Exercise modes and their association with hypoglycemia episodes in adults with type 1 diabetes mellitus: a systematic review

The Effects of Resistance Exercise Training on Skeletal Muscle Metabolism and Insulin Resistance Development in Female Rodents with Type 1 Diabetes

The etiology of insulin resistance (IR) development in type 1 diabetes mellitus (T1DM) remains unclear; however, impaired skeletal muscle metabolism may play a role. While IR development has been established in male T1DM rodents, female rodents have yet to be examined in this context. Resistance exercise training (RT) has been shown to improve IR and is associated with a lower risk of hypoglycemia onset in T1DM compared to aerobic exercise. The purpose of this study was to investigate the effects of RT on IR development in female T1DM rodents. Forty Sprague Dawley eight-week-old female rats were divided into four groups: control sedentary (CS; n = 10), control trained (CT; n = 10), T1DM sedentary (DS; n = 10), and T1DM trained (DT; n = 10). Multiple low-dose streptozotocin injections were used to induce T1DM. Blood glucose levels were maintained in the 4-9 mmol/l range with intensive insulin therapy. CT and DT underwent weighted ladder climbing 5 days/week for six weeks. Intravenous glucose tolerance tests (IVGTT) were conducted on all animals following the six-week period. Results demonstrate that DS animals exhibited significantly increased weekly blood glucose measures compared to all groups including DT (p < 0.0001), despite similar insulin dosage levels. This was concomitant with a significant increase in insulin-adjusted area under the curve following IVGTT in DS (p < 0.05), indicative of a reduction in insulin sensitivity. Both DT and DS exhibited greater serum insulin concentrations compared to CT and CS (p < 0.05). DS animals also exhibited significantly greater glycogen content in white gastrocnemius muscle compared to CS and DT (p < 0.05), whereas DT and DS animals exhibited greater p-Akt: Akt ratio in the white vastus lateralis muscle and citrate synthase activity in the red vastus lateralis muscle compared to CS and CT (p < 0.05). These results indicate that female rodents with T1DM develop poor glycemic control and IR which can be attenuated with RT, possibly related to differences in intramyocellular glycogen content.

Post-Exercise Protein Intake May Reduce Time in Hypoglycemia Following Moderate-Intensity Continuous Exercise among Adults with Type 1 Diabetes

Little is known about the role of post-exercise protein intake on post-exercise glycemia. Secondary analyses were conducted to evaluate the role of post-exercise protein intake on post-exercise glycemia using data from an exercise pilot study. Adults with T1D (n = 11), with an average age of 33.0 ± 11.4 years and BMI of 25.1 ± 3.4, participated in isoenergetic sessions of high-intensity interval training (HIIT) or moderate-intensity continuous training (MICT). Participants completed food records on the days of exercise and provided continuous glucose monitoring data throughout the study, from which time in range (TIR, 70-180 mg/dL), time above range (TAR, >180 mg/dL), and time below range (TBR, <70 mg/dL) were calculated from exercise cessation until the following morning. Mixed effects regression models, adjusted for carbohydrate intake, diabetes duration, and lean mass, assessed the relationship between post-exercise protein intake on TIR, TAR, and TBR following exercise. No association was observed between protein intake and TIR, TAR, or TBR (p-values ≥ 0.07); however, a borderline significant reduction of -1.9% (95% CI: -3.9%, 0.0%; p = 0.05) TBR per 20 g protein was observed following MICT in analyses stratified by exercise mode. Increasing post-exercise protein intake may be a promising strategy to mitigate the risk of hypoglycemia following MICT.

