucose control and decreases hypoglycemia risk during exercise better than PS at exercise onset, while not compromising the postexercise meal glucose control.
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Affiliation(s)
- Dessi P Zaharieva
- Muscle Health Research Centre, School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada
| | - Sarah McGaugh
- Muscle Health Research Centre, School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada
| | - Rubin Pooni
- Muscle Health Research Centre, School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada
| | - Todd Vienneau
- Insulet Canada Corporation, Oakville, Ontario, Canada
| | - Trang Ly
- Insulet Corporation, Billerica, MA
| | - Michael C Riddell
- Muscle Health Research Centre, School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada .,LMC Diabetes & Endocrinology, Toronto, Ontario, Canada
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Moser O, Eckstein ML, Mueller A, Birnbaumer P, Aberer F, Koehler G, Sourij C, Kojzar H, Holler P, Simi H, Pferschy P, Dietz P, Bracken RM, Hofmann P, Sourij H. Impact of physical exercise on sensor performance of the FreeStyle Libre intermittently viewed continuous glucose monitoring system in people with Type 1 diabetes: a randomized crossover trial. Diabet Med 2019; 36:606-611. [PMID: 30677187 DOI: 10.1111/dme.13909] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2018] [Indexed: 01/10/2023]
Abstract
AIMS To evaluate the sensor performance of the FreeStyle Libre intermittently viewed continuous glucose monitoring system using reference blood glucose levels during moderate-intensity exercise while on either full or reduced basal insulin dose in people with Type 1 diabetes. METHODS Ten participants with Type 1 diabetes [four women, mean ± sd age 31.4 ± 9.0 years, BMI 25.5±3.8 kg/m2 , HbA1c 55±7 mmol/mol (7.2±0.6%)] exercised on a cycle ergometer for 55 min at a moderate intensity for 5 consecutive days at the clinical research facility, while receiving either their usual or a 75% basal insulin dose. After a 4-week washout period, participants performed the second exercise period having switched to the alternative basal insulin dose. During exercise, reference capillary blood glucose values were analysed using the fully enzymatic-amperometric method and compared with the interstitial glucose values obtained. Intermittently viewed continuous glucose monitoring accuracy was analysed according to median (interquartile range) absolute relative difference, and Clarke error grid and Bland-Altman analysis for overall glucose levels during exercise, stratified by glycaemic range and basal insulin dosing scheme (P<0.05). RESULTS A total of 845 glucose values were available during exercise to evaluate intermittently viewed continuous glucose monitoring sensor performance. The median (interquartile range) absolute relative difference between the reference values and those obtained by the sensor across the glycaemic range overall was 22 (13.9-29.7)%, and was 36.3 (24.2-45.2)% during hypoglycaemia, 22.8 (14.6-30.6)% during euglycaemia and 15.4 (9-21)% during hyperglycaemia. Usual basal insulin dose was associated with a worse sensor performance during exercise compared with the reduced (75%) basal insulin dose [median (interquartile range) absolute relative difference: 23.7 (17.2-30.7)% vs 20.5 (12-28.1)%; P<0.001). CONCLUSIONS The intermittently viewed continuous glucose monitoring sensor showed diminished accuracy during exercise. Absolute glucose readings derived from the sensor should be used cautiously and need confirmation by additional finger-prick blood glucose measurements.
