Outcomes of algorithm-based modifications of insulinotherapy during exercise in MDI vs insulin pump-treated children with type 1 diabetes: Results from the TREAD-DIAB study

Impact of School Nurse on Managing Pediatric Type 1 Diabetes with Technological Devices Support: A Systematic Review

INTRODUCTION

Type 1 diabetes (T1D) is a disease that primarily occurs in pediatric populations. A school nurse (SN) can provide valuable support in the school setting for minors affected by this condition.

METHODS

The main objective of this study was to evaluate the impact of nursing care provided to adolescents and children with T1D using technological devices in school. Qualitative and quantitative outcomes considered in the included studies were collected and discussed. A systematic review was conducted in the PubMed, CINAHL, and Scopus databases and reported thought the PRISMA guidelines.

RESULTS

Eleven studies were included. The results showed that SNs need to enhance both their skills and organization to effectively manage young patients with T1D using technology. The response of both the pediatric population and their caregivers to the disease management by a SN has been positive.

CONCLUSIONS

The management of chronic diseases is one of the most urgent public health issues, especially for Western healthcare systems. Proper management of patients with T1D at the school level is definitely an aspect that policymakers and healthcare managers should consider to improve the quality of life of this extremely vulnerable population, particularly those using technological management T1D.

2022: Position of Brazilian Diabetes Society on exercise recommendations for people with type 1 and type 2 diabetes

INTRODUCTION

For individuals diagnosed with diabetes mellitus, the practice of properly oriented physical exercises brings significant benefits to the individual's health and is considered an indispensable tool for metabolic management. The individualization of exercise routines is an essential aspect for therapeutic success, despite the need to consider some general recommendations. This review is an authorized literal translation of the Brazilian Society of Diabetes (SBD) Guidelines 2021-2022, which is based on scientific evidence and provides guidance on physical activities and exercises aimed at individuals with type 1 and 2 diabetes.

METHODS

SBD designated 9 specialists from its "Department of Diabetes, Exercise & Sports" to author chapters on physical activities and exercises directed to individuals with type 1 and 2 diabetes. The aim of these chapters was to highlight recommendations in accordance with Evidence Levels, based on what is described in the literature. These chapters were analyzed by the SBD Central Committee, which is also responsible for the SBD 2021-2022 guidelines. Main clinical inquiries were selected to perform a narrated review by using MEDLINE via PubMed. Top available evidence, such as high-quality clinical trials, large observational studies and meta-analyses related to physical activity and exercise advisory, were analyzed. The adopted MeSh terms were [diabetes], [type 1 diabetes], [type 2 diabetes], [physical activity] [physical exercise].

RESULTS

17 recommendations were defined by the members. For this review, it was considered different Evidence Levels, as well as different Classes of Recommendations. As to Evidence Levels, the following levels were contemplated: Level A) More than one randomized clinical trial or a randomized clinical trial meta-analysis with low heterogeneity. Level B) Meta analysis with observational studies, one randomized clinical trial, sizeable observational studies and sub-groups analysis. Level C) Small non-randomized studies, cross-sectional studies, case control studies, guidelines or experts' opinions. In respect to Recommendation Classes, the following criteria were adopted: I. "Recommended": Meaning there was a consent of more than 90% of the panel; IIa. "Must be considered": meaning there is a general preference of the panel which 70-90% agrees; IIb. "Can be considered". 50-70% agrees; III Not recommended: There is a consensus that the intervention should not be performed.

CONCLUSION

Physical exercise aids on the glycemic control of type 2 diabetes individuals while also decreasing cardiovascular risk in individuals with type 1 and 2 diabetes. Individuals diagnosed with diabetes should perform combined aerobic and resistance exercises in order to manage the disease. In addition, exercises focusing on flexibility and balance should be specially addressed on elderly individuals. Diabetes individuals using insulin as therapeutic treatment should properly monitor glycemia levels before, during and after exercise sessions to minimize health incidents, such as hypoglycemia.

Quantifying the impact of physical activity on future glucose trends using machine learning

Prevention of hypoglycemia (glucose <70 mg/dL) during aerobic exercise is a major challenge in type 1 diabetes. Providing predictions of glycemic changes during and following exercise can help people with type 1 diabetes avoid hypoglycemia. A unique dataset representing 320 days and 50,000 + time points of glycemic measurements was collected in adults with type 1 diabetes who participated in a 4-arm crossover study evaluating insulin-pump therapies, whereby each participant performed eight identically designed in-clinic exercise studies. We demonstrate that even under highly controlled conditions, there is considerable intra-participant and inter-participant variability in glucose outcomes during and following exercise. Participants with higher aerobic fitness exhibited significantly lower minimum glucose and steeper glucose declines during exercise. Adaptive, personalized machine learning (ML) algorithms were designed to predict exercise-related glucose changes. These algorithms achieved high accuracy in predicting the minimum glucose and hypoglycemia during and following exercise sessions, for all fitness levels.