The Effect of High-Intensity Interval Exercise on Short-Term Glycaemic Control, Serum Level of Key Mediator in Hypoxia and Pro-Inflammatory Cytokines in Patients with Type 1 Diabetes-An Exploratory Case Study

Type 1 diabetes (T1D) is associated with hyperglycaemia-induced hypoxia and inflammation. This study assessed the effects of a single bout of high-intensity interval exercise (HIIE) on glycaemia (BG) and serum level of pro-inflammatory cytokines, and an essential mediator of adaptive response to hypoxia in T1D patients. The macronutrient intake was also evaluated. Nine patients suffering from T1D for about 12 years and nine healthy individuals (CG) were enrolled and completed one session of HIIE at the intensity of 120% lactate threshold with a duration of 4 × 5 min intermittent with 5 min rests after each bout of exercise. Capillary and venous blood were withdrawn at rest, immediately after and at 24 h post-HIIE for analysis of BG, hypoxia-inducible factor alpha (HIF-1α), tumour necrosis factor alpha (TNF-α) and vascular-endothelial growth factor (VEGF). Pre-exercise BG was significantly higher in the T1D patients compared to the CG (p = 0.043). HIIE led to a significant decline in T1D patients' BG (p = 0.027) and a tendency for a lower BG at 24 h post-HIIE vs. pre-HIIE. HIF-1α was significantly elevated in the T1D patients compared to CG and there was a trend for HIF-1α to decline, and for VEGF and TNF-α to increase in response to HIIE in the T1D group. Both groups consumed more and less than the recommended amounts of protein and fat, respectively. In the T1D group, a tendency for a higher digestible carbohydrate intake and more frequent hyperglycaemic episodes on the day after HIIE were observed. HIIE was effective in reducing T1D patients' glycaemia and improving short-term glycaemic control. HIIE has the potential to improve adaptive response to hypoxia by elevating the serum level of VEGF. Patients' diet and level of physical activity should be screened on a regular basis, and they should be educated on the glycaemic effects of digestible carbohydrates.

Where to Start? Physical Assessment, Readiness, and Exercise Recommendations for People With Type 1 or Type 2 Diabetes

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.

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

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

EXercise to Prevent frailty and Loss Of independence in insulin treated older people with DiabetEs (EXPLODE): protocol for a feasibility randomised controlled trial (RCT)

INTRODUCTION

There are 3.9 million people in the UK with diabetes. Sarcopenia, increased frailty and loss of independence are often unappreciated complications of diabetes. Resistance exercise shows promise in reducing these complications in older adult diabetes patients. The aim of this feasibility randomised controlled trial is to (1) characterise the physical function, cardiovascular health and the health and well-being of older adults with mild frailty with/without diabetes treated with insulin, (2) to understand the feasibility and acceptability of a 4-week resistance exercise training programme in improving these parameters for those with diabetes and (3) to test the feasibility of recruiting and randomising the diabetic participant group to a trial of resistance training.

METHODS AND ANALYSIS

Thirty adults aged ≥60 years with insulin-treated diabetes mellitus (type 1 or 2), and 30 without, all with mild frailty (3-4 on the Rockwood Frailty Scale) will be recruited. All will complete blood, cardiovascular and physical function testing. Only the diabetic group will then proceed into the trial itself. They will be randomised 1:1 to a 4-week semisupervised resistance training programme, designed to increase muscle mass and strength, or to usual care, defined as their regular physical activity, for 4 weeks. This group will then repeat testing. Primary outcomes include recruitment rate, attrition rate, intervention fidelity and acceptability, and adherence to the training programme. A subset of participants will be interviewed before and after the training programme to understand experiences of resistance training, impact on health and living with diabetes (where relevant) as they have aged. Analyses will include descriptive statistics and qualitative thematic analysis.

ETHICS AND DISSEMINATION

The North East-Newcastle and North Tyneside 2 Research Ethics Committee (20/NE/0178) approved the study. Outputs will include feasibility data to support funding applications for a future definitive trial, conference and patient and public involvement presentations, and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ISRCTN13193281.

Iranian National Clinical Practice Guideline for Exercise in Patients with Diabetes

CONTEXT

Growing evidence highlights the importance of physical activity as a critical element for the prevention and control of diabetes. However, there is no clinical practice guideline focusing on the different aspects of exercise in patients with diabetes, especially for the Iranian population.

OBJECTIVE

We aimed to prepare and adopt a clinical practice guideline to provide well-defined, simple, and concise responses to certain questions related to physical activity and exercise in all patients with diabetes, including type 1, 2, and gestational diabetes mellitus (GDM).