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Affiliation(s)
- O Moser
- Diabetes Research Group, Medical School, Swansea University, Swansea, UK
- Applied Sport, Technology, Exercise and Medicine Research Centre (A-STEM), College of Engineering, Swansea University, Swansea, UK
| | - M L Eckstein
- Diabetes Research Group, Medical School, Swansea University, Swansea, UK
- Applied Sport, Technology, Exercise and Medicine Research Centre (A-STEM), College of Engineering, Swansea University, Swansea, UK
| | - A Mueller
- Exercise Physiology, Training and Training Therapy Research Group, Institute of Sports Science, Medical University of Graz, Graz, Austria
- Sport Science Laboratory, FH Joanneum University of Applied Science, Bad Gleichenberg, Austria
| | - P Birnbaumer
- Exercise Physiology, Training and Training Therapy Research Group, Institute of Sports Science, Medical University of Graz, Graz, Austria
| | - F Aberer
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - G Koehler
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - C Sourij
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - H Kojzar
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - P Holler
- Sport Science Laboratory, FH Joanneum University of Applied Science, Bad Gleichenberg, Austria
| | - H Simi
- Sport Science Laboratory, FH Joanneum University of Applied Science, Bad Gleichenberg, Austria
| | - P Pferschy
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - P Dietz
- Department of Physical Activity and Public Health, Institute of Sports Science, Medical University of Graz, Graz, Austria
- Institute of Occupational, Social and Environmental Medicine, University Medical Centre of the University of Mainz, Mainz, Germany
| | - R M Bracken
- Diabetes Research Group, Medical School, Swansea University, Swansea, UK
- Applied Sport, Technology, Exercise and Medicine Research Centre (A-STEM), College of Engineering, Swansea University, Swansea, UK
| | - P Hofmann
- Exercise Physiology, Training and Training Therapy Research Group, Institute of Sports Science, Medical University of Graz, Graz, Austria
| | - H Sourij
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Abdulrahman A, Manhas J, Linane H, Gurney M, Fitzgerald C, O'Sullivan E. Use of continuous glucose monitoring for sport in type 1 diabetes. BMJ Open Sport Exerc Med 2019; 4:e000432. [PMID: 30774973 PMCID: PMC6350713 DOI: 10.1136/bmjsem-2018-000432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2018] [Indexed: 11/04/2022] Open
Abstract
Background The benefits of exercise for patients with type 1 diabetes (T1D) are difficult to balance with associated glycaemic excursions. The aim of this cohort study was to show that continuous glucose monitoring (CGM) could reduce glycaemic excursions in patients with T1D already using insulin pumps, exercising at moderate to high intensity. Methods Questionnaires were used to identify patients with T1D using insulin pumps and naive to CGM use, who reported regular exercise. Six were enrolled and trained on Enlite sensor use with Medtronic Minimed Paradigm Veo system and given activity trackers and written advice on adjustment of insulin or carbohydrate intake for exercise. Resting heart rate (HR) and age were used to determine HR surrogates of moderate and high-intensity exercise. They were to exercise as usual for 3 weeks (run-in week, week 1 and week 2) using the activity trackers and heart rate monitors. Problem areas in Diabetes, Hypoglycaemia fear survey II, Diabetes Technology Questionnaire and Gold scores were completed prior to run-in and at the end. The downloaded sensor glucose data were used to compare the change in time in range (glucose 3.9–10.0 mmol/L) from week 1 to week 2. Results For the duration of exercise, this time in glucose range increased from 72±20 to 88%±16 %, p=0.05. The time in hypoglycaemia range (glucose < 3.9 mmol/L) went from 3.9±7.9 to 2.4%±4.8 %, p=0.39. The time in hyperglycaemia range (> 10 mmol/L) reduced from 24±19 to 10%±17%, p=0.04. Conclusion These results demonstrate the benefit of CGM use for patients with T1DM doing moderate-intensity to high-intensity exercise.
