Care of the Athlete With Type 1 Diabetes Mellitus: A Clinical Review

Which people with diabetes are treated with a disposable, half-unit insulin pen? A real-world, retrospective, database study in Spain

INTRODUCTION

Insulin lispro 100 units/mL Jr KwikPen is the first prefilled, disposable, half-unit insulin pen that delivers 0.5-30 units in increments of 0.5 units for the treatment of patients with diabetes. This study describes the profile of patients in Spain who initiated insulin therapy with Jr KwikPen in a real-world setting.

METHODS

This retrospective, observational study based on IQVIA's electronic medical records database included patients with Type 1 (T1D) or Type 2 (T2D) diabetes who initiated therapy with Jr KwikPen between May 2018 and December 2020. Sociodemographic, clinical, and treatment characteristics at treatment initiation were analysed descriptively.

RESULTS

A total of 416 patients were included. The main characteristics of the T1D/T2D groups (N = 326/90), respectively were as follows: female sex, 61.7%/65.6%; mean age (standard deviation [SD]), 32.5 (20.7)/55.5 (16.6) years; body mass index, 20.9 (4.2)/25.2 (4.6) kg/m2 (N = 239/77); HbA1c, 7.8 (1.7)%/8.0 (1.5)% (N = 141/64); and presence of diabetes-associated comorbidities, 27.9%/64.4%. Only 32.8% of patients with T1D were < 18 years old. Among Jr KwikPen users, 12.3% (T1D/T2D, 7.7%/28.9%) were ≥ 65 years old, 17.1% patients were newly diagnosed, and 3.8% were pregnant women. The mean (SD) total insulin dose pre-index for T1D/T2D was 43.1 (23.6) and 40.7 (21.6) UI/day, respectively. The mean (SD) insulin dose at the start of Jr KwikPen use was 26.63 (16.56) and 22.58 (13.59) UI/day for T1D/T2D, respectively. Jr KwikPen was first prescribed mainly by endocrinologists (58.7%) or paediatricians (22.6%).

CONCLUSIONS

The profile of patients who initiated therapy with Jr KwikPen in routine practice was broad with many patients being adults. Most of these patients had T1D, inadequate glycemic control, and multiple associated comorbidities. These results suggest that Jr KwikPen is prescribed in patients who may benefit from finer insulin dose adjustments, namely children, adolescents, adults, older individuals, or pregnant women with T1D or T2D.

Considerations in the Care of Athletes With Type 1 Diabetes Mellitus

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.

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.

Personalized Approach for the Management of Exercise-Related Glycemic Imbalances in Type 1 Diabetes: Comparison with Reference Method

BACKGROUND

One of the most frequently adopted strategies to counterbalance the risk of exercise-induced hypoglycemia in patients with type 1 diabetes is carbohydrates supplement. Nevertheless, the estimation of its amount is still challenging. We investigated the efficacy of the personalized Exercise Carbohydrate Requirement Estimation System (ECRES) method compared to a tabular approach to estimate the glucose supplement needed for the prevention of exercise-related glycemic imbalances.

METHOD

Twenty-six patients performed two one-hour constant intensity exercises one week apart; the amount of extra carbohydrates was estimated, in random order, by the personalized ECRES method or through the tabular approach; glycemia was determined every 30 minutes. Continuous glucose monitoring (CGM) metrics were calculated over the 48 hours preceding, and the afternoon and night following the trials.

RESULTS

Applying the personalized ECRES method, a significantly lower amount of carbohydrates was administered to the active patients compared to the tabular approach, median (interquartile range): 9.0 (0.5-21.0) g vs 23.0 (21.0-25.0) g; P < .01; the two methods were similar for the sedentary patients, 18 (13.5-36.0) g vs 23.0 (21.0-27.0) g; P = NS. After overlapping CGM metrics before the exercises, both methods avoided hypoglycemia and resulted in similar glucose levels throughout them. The ECRES method led to CGM metrics within the guidelines for either the afternoon and the night just following the trials, whereas the tabular approach resulted in a significantly greater time below range in the afternoon (11.8% ± 18.2%; P < .05) and time above range during the night (39.3% ± 29.8%; P < .05).

CONCLUSIONS

The results support the validity of the personalized ECRES method: although the estimated amounts of carbohydrates were lower, patients' glycemia was maintained within safe clinical limits.