EVIDENCE ACQUISITION

A multidisciplinary team of experts in various fields (sports medicine specialists, endocrinologists, and cardiologists) developed the guideline. This group did the task in four stages: (1) identifying and refining the subject area using 17 clinical questions; (2) appraising evidence through a systematic review of the literature; (3) extracting recommendations from evidence and grading them as A, B, C, or D based on the quality, quantity, and consistency of existing evidence; and (4) subjecting the guideline to external review and finally selecting the recommendations with high scores of appropriateness and agreement. The final version was evaluated and approved by the National Deputy for Curative Affairs - Ministry of Health and Medical Education and has also been endorsed by the Iran Endocrine Society (IES) and Iranian Association of Sports and Exercise Medicine (IASEM).

RESULTS

The guideline consists of 52 recommendations addressing 17 important questions concerning different aspects of exercise prescription in Iranian patients with diabetes.

CONCLUSIONS

The guideline provides evidence-based information that may help physicians to prescribe exercise for Iranian patients with diabetes safely and effectively.

Comparing Two Treatment Approaches for Patients with Type 1 Diabetes During Aerobic Exercise: a Randomised, Crossover Study

BACKGROUND

In a randomised, counterbalanced, crossover design, eight men with type 1 diabetes (T1D; mean ± SD age, 27.6 ± 11.4 years) reduced insulin (INS) by 50% of their normal dose or consumed carbohydrates equivalent to 1 g of carbohydrate per kilogramme of their body weight without the usual insulin bolus (CARBS) over two sessions, held a week apart. Each session included standardised meals, a 45-min treadmill walk at 7.24 km h-1 and a 6-min walk test (6MWT). Rate of perceived exertion (RPE), blood glucose, ketone and lactate measures were taken before, during and immediately after the aerobic exercise. The distance covered in metres and the predicted VO2 max (mL kg-1 min-1) were also calculated for the 6MWT.

RESULTS

Participants completing the INS intervention spent more time in normoglycaemia (242 ± 135 min vs 88 ± 132 min; P < 0.01) and less time in hyperglycaemia (41 ± 95 min vs 154 ± 125 min; P = 0.01) as compared to the CARBS intervention. Mild hypoglycaemia occurred in two participants during INS and no participants during CARBS. Furthermore, there was no significant difference for blood lactate, ketone, RPE, distance covered and predicted VO2 max between interventions.

CONCLUSION

Based on this pilot study, INS intervention appears to be the best approach for maintaining blood glucose levels in those with T1D during aerobic exercise, though this does need evaluation in other groups, including women, children and those with suboptimal glycaemic control.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry, ACTRN12619001397101p . Registered 09 September 2019.

An Effective Model of Diabetes Care and Education: The ADCES7 Self-Care Behaviors™

PURPOSE

The ADCES7 Self-Care Behaviors^™ (ADCES7) is a robust framework for self-management of diabetes and other related conditions, such as prediabetes and cardiometabolic diseases. It is the position of the Association of Diabetes Care and Education Specialists (ADCES) that at the cornerstone of diabetes self-management education and support, the ADCES7 is the framework for achieving behavior change that leads to effective self-management through improved behavior and clinical outcome measures. The ADCES7 model guides the health care team in effective person-centered collaboration and goal setting to achieve health-related outcomes and improved quality of life. Continued research and evidence are critical to expand this model and broaden its application to other chronic conditions. Given the advances in the science of diabetes management as well as diabetes self-management education and support, ADCES has evaluated the ADCES7 within the framework of these advances, including the digital and dynamic health care landscape.

CONCLUSION

This revised position statement blends the updates in research and ADCES's vision and expansion beyond diabetes to refresh the ADCES7 framework. This revision reflects the perspectives of all members of the health care team as they problem solve with individuals who are at risk for or who have diabetes and related conditions to achieve healthier outcomes.