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Affiliation(s)
- Alif Abdulrahman
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Janisha Manhas
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Hannah Linane
- Department of Diabetes, Endocrinology and Metabolism, Galway University Hospital, Galway, Ireland
| | - Mark Gurney
- Department of Diabetes, Endocrinology and Metabolism, Galway University Hospital, Galway, Ireland
| | | | - Esther O'Sullivan
- School of Medicine, National University of Ireland, Galway, Ireland.,Department of Diabetes, Endocrinology and Metabolism, Galway University Hospital, Galway, Ireland
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Teich T, Zaharieva DP, Riddell MC. Advances in Exercise, Physical Activity, and Diabetes Mellitus. Diabetes Technol Ther 2019; 21:S112-S122. [PMID: 30785316 DOI: 10.1089/dia.2019.2509] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Trevor Teich
- 1 School of Kinesiology and Health Science, Faculty of Health, Muscle Health Research Centre, York University, Toronto, Ontario, Canada
| | - Dessi P Zaharieva
- 1 School of Kinesiology and Health Science, Faculty of Health, Muscle Health Research Centre, York University, Toronto, Ontario, Canada
| | - Michael C Riddell
- 1 School of Kinesiology and Health Science, Faculty of Health, Muscle Health Research Centre, York University, Toronto, Ontario, Canada
- 2 LMC Diabetes & Endocrinology, Toronto, Ontario, Canada
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Chetty T, Shetty V, Fournier PA, Adolfsson P, Jones TW, Davis EA. Exercise Management for Young People With Type 1 Diabetes: A Structured Approach to the Exercise Consultation. Front Endocrinol (Lausanne) 2019; 10:326. [PMID: 31258513 PMCID: PMC6587067 DOI: 10.3389/fendo.2019.00326] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 05/07/2019] [Indexed: 12/11/2022] Open
Abstract
Regular physical activity during childhood is important for optimal physical and psychological development. For individuals with Type 1 Diabetes (T1D), physical activity offers many health benefits including improved glycemic control, cardiovascular function, blood lipid profiles, and psychological well-being. Despite these benefits, many young people with T1D do not meet physical activity recommendations. Barriers to engaging in a physically active lifestyle include fear of hypoglycemia, as well as insufficient knowledge in managing diabetes around exercise in both individuals and health care professionals. Diabetes and exercise management is complex, and many factors can influence an individual's glycemic response to exercise including exercise related factors (such as type, intensity and duration of the activity) and person specific factors (amount of insulin on board, person's stress/anxiety and fitness levels). International guidelines provide recommendations for clinical practice, however a gap remains in how to apply these guidelines to a pediatric exercise consultation. Consequently, it can be challenging for health care practitioners to advise young people with T1D how to approach exercise management in a busy clinic setting. This review provides a structured approach to the child/adolescent exercise consultation, based on a framework of questions, to assist the health care professional in formulating person-specific exercise management plans for young people with T1D.
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Affiliation(s)
- Tarini Chetty
- Children's Diabetes Centre, Perth Children's Hospital, Perth, WA, Australia
- *Correspondence: Tarini Chetty
| | - Vinutha Shetty
- Children's Diabetes Centre, Perth Children's Hospital, Perth, WA, Australia
- UWA Centre for Child Health Research, University of Western Australia, Perth, WA, Australia
| | - Paul Albert Fournier
- School of Human Sciences, University of Western Australia, Perth, WA, Australia
- Telethon Kids Institute, Perth Children's Hospital, Perth, WA, Australia
| | - Peter Adolfsson
- Department of Pediatrics, The Hospital of Halland, Kungsbacka, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Timothy William Jones
- Children's Diabetes Centre, Perth Children's Hospital, Perth, WA, Australia
- UWA Centre for Child Health Research, University of Western Australia, Perth, WA, Australia
- Telethon Kids Institute, Perth Children's Hospital, Perth, WA, Australia
| | - Elizabeth Ann Davis