Circulating cell free DNA response to exhaustive exercise in average trained men with type I diabetes mellitus

It is believed that neutrophils extracellular traps (NETs) formation is responsible for the increase in cf DNA after exercise. Since T1DM is accompanied by enhanced NETs generation, we compared exercise-induced increase in cf DNA in 14 men with T1DM and 11 healthy controls and analyzed its association with exercise load. Subjects performed a treadmill run to exhaustion at speed corresponding to 70% of their personal VO2max. Blood was collected before and just after exercise for determination of plasma cf nuclear and mitochondrial DNA (cf n-DNA, cf mt-DNA) by real-time PCR, blood cell count and metabolic markers. Exercise resulted in the increase in median cf n-DNA from 3.9 ng/mL to 21.0 ng/mL in T1DM group and from 3.3 ng/mL to 28.9 ng/mL in controls. Median exercise-induced increment (∆) in cf n-DNA did not differ significantly in both groups (17.8 ng/mL vs. 22.1 ng/mL, p = 0.23), but this variable correlated with run distance (r = 0.66), Δ neutrophils (r = 0.86), Δ creatinine (r = 0.65) and Δ creatine kinase (r = 0.77) only in controls. Pre- and post-exercise cf mt-DNA were not significantly different within and between groups. These suggest low usefulness of Δ cf n-DNA as a marker of exercise intensity in T1DM men.

Nutritional Therapy for Athletes with Diabetes

Diabetes is a worldwide disease also affecting the sports field. The two main forms of diabetes, namely type 1 diabetes (T1D) and type 2 diabetes (T2D), differ in both their pathological and pharmacological characteristics and thus require a distinct nutritional treatment. Diet plays an important role in the management of athletes with diabetes and is crucial to achieving their best performance. This review aims to investigate the objectives of nutritional therapy before, during and after training, in order to improve the best composition of macronutrients during meals. In this review, we provide a brief overview of recent studies about nutritional approaches to people with diabetes for performance optimization and for the control of diabetes-related complications. Thereafter, we discuss the differences between macronutrients and dietary intake before, during and after training. It can be concluded that each sport has particular characteristics in terms of endurance and power, hence demanding a specific energy expenditure and consequent nutritional adjustments. Therefore, the management of athletes with diabetes must be personalized and supported by medical professionals, including a diabetologist, physiologist and a nutritionist.

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.

MUSCLE MITOCHONDRIAL CAPACITY AND ENDURANCE IN ADULTS WITH TYPE 1 DIABETES

The impact of type 1 diabetes (T1D) on muscle endurance and oxidative capacity is currently unknown.

Purpose

Measure muscle endurance and oxidative capacity of adults with T1D compared to controls.

Methods

A cross-sectional study design with a control group was used. Subjects (19-37 years old) with T1D (n=17) and controls (n=17) were assessed with hemoglobin A1c (HbA1c) and casual glucose. Muscle endurance was measured with an accelerometer at stimulation frequencies of 2, 4, and 6 Hz for a total of nine minutes. Mitochondrial capacity was measured using near-infrared spectroscopy after exercise as the rate constant of the rate of recovery of oxygen consumption.

Results

T1D and control groups were similar in age, sex, height, and race. The T1D group had slightly higher BMI values and adipose tissue thickness over the forearm muscles. Casual glucose was 150±70 mg/dL for T1D and 98±16 mg/dL for controls (P=0.006). HbA1c of T1D subjects was 7.1±0.9% and 5.0±0.4% for controls (P<0.01). Endurance indexes at 2, 4, and 6 Hz were 94.5±5.2%, 81.8±8.4%, and 68.6±13.5% for T1D and 94.6±4.1%, 85.9±6.3%, and 68.7±15.4% for controls (p = 0.97, 0.12, 0.99, respectively). There were no differences between groups in mitochondrial capacity (T1D= 1.9±0.5 min^-1 and control=1.8±0.4 min^-1, P=0.29) or reperfusion rate (T1D= 8.8±2.8s and control=10.3±3.0s, P=0.88). There were no significant correlations between HbA1c and either muscle endurance, mitochondrial capacity or reperfusion rate.

Conclusions

Adults with T1D did not have reduced oxidative capacity, muscle endurance or muscle reperfusion rates compared to controls. HbA1c also did not correlate with muscle endurance, mitochondrial capacity or reperfusion rates. Future studies should extend these measurements to older people or people with poorly-controlled T1D.

Assessment of Safety and Glycemic Control During Football Tournament in Children and Adolescents With Type 1 Diabetes-Results of GoalDiab Study

PURPOSE

To assess glycemic control and safety of children and adolescents with type 1 diabetes participating in a 2-day football tournament.