Continuous Blood Glucose Monitoring Increases Vigorous Physical Activity Levels and Is Associated With Reduced Hypoglycemia Avoidance Behavior In Youth With Type 1 Diabetes

The primary goal of this study was to explore physical activity (PA) levels, hypoglycemia fear scores and hypoglycemia episodes according to insulin administration and blood glucose monitoring methods in youth with type 1 diabetes (T1D). A self-administered questionnaire was completed by 28 children and 33 adolescents with T1D, and their PA was assessed. Hypoglycemia episodes, fear of hypoglycemia scores, insulin therapy (pump vs. injection) and blood glucose monitoring (continuous blood glucose monitors [CGMs] vs. blood glucose meters) methods are reported in the present work. There were no significant differences in the number of hypoglycemic episodes, child hypoglycemia fear survey behavior or total scores, or any components of the PA profile between youth using injections and those using a pump. However, these variables differed significantly when compared according to blood glucose monitoring method (CGMs vs. blood glucose meters): 41.2 vs. 81.8, p<0.01; 1.03 ± 0.05 vs. 2.6 ± 0.63, p<0.01; 1.09 ± 0.43 vs. 2.94 ± 0.22, p<0.01; and 222 ± 18 vs. 49 ± 11, p<0.01 (for total time in vigorous PA in minutes per week), respectively. CGM use correlated significantly with VPA levels (β=0.6; p=0.04). Higher VPA levels were associated with higher child hypoglycemia fear survey behavior scores (β=0.52; p=0.04). The latter correlates negatively with the number of episodes of hypoglycemia in the past 12 months in all category groups. The type of insulin injection was not associated with more activity in youth with T1D. In contrast, CGM use may be associated with increased vigorous PA among T1D youth. Those with higher hypoglycemia fear survey behavior scores engaged in more VPA and had fewer hypoglycemia episodes. Although CGM use ensures continuous monitoring of glycemia during exercise, increasing hypoglycemia avoidance behavior is still a necessary part of exercise management strategies in active youth with T1D.

Time spent in hypoglycemia is comparable when the same amount of exercise is performed 5 or 2 days weekly: a randomized crossover study in people with type 1 diabetes

INTRODUCTION

People with type 1 diabetes are recommended to exercise regularly. However, limited evidence exists on how frequency and duration of exercise affect the risk of hypoglycemia. The study aimed to compare the percentage of time spent in hypoglycemia between two 5-day periods with different frequency and duration of physical activity.

RESEARCH DESIGN AND METHODS

In this outpatient randomized crossover study, 26 participants aged 18-65 years with type 1 diabetes for ≥2 years and insulin pump use for ≥1 year were included. After a 7-day observation period, participants completed two 5-day intervention periods separated by a washout period of at least 14 days. One period included five exercise sessions on 5 consecutive days (5S), each consisting of 4 min of resistance training and 30 min of aerobic exercise. Another period included two exercise sessions on 2 days with at least 2 days in between (2S), each consisting of 10 min of resistance training and 75 min of aerobic exercise. During each period, participants performed in total 150 min of aerobic exercise and 20 min of resistance training and wore continuous glucose monitors (Dexcom G6) and accelerometers (ActiGraph wGT3X-BT).

RESULTS

Twenty insulin pump-treated adults (10 women) with type 1 diabetes completed the study. The baseline median (range) age was 48 (24-64) years, glycated hemoglobin 55 (44-66) mmol/mol, diabetes duration 24 (8-57) years, and body mass index 28.4 (22.3-35.8) kg/m². No differences were observed between 5S and 2S in the percentage (mean±SD) of time spent below 3.9 mmol/L (3.5%±2.8% vs 4.5%±4.2%, p=0.28), time spent in 3.9-10.0 mmol/L (65.3%±15.0% vs 68.5%±13.6%, p=0.31), time spent above 10.0 mmol/L (31.2%±16.4% vs 27.3%±14.5%, p=0.15), mean glucose (8.7±1.3 mmol/L vs 8.5±1.2 mmol/L, p=0.33) and glycemic variability (35.8%±5.3% vs 35.8%±6.6%, p=0.97).

CONCLUSIONS

Time spent in hypoglycemia was comparable between the two 5-day periods with different duration and frequency of physical activity.

TRIAL REGISTRATION NUMBER

NCT04089462.