- Children's Diabetes Centre, Perth Children's Hospital, Perth, WA, Australia
- UWA Centre for Child Health Research, University of Western Australia, Perth, WA, Australia
- Telethon Kids Institute, Perth Children's Hospital, Perth, WA, Australia
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Sigal RJ, Armstrong MJ, Bacon SL, Boulé NG, Dasgupta K, Kenny GP, Riddell MC. Physical Activity and Diabetes. Can J Diabetes 2018; 42 Suppl 1:S54-S63. [PMID: 29650112 DOI: 10.1016/j.jcjd.2017.10.008] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Indexed: 12/15/2022]
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Thomakos P, Vazeou A, Sakkas D, Panagopoulos G, Anifantakis K, Smyrnaki P, Arvanitaki T, Kyrlaki E, Kefalogiannis N, Mamoulakis D, Pappas A, Mitrakou A. Avoiding hypoglycemia: the use of insulin pump combined with continuous glucose monitor in type 1 diabetes crossing a Rocky Gorge. QJM 2018; 111:629-633. [PMID: 29939323 DOI: 10.1093/qjmed/hcy136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring systems (CGMS) have been proven very effective in diabetes management. AIM This study evaluated the usefulness of these devices during prolonged, intense physical activity in an uncontrolled natural environment away from the clinical research center. DESIGN Non-randomized, prospective and observational study. METHODS During the summer, 38 participants with type 1 diabetes crossed the Samaria gorge, the second largest gorge in Europe (17 km). Twenty subjects on CSII combined with real-time CGMS and 18 on multiple daily injections (MDI) combined with professional (retrospective) CGMS participated in the program. All participants were unsupervised during the event. RESULTS All 38 participants managed to reach the destination point safely. There were no episodes of severe hypoglycemia. The duration of the exercise (mean ±SD) was 6.4 ± 1.3 h. The CSII group exhibited significantly lower hypoglycemic episodes during exercise (0.1 ± 0.3 vs. 0.4 ± 0.6; P = 0.047) as well as lower AUC below 70 mg/dl compared with the MDI, during the 24 h (0.61 ± 0.78 vs. 1.84 ± 1.55; P = 0.007). Individuals on CSII were significantly less likely to develop a hypoglycemic episode during exercise (P = 0.038). Exercise induced nocturnal hypoglycemia was not prevented effectively in neither group. CONCLUSIONS CSII combined with CGMS is effective in controlling blood glucose levels in type 1 diabetics who perform prolonged strenuous exercise. The use of insulin pump technology in regions with hot Mediterranean climates is safe and can provide protection against exercise-induced hypoglycemia. Development of precise instructions for T1DM who occasionally get involved in exercise activities, requires further studies.
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Affiliation(s)
- P Thomakos
- From the Department of Clinical Therapeutics Medical School of National and Kapodistrian University of Athens, Alexandra Hospital, Lourou Street, 115 28 Athens, Greece
- Hygeia General Hospital, Diabetes Center, 4, Erythrou Stavrou, 151 23 Marousi, Athens, Greece
| | - A Vazeou
- Pediatric Unit, P&A Kyriakou Children's Hospital, Diabetes Unit, Livadias Street, 115 27 Athens, Greece
| | - D Sakkas
- From the Department of Clinical Therapeutics Medical School of National and Kapodistrian University of Athens, Alexandra Hospital, Lourou Street, 115 28 Athens, Greece
| | - G Panagopoulos
- From the Department of Clinical Therapeutics Medical School of National and Kapodistrian University of Athens, Alexandra Hospital, Lourou Street, 115 28 Athens, Greece
| | - K Anifantakis
- Venizeleio Hospital-PAGN, Diabetes Unit, Knosou Avenue, 714 09 Heraclion, Greece
| | - P Smyrnaki
- Venizeleio Hospital-PAGN, Diabetes Unit, Knosou Avenue, 714 09 Heraclion, Greece
| | - T Arvanitaki
- Chania General Hospital, Pediatric Unit, Diabetes Unit, Agiou Eleftheriou Street, 733 00 Chania, Greece
| | - E Kyrlaki
- Venizeleio Hospital-PAGN, Diabetes Unit, Knosou Avenue, 714 09 Heraclion, Greece
| | - N Kefalogiannis
- Asklipios Center, Diabetes Unit, 10, Mahis Critis Street, 713 03 Heraclion, Greece
| | - D Mamoulakis
- Venizeleio Hospital-PAGN, Diabetes Unit, Knosou Avenue, 714 09 Heraclion, Greece
| | - A Pappas
- Venizeleio Hospital-PAGN, Diabetes Unit, Knosou Avenue, 714 09 Heraclion, Greece
| | - A Mitrakou
- From the Department of Clinical Therapeutics Medical School of National and Kapodistrian University of Athens, Alexandra Hospital, Lourou Street, 115 28 Athens, Greece