American Medical Society for Sports Medicine Position Statement on the Care of the Athlete and Athletic Person With Diabetes

ABSTRACT

The American Medical Society for Sports Medicine (AMSSM) developed this position statement to assist physicians and other health professionals in managing athletes and active people with diabetes. The AMSSM selected the author panel through an application process to identify members with clinical and academic expertise in the care of active patients with diabetes. This article reviews the current knowledge and gaps regarding the benefits and risks of various types of exercise and management issues for athletes and physically active people with diabetes, including nutrition and rehabilitation issues. Resistance exercises seem to be beneficial for patients with type 1 diabetes, and the new medications for patients with type 2 diabetes generally do not need adjustment with exercise. In preparing this statement, the authors conducted an evidence review and received open comment from the AMSSM Board of Directors before finalizing the recommendations.

Combined Algorithm-Based Adaptations of Insulin Dose and Carbohydrate Intake During Exercise in Children With Type 1 Diabetes: Results From the CAR2DIAB Study

Objectives

To evaluate the evolution of subcutaneous glucose during two sessions of monitored aerobic exercise in children or adolescents with type 1 diabetes after adaptation of insulin doses and carbohydrate intake according to a combined algorithm.

Methods

Twelve patients with type 1 diabetes (15.1 ± 2 years; diabetes duration: 9.5 ± 3.1 years) performed two series of exercise sessions after cardiac evaluation. The first series (TE#1) consisted in a monitored exercise of moderate to vigorous intensity coupled with a bout of maximum effort. The second series of exercises (TE#2) was carried out in real life during exercises categorized and monitored by connected watches. TE#2 sessions were performed after adaptation of insulin doses and fast-acting carbohydrates according to decision algorithms.

Results

Patients did not experience episodes of severe hypoglycemia, symptomatic hyperglycemia, or hyperglycemia associated with ketosis. Analysis of CGM data (15 h) during TE#2 sessions revealed an overall improvement in glycemic average [± standard deviation] (104 ± 14 mg/dl vs. 122 ± 17 mg/dl during TE#1; p < 0.001), associated with a decrease in proportion of hyperglycemia in periods ranging from 4 h to 15 h after performing the exercises. The proportion of hypoglycemia was not changed, except during the TE#2 +4-8 h period, where a significant increase in hypoglycemia <60 mg/dl was observed (25% vs. 6.2%; p = 0.04), yet without concurrent complications.

Conclusion

In our pediatric series, the application of algorithmic adaptations of insulin doses and carbohydrate intake has globally improved glycemic control during 15 h after real-time exercises performed by children and adolescents with type 1 diabetes.

Technological Ecological Momentary Assessment Tools to Study Type 1 Diabetes in Youth: Viewpoint of Methodologies

Type 1 diabetes (T1D) is one of the most common chronic childhood diseases, and its prevalence is rapidly increasing. The management of glucose in T1D is challenging, as youth must consider a myriad of factors when making diabetes care decisions. This task often leads to significant hyperglycemia, hypoglycemia, and glucose variability throughout the day, which have been associated with short- and long-term medical complications. At present, most of what is known about each of these complications and the health behaviors that may lead to them have been uncovered in the clinical setting or in laboratory-based research. However, the tools often used in these settings are limited in their ability to capture the dynamic behaviors, feelings, and physiological changes associated with T1D that fluctuate from moment to moment throughout the day. A better understanding of T1D in daily life could potentially aid in the development of interventions to improve diabetes care and mitigate the negative medical consequences associated with it. Therefore, there is a need to measure repeated, real-time, and real-world features of this disease in youth. This approach is known as ecological momentary assessment (EMA), and it has considerable advantages to in-lab research. Thus, this viewpoint aims to describe EMA tools that have been used to collect data in the daily lives of youth with T1D and discuss studies that explored the nuances of T1D in daily life using these methods. This viewpoint focuses on the following EMA methods: continuous glucose monitoring, actigraphy, ambulatory blood pressure monitoring, personal digital assistants, smartphones, and phone-based systems. The viewpoint also discusses the benefits of using EMA methods to collect important data that might not otherwise be collected in the laboratory and the limitations of each tool, future directions of the field, and possible clinical implications for their use.

American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons With Diabetes Mellitus

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.