Diabetes mellitus and the risk of ovarian cancer: a systematic review and meta-analysis of cohort and case-control studies

OBJECTIVE

Emerging evidence from observational studies (cohort and case-control studies) suggests that a history of diabetes mellitus (DM) has been linked to increased risk of ovarian cancer (OC), but the association between them remains inconclusive. The aim of this systematic review and meta-analysis of observational studies was to clarify this association.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched PubMed, Embase and the Cochrane library databases published from the inception through 9 April 2020 without language restriction. Observational studies that evaluated the correlation between DM and the incidence of OC were included in our study. Relative risk (RR) with 95% CI was pooled by use of a random-effects model.

RESULTS

A total of 36 epidemiological articles, including 9 case-control and 27 cohort studies, were finally enrolled, consisting of 14 496 incident cases of OC. Synthesised RRs of developing OC by history of DM were 1.20 (95% CI=1.10 to 1.31) for all eligible studies, 1.08 (95% CI=0.77 to 1.53) for case-control studies and 1.22 (95% CI=1.11 to 1.33) for cohort studies. The above-mentioned positive association persisted across most of subgroup analyses, whereas it was not significant among studies from North American and European countries, level of unadjusted, and patients with low-quality and gestational DM group. The cumulative meta-analysis and sensitivity analysis showed pooled effect was stable and reliable, and no apparent publication bias was identified in this study.

CONCLUSIONS

Our study found weaker but still association between DM and OC risk. However, further well-designed prospective studies that control for potential confounders are warranted.

Vigorous Physical Activity Is Associated With Better Glycated Hemoglobin and Lower Fear of Hypoglycemia Scores in Youth With Type 1 Diabetes: A 2-Year Follow-Up Study

To correlate glycated hemoglobin (HbA1c) and fear of hypoglycemia scores with physical activity (PA) levels in children and adolescents with type 1 diabetes (T1D) over a period of 2 years. Twenty-eight children and 33 adolescents with T1D have been assessed for their PA profile. Personal and medical data for the patients were collected at baseline (visit 0: V0), 1 year later (V1), and 2 years later (V2). At baseline, children with T1D engaged in less moderate to vigorous PA (MVPA) (p < 0.01) per day than adolescents. These results did not differ across visits. On the contrary, adolescents spent fewer time in vigorous physical activity (VPA) (p < 0.01) than children did (p < 0.01). Fear of hypoglycemia scores correlated significantly with VPA levels (β = −0.41, p = 0.03; β = −0.44, p = 0.06; β = −0.61, p = 0.001). For HbA1c (%), significant correlations were reported with VPA levels (β = −0.54, p = 0.02; β = −0.47, p = 0.03; β = −0.62, p = 0.01) across visits. Body mass index percentile correlated with total screen time (β = 0.28, p = 0.02; β = 0.29, p = 0.01; β = 0.31, p = 0.04) and overall PA levels (β = −0.52, p = 0.02; β = −0.42, p = 0.03; β = −0.42, p = 0.01). Performing more vigorous PA a day is associated with better HbA1c with lower perceived fear of hypoglycemia among youth with T1D. Therefore, dedicating more time in VPA may be an appropriate advice for patients with T1D.

Recovery of Diabetic Rats After Physical Exhaustion: Kinetic Alterations in Muscle Inflammation and Muscle-Signaling Proteins to Atrophy and Hypertrophy

The complexity of the adaptive response of diabetics to intense exercise is still poorly understood. To optimize exercise interventions in diabetics, the chronology of inflammatory mediators in muscle and the signaling involved in muscle hypertrophy/atrophy must be understood. Herein, we studied the kinetic inflammatory profile and cellular signaling pathways modulated by physical exhaustion after the induction of type 1 diabetes by streptozotocin in rats. Soleus muscle samples were obtained from diabetic and control groups at the following moments: baseline (no exercise); immediately after exhaustive exercise; and at 2 h, 24 h, 48 h, and 72 h after a treadmill exhaustive exercise. Kinetic production of cytokines and kinetic activation of proteins related to muscle synthesis (p70S6K and Akt) and degradation (GSK3, MuRF1, and MAFbx) were measured in the soleus muscle. We observed that the muscle TNF-α (0.9-fold; p = 0.0007), IL-1β (0.8-fold; p = 0.01), IL-6 (0.8-fold; p = 0.0013), L-selectin (1.0-fold; p = 0.0019), and CINC-2α/β (0.9-fold; p = 0.04) levels were higher in almost all stages of the study in the diabetic animals compared with the control group. Our data showed that exhaustive exercise decreased MAFbx expression in diabetic animals compared to the control group in a time-dependent manner. The decreased activation ratios of MAFbx were followed by a decrease in TNF-α, IL-1β, and IL-6 levels. p70S6k phosphorylation was also decreased in the diabetic group compared to the control group after physical exhaustion. Regarding the activation of proteins related to muscle synthesis and degradation, we found that the alterations induced by exhaustive exercise in the diabetic rats might involve pathways related to synthesis and muscle breakdown. Moreover, after an exhaustive exercise session, the recovery of the inflammatory response in the diabetic animals was slower than that in the control rats while the return of inflammatory cytokines to baseline levels was more effective in the diabetic animals.