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Rickels MR, DuBose SN, Toschi E, Beck RW, Verdejo AS, Wolpert H, Cummins MJ, Newswanger B, Riddell MC, Rickels M, Peleckis A, Evangelisti M, Dalton-Bakes C, Fuller C, Toschi E, Wolpsert H, Middelbeek R, Cherng Jye LS, Shahar J, Slyne C, Edwards S, Castillo AA, DuBose SN, Beck RW, Verdejo AS, Cummins M, Newswanger B, Prestrelski S. Mini-Dose Glucagon as a Novel Approach to Prevent Exercise-Induced Hypoglycemia in Type 1 Diabetes. Diabetes Care 2018; 41:1909-1916. [PMID: 29776987 PMCID: PMC6463733 DOI: 10.2337/dc18-0051] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 04/25/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Patients with type 1 diabetes who do aerobic exercise often experience a drop in blood glucose concentration that can result in hypoglycemia. Current approaches to prevent exercise-induced hypoglycemia include reduction in insulin dose or ingestion of carbohydrates, but these strategies may still result in hypoglycemia or hyperglycemia. We sought to determine whether mini-dose glucagon (MDG) given subcutaneously before exercise could prevent subsequent glucose lowering and to compare the glycemic response to current approaches for mitigating exercise-associated hypoglycemia. RESEARCH DESIGN AND METHODS We conducted a four-session, randomized crossover trial involving 15 adults with type 1 diabetes treated with continuous subcutaneous insulin infusion who exercised fasting in the morning at ∼55% VO2max for 45 min under conditions of no intervention (control), 50% basal insulin reduction, 40-g oral glucose tablets, or 150-μg subcutaneous glucagon (MDG). RESULTS During exercise and early recovery from exercise, plasma glucose increased slightly with MDG compared with a decrease with control and insulin reduction and a greater increase with glucose tablets (P < 0.001). Insulin levels were not different among sessions, whereas glucagon increased with MDG administration (P < 0.001). Hypoglycemia (plasma glucose <70 mg/dL) was experienced by six subjects during control, five subjects during insulin reduction, and none with glucose tablets or MDG; five subjects experienced hyperglycemia (plasma glucose ≥250 mg/dL) with glucose tablets and one with MDG. CONCLUSIONS MDG may be more effective than insulin reduction for preventing exercise-induced hypoglycemia and may result in less postintervention hyperglycemia than ingestion of carbohydrate.
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Affiliation(s)
- Michael R. Rickels
- Institute for Diabetes, Obesity and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Elena Toschi
- Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | | | | | - Howard Wolpert
- Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | | | | | - Michael C. Riddell
- Muscle Health Research Centre, York University School of Kinesiology and Health Science, Toronto, Ontario, Canada
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Zaharieva DP, Riddell MC. Insulin Management Strategies for Exercise in Diabetes. Can J Diabetes 2018; 41:507-516. [PMID: 28942788 DOI: 10.1016/j.jcjd.2017.07.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/16/2017] [Accepted: 07/31/2017] [Indexed: 11/19/2022]
Abstract
There is no question that regular exercise can be beneficial and lead to improvements in overall cardiovascular health. However, for patients with diabetes, exercise can also lead to challenges in maintaining blood glucose balance, particularly if patients are prescribed insulin or certain oral hypoglycemic agents. Hypoglycemia is the most common adverse event associated with exercise and insulin therapy, and the fear of hypoglycemia is also the greatest barrier to exercise for many patients. With the appropriate insulin dose adjustments and, in some cases, carbohydrate supplementation, blood glucose levels can be better managed during exercise and in recovery. In general, insulin strategies that help facilitate weight loss with regular exercise and recommendations around exercise adjustments to prevent hypoglycemia and hyperglycemia are often not discussed with patients because the recommendations can be complex and may differ from one individual to the next. This is a review of the current published literature on insulin dose adjustments and starting-point strategies for patients with diabetes in preparation for safe exercise.