METHODS

In total, 189 children with type 1 diabetes from 11 diabetes care centers, in Poland, participated in a football tournament in 3 age categories: 7-9 (21.2%), 10-13 (42.9%), and 14-17 (36%) years. Participants were qualified and organized in 23 football teams, played 4 to 6 matches of 30 minutes, and were supervised by a medical team. Data on insulin dose and glycemia were downloaded from personal pumps, glucose meters, continuous glucose monitoring, and flash glucose monitoring systems.

RESULTS

The median level of blood glucose before the matches was 6.78 (4.89-9.39) mmol/L, and after the matches, it was 7.39 (5.5-9.87) mmol/L (P = .001). There were no episodes of severe hypoglycemia or ketoacidosis. The number of episodes of low glucose value (blood glucose ≤3.9 mmol/L) was higher during the tournament versus 30 days before: 1.2 (0-1.5) versus 0.7 (0.3-1.1) event/person/day, P < .001. Lactate levels increased during the matches (2.2 [1.6-4.0] mmol/L to 4.4 [2.6-8.5] mmol/L after the matches, P < .001).

CONCLUSIONS

Large football tournaments can be organized safely for children with type 1 diabetes. For the majority of children, moderate mixed aerobic-anaerobic effort did not adversely affect glycemic results and metabolic safety.

Common Prescription Medications Used in Athletes

Athletes of various skill levels commonly use many different types of medications, often at rates higher than the general population. Common medication classes used in athletes include analgesics such as nonsteroidal anti-inflammatory drugs and acetaminophen, inhalers for asthma and exercise-induced bronchoconstriction, antihypertensives, antibiotics, and insulin. Prescribers must be aware of the unique considerations for each of these medications when using them in patients participating in physical activity. The safety, efficacy, impact on athletic performance, and regulatory restrictions of the most common medications used in athletes are discussed in this article.

Patient Perspectives on Managing Type 1 Diabetes During High-Performance Exercise: What Resources Do They Want?

OBJECTIVE

Athletes with type 1 diabetes face unique challenges that make it difficult for health care providers to offer concise recommendations for diabetes management. Moreover, little is known about patient preferences for diabetes management during high-level and competitive exercise. We undertook a qualitative study to understand patient perspectives on managing type 1 diabetes during exercise.

METHODS

A qualitative design using focus groups was selected. Samples of 5-10 participants per group were recruited to participate in one of three 1.5-hour sessions focusing on experiences in managing diabetes, supports, and desired resources. Sessions were audiotaped and transcribed verbatim. Data were analyzed iteratively among team members.

RESULTS

The study included 21 participants (10 male and 11 female) with a mean age of 41 years. Most participants used trial and error to manage their blood glucose around exercise. Frequent monitoring of blood glucose was a common strategy and a challenge during exercise. Hypoglycemia after exercise and adrenaline-fueled hyperglycemia during exercise were the most prevalent concerns. Most participants relied on themselves, an endocrinologist, or the Internet for support but said they would prefer to rely more on peers with type 1 diabetes and mobile apps. Peer support or mentorship was strongly supported with recommendations for moving forward.

CONCLUSION

This study highlights the individualized nature of balancing glycemic control in athletes and athletes' heavy self-reliance to develop strategies. Expanding the availability of resources such as peer mentoring and mobile apps could potentially support athletes with type 1 diabetes.

Safe Completion of a Trail Running Ultramarathon by Four Men with Type 1 Diabetes

In this brief report, we describe the feat of four men with type 1 diabetes mellitus (T1DM) who decided to take part in a mountain ultramarathon in Bieszczady, Poland on May 27, 2016. Before participating in the competition, they asked two diabetologists for a consultation and to assist in diabetic control during the marathon. The aim of the study was to assess the metabolic safety in people with T1DM during extreme physical exertion in a mountain ultramarathon. All subjects were treated with continuous subcutaneous insulin infusion. The marathon route was 82 km, and the sum of the climbs and descents was 3235 and 3055 m, respectively. Diabetologists controlled glucose levels using a glucometer, plasma lactate levels, and ketones in the capillary blood. In addition, they monitored the intake of carbohydrates and fluids. Clinical tests were performed at the three checkpoints (at 32, 49, and 66 km) during the race and after completing the race (at 82 km). This study shows that extreme physical exertion by a person with type 1 diabetes is possible. All subjects avoided severe hypoglycemia by significantly reducing their insulin dose and consuming additional carbohydrates. Such actions, despite the occurrence of hyperglycemia >250 mg/dL did not result in ketoacidosis. Safe participation in mountain ultramarathons by people with type 1 diabetes can be achieved if they undertake appropriate physical and diabetologic preparation.