Benefits of physical activity in children and adolescents with type 1 diabetes: A systematic review

AIMS

We performed a systematic review of clinical trials investigating the health benefits of physical activity in pediatric patients with type 1 diabetes.

METHODS

To perform this systematic review, search strategies were created and adapted to four databases. Only randomized controlled trials written in English before 1998 and that answered to the PICOS criteria were included. The PRISMA guidelines were followed to ensure highest scientific rigor within studies.

RESULTS

Seven studies out of 2655 were included in this systematic review according to the inclusion criteria. These studies showed positive gains on global health: blood lipid profile, physical fitness, quality of life and body size and body composition but only one demonstrated a positive effect on glycemic control.

CONCLUSION

Globally, physical activity exerts a positive impact on metabolic (i.e., decrease in total cholesterol, improvement of physical fitness, etc.) and psychological health in children with type 1 diabetes. Yet variations in study protocols or sample size restrict statistical power to reach the outcome of improving glycemic control in most studies. Here, we address the measured outcomes in individual trials and discuss potential key elements to consider for future clinical trials.

A Systematic Review of Physical Activity and Exercise on Physiological and Biochemical Outcomes in Children and Adolescents With Type 1 Diabetes

PURPOSE

In this systematic review we aimed to evaluate the effects of physical activity (PA) and exercise on biochemical and physiological outcomes in children and adolescents with type 1 diabetes (T1D).

DESIGN

The review was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

METHODS

The search of literature was performed using PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, the Cochrane Library, Scopus, Medline, PsycINFO, the Nursing Reference Center, and Google Scholar. The search was limited to include peer-reviewed articles published in English from May 2012 to May 2018 and included adolescents <19 years of age with T1D. Twenty-seven studies met the inclusion criteria: 8 interventional and 19 observational studies.

FINDINGS

Both observational and interventional studies showed considerable agreement that supervised regular moderate to vigorous physical activity (MVPA) is more effective on adiposity and cardiorespiratory fitness than habitual PA. Further, it was reported that PA of different intensities improves insulin sensitivity and decreases daily insulin dosage. Results of glycemic control were equivocal. Although observational studies reported improvement in glycemic control with PA of different intensities, most of the experimental studies revealed no significant associations. A consistent agreement among the studies revealed a considerable benefit of regular habitual PA of light to moderate intensity on blood glucose regulation and lipid profile.

CONCLUSIONS

The reviewed studies showed that regular MVPA was associated with several health benefits in adolescents with T1D; however, additional studies are needed to fully understand the effect of PA on health outcomes.

CLINICAL RELEVANCE

Regular MVPA (at least 4 hr per week) with good glycemic control is a promising option for adolescents with T1D when risk management of hypoglycemia is appropriately taken.

Optimization of insulin regimen and glucose outcomes with short-term real-time continuous glucose monitoring (RT-CGM) in type 1 diabetic children with sub-optimal glucose control on multiple daily injections: The pediatric DIACCOR study

BACKGROUND

The impact of 7-day real-time continuous glucose monitoring (RT-CGM) on type 1 diabetes (T1D) management remains unknown in youths with suboptimal control by multiple daily injections (MDI). The DIACCOR Study aimed to describe treatment decisions and glucose outcomes after a short-term RT-CGM sequence in real-life conditions.

METHODS

This French multicenter longitudinal observational study included T1D youths with HbA1c>7.5% or a history of severe hypoglycemia (SH) or recurrent documented hypoglycemia. A sensor was inserted at the study-inclusion visit, and one of three predefined treatment changes was 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

A total of 229 children (12.2±3.5 years old) were recruited by 74 pediatricians; 12.8% had a history of SH, 22.2% had recurrent hypoglycemia. Baseline HbA1c was 8.7±1.5% (>7.5% in 82.8%). Overall, 139 (79.4%), 19 (10.9%), and 17 patients (9.7%) were, respectively, included in the INT, CSII, and ER subgroups. At M4, the global incidence of SH and recurrent hypoglycemia dropped (3.4% vs. 12.8% and 6.0% vs. 22.2%, respectively) as well as the incidence of ketoacidosis (2.1% vs. 8.1%) or ketosis (6.9% vs. 11.4%). The HbA1c decrease was significant overall and in the INT subgroup (adjusted difference -0.29%, P=0.009). The satisfaction rate was≥93.0% among children.

CONCLUSION

In a real-life setting, a 1-week RT-CGM can promote treatment optimization in youths with uncontrolled T1D resulting mostly in less acute events. CGM acceptance may improve with new-generation sensors.

10th Annual Symposium on Self-Monitoring of Blood Glucose, April 27-29, 2017, Warsaw, Poland

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.