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Affiliation(s)
- Dessi P Zaharieva
- School of Kinesiology & Health Science, Faculty of Health, Muscle Health Research Centre and Physical Activity & Chronic Disease Unit, York University, Toronto, Ontario, Canada
| | - Michael C Riddell
- School of Kinesiology & Health Science, Faculty of Health, Muscle Health Research Centre and Physical Activity & Chronic Disease Unit, York University, Toronto, Ontario, Canada; LMC Diabetes & Endocrinology, Toronto, Ontario, Canada.
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45
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Houlder SK, Yardley JE. Continuous Glucose Monitoring and Exercise in Type 1 Diabetes: Past, Present and Future. BIOSENSORS-BASEL 2018; 8:bios8030073. [PMID: 30081478 PMCID: PMC6165159 DOI: 10.3390/bios8030073] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 07/31/2018] [Accepted: 08/01/2018] [Indexed: 12/29/2022]
Abstract
Prior to the widespread use of continuous glucose monitoring (CGM), knowledge of the effects of exercise in type 1 diabetes (T1D) was limited to the exercise period, with few studies having the budget or capacity to monitor participants overnight. Recently, CGM has become a staple of many exercise studies, allowing researchers to observe the otherwise elusive late post-exercise period. We performed a strategic search using PubMed and Academic Search Complete. Studies were included if they involved adults with T1D performing exercise or physical activity, had a sample size greater than 5, and involved the use of CGM. Upon completion of the search protocol, 26 articles were reviewed for inclusion. While outcomes have been variable, CGM use in exercise studies has allowed the assessment of post-exercise (especially nocturnal) trends for different exercise modalities in individuals with T1D. Sensor accuracy is currently considered adequate for exercise, which has been crucial to developing closed-loop and artificial pancreas systems. Until these systems are perfected, CGM continues to provide information about late post-exercise responses, to assist T1D patients in managing their glucose, and to be useful as a tool for teaching individuals with T1D about exercise.
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Affiliation(s)
- Shaelyn K Houlder
- Augustana Faculty, University of Alberta, 4901-46 Ave, Camrose, AB T4V 2R3, Canada.
| | - Jane E Yardley
- Augustana Faculty, University of Alberta, 4901-46 Ave, Camrose, AB T4V 2R3, Canada.
- Alberta Diabetes Institute, 112 St. NW, Edmonton, AB T6G 2T9, Canada.
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Hu Y, Zhang DF, Dai L, Li Z, Li HQ, Li FF, Liu BL, Sun XJ, Ye L, He K, Ma JH. Pre-exercise blood glucose affects glycemic variation of aerobic exercise in patients with type 2 diabetes treated with continuous subcutaneous insulin infusion. Diabetes Res Clin Pract 2018; 141:98-105. [PMID: 29730390 DOI: 10.1016/j.diabres.2018.04.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 04/08/2018] [Accepted: 04/26/2018] [Indexed: 01/04/2023]
Abstract
AIMS Considering the insulin sensitivity may increase by exercise particularly in patients with type 2 diabetes (T2D), glycemic variation during exercise needs to be studied when the patients are treated with insulin. This study aimed to explore the influence factors of the efficacy and safety of aerobic exercise in patients with T2D treated with Continuous Subcutaneous Insulin Infusion (CSII). METHODS A total of 267 patients with T2D, treated with CSII, were included. Glycemic variations were assessed by continuous glucose monitoring (CGM). Patients were asked to complete 30 min aerobic exercise for at least one time during CGM. The patients were divided into effective and ineffective group by incremental glucose area under curve from 0 to 60 min after exercise (AUC0-60 min). RESULTS The patients completed a total of 776 times of aerobic exercises. Blood glucose decreased fastest in the first 60 min of exercise. Pre-exercise blood glucose (PEBG) was negatively correlated with AUC0-60 min (standardized β = -0.386, P < 0.001) and incremental AUC of blood glucose ≤ 4.4 mmol/L (standardized β = -0.078, P = 0.034), and was significantly higher in effective group than in ineffective group (P < 0.001). The Δglucose AUC0-60 min during post-dinner was significantly higher than that during pre-lunch, post-lunch and pre-dinner (P < 0.05 for all). CONCLUSIONS PEBG is positively correlated with efficacy of aerobic exercise. Aerobic exercise will not worsen hyperglycemia when the PEBG > 16.7 mmol/L. Post-dinner exercise decreases the blood glucose better than other periods of the day. CLINICAL TRIALS REGISTRATION ChiCTR-ONC-17010400, www.chictr.org.cn.
