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

Fear of hypoglycemia relates to glycemic levels during and after real-world physical activity in adolescents with type 1 diabetes

BACKGROUND

We explore the association between hypoglycaemia fear (FH) and glycaemia during and after exercise sessions in a large sample of physically active youth with type 1 diabetes (T1D).

METHODS

We used data from the Type 1 Diabetes Exercise Initiative Paediatric (T1DEXIP) Study. Youth self-reported on FH using the Hypoglycaemia Fear Survey-Child (HFS-C). They used a smart phone application to self-report food intake and insulin dosing (multiple daily injection only). We collected pump and continuous glucose monitoring data directly from the device.

RESULTS

Our sample included n = 251 youth (mean age: 14 ± 2 years, 55% closed loop pump; 42% women). Youth reporting higher HFS-C Total and Helplessness/Worry scores (HFS-C subscale) had slightly fewer competitive and fewer high intensity exercise events compared to youth with lower HFS-C Total and Helplessness/Worry scores. Youth reporting the highest Maintain High Blood Glucose scores (HFS-C subscale) had the lowest percent glucose time in range, higher mean glucose levels, and higher percent time above range during exercise. Youth reporting the highest Maintain High Blood Glucose scores also tended to have higher mean glucose levels post-exercise and a smaller drop in glucose during exercise.

CONCLUSION

FH relates to glycaemia during and after exercise in adolescents with T1D and may signal an inclination for some youth to engage in avoidance behaviours to reduce their vulnerability to exercise-induced hypoglycaemia.

Glucometrics and Patient-Reported Outcomes in Individuals With Type 1 Diabetes Mellitus: Insights From the Correlation of Time in Range (CorrelaTIR) Study in Real-World Settings

Background This study aimed to measure the association between time in range (TIR) and other continuous glucose monitoring (CGM)-derived glucometrics, quality of life (QoL), healthcare resource use (HCRU), and costs in persons with type 1 diabetes mellitus (T1DM) in routine clinical practice in Spain. Methods This observational, cross-sectional, multicentre study evaluated persons with T1DM who received insulin via multiple daily injections. The study collected data on the participants (demographic and clinical), the use of the CGM devices, patient-reported outcomes (PROs) for general and diabetes-related QoL, treatment satisfaction, work productivity and activity impairment, HCRU, and costs. Data were analysed descriptively. The Spearman correlation coefficient was used to measure the association between glucometrics and PROs, HCRU and costs. Results Participants (N=114) had a mean age (standard deviation) of 44.53 (14.39) years, were 50.88% men, and 53.51% had glycated haemoglobin ≤7%. A higher TIR was significantly associated with better diabetes-related QoL but not with general QoL. HCRU and PRO scores for treatment satisfaction and work productivity and activity impairment showed no correlation with TIR. Higher TIR correlated with a lower number of emergency room visits. Conclusion Good glycaemic control (high TIR) is favourably associated with some aspects of diabetes-related QoL.

Applying technologies to simplify strategies for exercise in type 1 diabetes

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

Barriers to Physical Activity in Children and Adults Living With Type 1 Diabetes: A Complex Link With Real-life Glycemic Excursions

OBJECTIVES

Ever since the first research on barriers to physical activity (PA) highlighting fear of hypoglycemia as a major barrier, many studies have attempted to understand their demographic and behavioural determinants. However, no research has been conducted on whether these perceived barriers toward PA are based on real-life-experienced adverse glycemic effects of exercise.

METHODS

Sixty-two adults and 53 children/adolescents living with type 1 diabetes, along with their parents, completed the Barriers to Physical Activity in Type 1 Diabetes-1 (BAPAD-1) questionnaire on barriers to PA. Continuous glucose-monitoring data were collected during 1 week of everyday life for 26 adults and 33 children/adolescents. Multiple linear regressions were used to explore links between BAPAD-1 scores and glycemic excursions experienced during and after everyday-life self-reported PA sessions, controlling for behavioural (accelerometry) and demographic confounders.

RESULTS

In children/adolescents, the more time spent in hypoglycemia on nights after PA sessions, the more they reported hypoglycemic risk as a barrier (ß=+0.365, p=0.034). Conversely, in adults, the higher the proportion of PA sessions accompanied by a drop in blood glucose, the less hypoglycemia was a barrier (ß=-0.046, p=0.004). In parents, BAPAD-1 scores were unrelated to children/adolescents' everyday-life exercise-induced hypo/hyperglycemia.