Carbohydrate Requirement for Exercise in Type 1 Diabetes: Effects of Insulin Concentration

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.

Four weeks of high-intensity interval training (HIIT) improve the cardiometabolic risk profile of overweight patients with type 1 diabetes mellitus (T1DM)

This study investigated the effects of a four-week HIIT intervention on the cardiometabolic risk profile, liver fat content, insulin requirement, hypoglycaemia, physical fitness, and health-related quality of life in patients with T1DM. A supervised exercise intervention with baseline to follow-up comparison between overweight (BMI = 28.6 ± 2.1 kg/m²) and normal weight (BMI = 23.2 ± 1.40 kg/m²) T1DM patients was performed. Eleven overweight (age = 40.7 ± 14.3 years) and 11 normal weight (age = 42.2 ± 15.5 years) T1DM patients performed a four-week, low-volume, all-out cycling HIIT (4-6 bouts, work/relief ratio 1:1) twice weekly. HIIT lowered low-density lipoprotein and uric acid levels in overweight patients by up to 10.5% (vs. normal weight, p≤0.0312). HbA1c, high-density lipoprotein, and triglyceride levels did not change in any of the groups. Participants' maximal exercise capacity and power output at individual anaerobic lactate threshold increased to an equal extend of up to 10% (p≤0.0002) in both groups. During the intervention, participants used fewer daily bolus insulin (-5.22 ± 12.80%) and less total units of insulin (-4.42 ± 10.20%, p≤0.023) compared to the pre-intervention period with no between-group difference. Overall, the average daily number of hypoglycaemias increased from 0.90 ± 0.56-1.08 ± 0.63 during the intervention (p = 0.033). SF-36 subscales showed higher scores after the intervention, with a significant improvement of "role limitations due to physical problems" (p<0.05) for both groups. We conclude that in T1DM, HIIT may exert beneficial effects on physical fitness, insulin requirement and health-related quality of life. Of note, beneficial HIIT effects on the cardiometabolic risk profile in T1DM may be larger in overweight T1DM patients.

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

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.

An Effective Model of Diabetes Care and Education: Revising the AADE7 Self-Care Behaviors®

PURPOSE

The AADE7 Self-Care Behaviors^® (AADE7) is a robust framework for self-management of diabetes and other related conditions, such as prediabetes and cardiometabolic diseases. It is the position of the American Association of Diabetes Educators (AADE) that, at the cornerstone of diabetes self-management education and support, the AADE7 is the framework for achieving behavior change that leads to effective self-management through improved behavior and clinical outcome measures. The AADE7 model guides the health care team in effective person-centered collaboration and goal setting to achieve health-related outcomes and improved quality of life. Continued research and evidence are critical to expand this model and broaden its application to other chronic conditions. Given the advances in the science of diabetes management, as well as in diabetes self-management education and support, AADE has evaluated the AADE7 within the framework of these advances, including the digital and dynamic health care landscape.

CONCLUSION

This revised position statement blends the updates in research and AADE's vision and expansion beyond diabetes to refresh the AADE7 framework. This revision reflects the perspectives of all members of the health care team as they problem solve with individuals who are at risk for or who have diabetes and related conditions to achieve healthier outcomes.