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Affiliation(s)
- Yun Hu
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Jiangsu 210012, China
| | - Dan-Feng Zhang
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Jiangsu 210012, China
| | - Lu Dai
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Jiangsu 210012, China
| | - Zheng Li
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Jiangsu 210012, China
| | - Hui-Qin Li
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Jiangsu 210012, China
| | - Feng-Fei Li
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Jiangsu 210012, China
| | - Bing-Li Liu
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Jiangsu 210012, China
| | - Xiao-Juan Sun
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Jiangsu 210012, China
| | - Lei Ye
- National Heart Research Institute Singapore, National Heart Centre Singapore, 169609, Singapore
| | - Ke He
- Department of Endocrinology, Wuxi Hospital Affiliated to Nanjing University of Chinese Medicine, Jiangsu 214000, China
| | - Jian-Hua Ma
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Jiangsu 210012, China.
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Picard S, Hanaire H, Reznik Y, Benhamou PY, Fendri S, Dufaitre L, Leutenegger E, Guerci B. Optimization of Insulin Regimen and Glucose Outcomes with Short-Term Real-Time Continuous Glucose Monitoring in Adult Type 1 Diabetes Patients with Suboptimal Control on Multiple Daily Injections: The Adult DIACCOR Study. Diabetes Technol Ther 2018; 20:403-412. [PMID: 29847735 DOI: 10.1089/dia.2018.0002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The impact of a 7-day real-time continuous glucose monitoring (RT-CGM) on type 1 diabetes (T1D) management remains unclear in patients suboptimally controlled by multiple daily injections (MDI). The DIACCOR Study aimed to describe treatment decisions and glucose outcomes after a short-term RT-CGM sequence. PATIENTS AND METHODS This French multicenter longitudinal observational study included T1D patients with HbA1c >7.5% or history of severe hypoglycemia (SH) or recurrent documented hypoglycemia. A sensor was inserted at the inclusion visit, treatment changes were proposed by the investigator within 7-15 days ("INT" = MDI intensification, "CSII" = switch to continuous insulin infusion, or "ER" = educational reinforcement with no change in insulin regimen), and a 4-month follow-up visit (M4) was scheduled. RESULTS Four hundred fifty-nine patients were recruited by 155 diabetologists, 17.0% had SH history, and 24.2% had recurrent hypoglycemia. Baseline HbA1c was 8.34% ± 1.21% (>7.5% in 79.6%). Overall, 253 (64.4%), 64 (16.3%), and 76 patients (19.3%) were, respectively, included in the "INT," "CSII," and "ER" subgroups. The number of patients who experienced SH or recurrent hypoglycemia dropped dramatically (7.9% vs. 17.0% and 10.8% vs. 24.2%, respectively). The same trend was observed for ketoacidosis and ketosis (0.3% vs. 3.3% and 2.2% vs. 4.8%). At M4, HbA1c was significantly reduced in the whole cohort to 7.98% ± 1.01% (P < 0.0001). The adjusted differences in HbA1c level in the INT, CSII, and ER subgroups were, respectively, -0.32%, -0.69%, and -0.50% (P < 0.0001 for all). CONCLUSION In real-life setting, a 1-week diagnostic RT-CGM supports appropriate treatment changes in patients with uncontrolled T1D resulting in better glucose control and less hypoglycemia.