CONCLUSIONS

In children/adolescents, fear of hypoglycemia was predominant in those exposed to nocturnal hypoglycemia associated with PA sessions. In adults, fewer barriers may mean they accept a bigger drop in their glycemia during PA. This shows the importance of finding and promoting age-specific solutions to prevent exercise-induced hypoglycemia.

Association of BMAL1 clock gene polymorphisms with fasting glucose in children

BACKGROUND

The brain and muscle Arnt-like protein-1 (BMAL1) gene is an important circadian clock gene and previous studies have found that certain polymorphisms are associated with type 2 diabetes in adults. However, it remains unknown if such polymorphisms can affect fasting glucose in children and if other factors modify the associations.

METHODS

A school-based cross-sectional study with 947 Chinese children was conducted. A multivariable linear regression model was used to analyze the association between BMAL1 gene polymorphisms and fasting glucose level.

RESULTS

After adjusting for age, sex, body mass index (BMI), physical activity, and unhealthy diet, GG genotype carriers of BMAL1 rs3789327 had higher fasting glucose than AA/GA genotype carriers (b = 0.101, SE = 0.050, P = 0.045). Adjusting for the same confounders, rs3816358 was shown to be significantly associated with fasting glucose (b = 0.060, SE = 0.028, P = 0.032). Furthermore, a significant interaction between rs3789327 and nutritional status on fasting glucose was identified (P_interaction = 0.009); rs3789327 was associated with fasting glucose in the overweight/obese subgroup (b = 0.353, SE = 0.126, P = 0.006), but not in non-overweight/non-obese children.

CONCLUSIONS

BMAL1 polymorphisms were significantly associated with the fasting glucose level in children. Additionally, the observed interaction between nutritional status and BMAL1 supports promoting an optimal BMI in children genetically predisposed to higher glucose level.

IMPACT

Polymorphisms in the essential circadian clock gene BMAL1 were associated with fasting blood glucose levels in children. Additionally, there was a significant interaction between nutritional status and BMAL1 affecting fasting glucose levels. BMAL1 rs3789327 was associated with fasting glucose only in overweight/obese children. This finding could bring novel insights into mechanisms by which nutritional status influences fasting glucose in children.

Are nocturnal hypoglycemia prevention strategies influenced by diabetes technology usage? A BETTER registry analysis

AIM

To assess the association of nocturnal hypoglycemia prevention strategies (NH-PS) and diabetes technology usage (insulin pump and/or continuous glucose monitors [CGM]) in people with type 1 diabetes (PWT1D).

METHODS

Logistic regression models were used to describe associations between self-reported NH-PS and diabetes technology (pump with intermittently-scanned or real-time CGM (isCGM or rtCGM), or automated insulin delivery (AID)), hypoglycemia history, and fear of hypoglycemia (FOH).

RESULTS

Among 831 adults (65 % female, aged 44 ± 15 years, T1D duration 26 ± 15 years), 32 % reported HbA1c ≤ 7.0 %, 88 % used ≥ 1 diabetes technology, 66 % reported ≥ 1 symptomatic NH in the past month, and 64 % used ≥ 2 NH-PS. Compared to multiple daily injections (MDI) + capillary blood glucose (CBG), bedtime snack consumption was less likely among pump + isCGM (OR [95 %CI]: 0.55 [0.31, 0.98]), pump + rtCGM (0.40 [0.20, 0.81]), and AID (0.34 [0.17, 0.66]) users, while evening insulin basal reduction was associated with CSII + CBG (3.15 [1.25, 7.99]), pump + isCGM 4.00 [1.99, 8.01]), and pump + rtCGM 2.89 [1.28, 6.50] use. Elevated FOH was associated with snack consumption (1.37 [1.00, 1.89]), evening bolus insulin avoidance (1.77 [1.11, 2.83]), limiting exercise (2.50 [1.30, 4.82]), and limiting alcohol consumption (2.33 [1.15, 4.70]) as NH-PS.

CONCLUSION

Technology use and elevated FOH might influence PWT1D' choice of NH-PS.