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Zusammenfassung. Wir berichten über einen 64-jährigen Marathonläufer mit bisher 990 erfolgreich gefinishten Marathons, der fälschlicherweise mit Diabetes mellitus Typ 2 diagnostiziert und therapiert wurde. Unter peroraler Therapie mit Metformin kam es zu keiner Reduktion der Blutzuckerwerte. Nach korrekter Diagnose und Therapie mit Insulin ist der Läufer wieder voll im Training, um bald seinen 1000. Marathon zu laufen. Für Sportler mit Diabetes mellitus Typ 1 ist es wichtig, den Blutzucker vor, während und nach Belastung zu messen und die Insulindosis individuell während eines Wettkampfs, wie etwa einem Marathon, zu reduzieren.

Why should people with type 1 diabetes exercise regularly?

Plethoric evidence reminds of the protective effects of exercise against a number of health risks, across all ages, in the general population. The benefits of exercise for individuals with type 2 diabetes are indisputable. An in-depth understanding of energy metabolism has reasonably entailed exercise as a cornerstone in the lifestyle of almost all subjects with type 1 diabetes. Nevertheless, individuals with type 1 diabetes often fail in accomplishing exercise guidelines and they are less active than their peer without diabetes. Two major obstacles are feared by people with type 1 diabetes who wish to exercise regularly: management of blood glucose control and hypoglycemia. Nowadays, strategies, including glucose monitoring technology and insulin pump therapy, have significantly contributed to the participation in regular physical activity, and even in competitive sports, for people with type 1 diabetes. Novel modalities of training, like different intensity, interspersed exercise, are as well promising. The beneficial potential of exercise in type 1 diabetes is multi-faceted, and it has to be fully exploited because it goes beyond the insulin-mimetic action, possibly through immunomodulation.

Management of diabetes mellitus in children and adolescents: engaging in physical activity

Regular physical activity is an important component in the management of both type 1 and type 2 diabetes mellitus (T1DM and T2DM), as it has the potential to improve glycemic control, delay cardiovascular complications, and increase overall well-being. Unfortunately, many children and adolescents with diabetes do not partake in regular exercise and physical activity for multiple reasons. This review identifies the barriers to participation from the aspect of the patient, caregiver, and the healthcare provider. The management of physical activity of children and adolescents with diabetes mellitus is unique and requires an understanding of exercise physiology and how it differs in these children and adolescents from those without the condition. These individuals are at risk for important and potentially life threatening complications including, but not limited to, severe or delayed nocturnal hypoglycemia. It is essential to identify these risks as well as, monitor and manage adjustments to carbohydrate intake and insulin dosing through basal-bolus regimen or insulin pump adjustments appropriately before, during, and after the exercise activity. This review discusses these issues and also outlines differences in management between patients with T1DM and T2DM.

Striving for control: lessons learned from a successful international Type 1 Diabetes Youth Challenge

AIMS

To demonstrate whether young people with T1D using modern insulin treatment and CGM could successfully participate in extreme sport activity while maintaining good glycemic control.

METHODS

The challenge took place in Crete/Greece over 4 days combining a long-distance trek of different levels of severity with final destination the summit of the White Mountains at 2080 m. Eleven participants (5/6 female/male, age 18.2 ± 1.3 years, T1D duration 7.9 ± 3.5 years, HbA1c 7.3 ± .7% (56 ± 16 mmol/mol); mean ± SD) from 11 SWEET centers in Belgium, Brazil, Canada, Germany, Greece, France, India, Italy, Portugal, Slovenia and Sweden participated to the challenge. Five participants were on CSII, six on MDI; all were wearing a continuous glucose monitoring system. The glycemic targets during trekking were defined as 80-180 mg/dl (4.4-10 mmol/l).

RESULTS

All participants completed the challenge. In total, the group walked 54.5 km under varying climate conditions (temperature 14-35 °C). During the challenge, insulin requirements decreased significantly compared to baseline: total daily insulin by 31.1 ± 16.7% (p < .001), basal by 30.8 ± 14.9% (p < .001), and prandial by 32.5 ± 28.0% (p = .023), with no differences between participants with CSII or MDI. No episode of severe hypoglycemia or DKA occurred. Mean glucose levels were 170.7 ± 60.1 mg/dl with 61.5 ± 18.7% of CGM values in the target range, 5.4 ± 5.4% under 80 mg/dl and 32.8 ± 16.6% above 180 mg/dl.

CONCLUSIONS

The results of this SWEET Initiative activity demonstrated that well-educated adolescents and young adults with T1D using modern insulin treatments are able to perform successfully even extraordinary physical challenges while maintaining good glycemic control without diabetes-related acute complications.