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Affiliation(s)
- Sylvie Picard
- 1 Point Médical, Rond-Point de la Nation , Dijon, France
| | - Hélène Hanaire
- 2 Endocrinology-Diabetes Care Unit, Toulouse University Hospital , Toulouse, France
| | - Yves Reznik
- 3 Endocrinology-Diabetes Care Unit, Caen University Hospital , Caen, France
| | - Pierre-Yves Benhamou
- 4 Endocrinology-Diabetes Care Unit, Grenoble University Hospital , Grenoble, France
| | - Salha Fendri
- 5 Endocrinology-Diabetes Care Unit, Amiens University Hospital , Amiens, France
| | - Lise Dufaitre
- 6 Endocrinology-Diabetes Care Unit, Marseille University Hospital , Marseille, France
| | | | - Bruno Guerci
- 8 Endocrinology, Diabetology and Nutrition, Brabois Adult Hospital CHRU of Nancy, University of Lorraine , Vandoeuvre Lès Nancy, France
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48
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Affiliation(s)
- Aoibhe M Pasieka
- 1 School of Kinesiology and Health Science, York University, Toronto, Canada
| | - Michael C Riddell
- 1 School of Kinesiology and Health Science, York University, Toronto, Canada
- 2 LMC Diabetes & Endocrinology, Toronto, Canada
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49
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Tagougui S, Taleb N, Rabasa-Lhoret R. The Benefits and Limits of Technological Advances in Glucose Management Around Physical Activity in Patients Type 1 Diabetes. Front Endocrinol (Lausanne) 2018; 9:818. [PMID: 30713524 PMCID: PMC6346637 DOI: 10.3389/fendo.2018.00818] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 12/31/2018] [Indexed: 12/20/2022] Open
Abstract
Physical activity is highly recommended for patients living with type 1 diabetes (T1D) due to its varied health benefits. Nevertheless, glucose management, during and in the hours following exercise, represents a great challenge for these patients who most often end up leading a sedentary life style. Important technological advances in insulin delivery devices and glucose monitoring are now available and continue to progress. These technologies could be used to alleviate glucose management related to physical activity in T1D. Continuous glucose monitoring (CGM) helps patients observe the trends of glycemic fluctuations when exercising and in the following night to deal pre-emptively with hypoglycemic risks and treat hypoglycemic episodes in a timely manner. Insulin pumps offer the flexibility of adjusting insulin basal rates and boluses according to patient's specific needs around exercise. The artificial pancreas links CGM to pump through an intelligent hormone dosing algorithm to close the loop of glucose control and has thus the potential to ease the burden of exercise in T1D. This review will examine and discuss the literature related to physical activity practice using each of these technologies. The aim is to discuss their benefits as well as their limitations and finally the additional research needed in the future to optimize their use in T1D.
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Affiliation(s)
- Sémah Tagougui
- Institut de Recherches Cliniques de Montréal, Montreal, QC, Canada
- Département de Nutrition, Faculté de Médicine, Université de Montréal, Montreal, QC, Canada
| | - Nadine Taleb
- Institut de Recherches Cliniques de Montréal, Montreal, QC, Canada
- Département des Sciences Biomédicales, Faculté de Médicine, Université de Montréal, Montreal, QC, Canada
| | - Rémi Rabasa-Lhoret
- Institut de Recherches Cliniques de Montréal, Montreal, QC, Canada
- Département de Nutrition, Faculté de Médicine, Université de Montréal, Montreal, QC, Canada
- Département des Sciences Biomédicales, Faculté de Médicine, Université de Montréal, Montreal, QC, Canada
- Division of Endocrinology, McGill University, Montreal, QC, Canada
- Endocrinology Division, Montreal Diabetes Research Center, Montreal, QC, Canada
- *Correspondence: Rémi Rabasa-Lhoret
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Parkin CG, Homberg A, Hinzmann R. 10th Annual Symposium on Self-Monitoring of Blood Glucose, April 27-29, 2017, Warsaw, Poland. Diabetes Technol Ther 2018; 20:68-89. [PMID: 29135283 PMCID: PMC5770081 DOI: 10.1089/dia.2017.0356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
International experts in the field of diabetes and diabetes technology met in Warsaw, Poland, for the 10th Annual Symposium on Self-Monitoring of Blood Glucose. The goal of these meetings is to establish a global network of experts to facilitate new collaborations and research projects that can improve the lives of people with diabetes. The 2017 meeting comprised a comprehensive scientific program, parallel interactive workshops, and four keynote lectures.
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