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Davis EA, Shetty VB, Teo SY, Lim RJ, Patton SR, Taplin CE. Physical Activity Management for Youth With Type 1 Diabetes: Supporting Active and Inactive Children. Diabetes Spectr 2023; 36:137-145. [PMID: 37193201 PMCID: PMC10182969 DOI: 10.2337/dsi22-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Regular physical activity and exercise are important for youth and essential components of a healthy lifestyle. For youth with type 1 diabetes, regular physical activity can promote cardiovascular fitness, bone health, insulin sensitivity, and glucose management. However, the number of youth with type 1 diabetes who regularly meet minimum physical activity guidelines is low, and many encounter barriers to regular physical activity. Additionally, some health care professionals (HCPs) may be unsure how to approach the topic of exercise with youth and families in a busy clinic setting. This article provides an overview of current physical activity research in youth with type 1 diabetes, a basic description of exercise physiology in type 1 diabetes, and practical strategies for HCPs to conduct effective and individualized exercise consultations for youth with type 1 diabetes.
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Affiliation(s)
- Elizabeth A. Davis
- Department of Endocrinology and Diabetes, Perth Children’s Hospital, Perth, Western Australia, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Centre for Child Health Research, University of Western Australia, Perth, Western Australia, Australia
| | - Vinutha B. Shetty
- Department of Endocrinology and Diabetes, Perth Children’s Hospital, Perth, Western Australia, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Centre for Child Health Research, University of Western Australia, Perth, Western Australia, Australia
| | - Shaun Y.M. Teo
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Rachel J. Lim
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | | | - Craig E. Taplin
- Department of Endocrinology and Diabetes, Perth Children’s Hospital, Perth, Western Australia, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Centre for Child Health Research, University of Western Australia, Perth, Western Australia, Australia
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Soon WHK, Fournier PA, Abraham MB, Smith GJ, Paramalingam N, Shetty VB, Guelfi KJ, Jones TW, Davis EA. Reproducibility of plasma glucose responses to moderate-intensity exercise in individuals with type 1 diabetes. Diabet Med 2023; 40:e15000. [PMID: 36336990 DOI: 10.1111/dme.15000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/11/2022] [Indexed: 11/09/2022]
Abstract
AIM To examine the within-person variability in plasma glucose responses to moderate-intensity morning exercise in young individuals with type 1 diabetes after overnight fasting and under basal insulin conditions. METHODS In this pilot study, eight participants completed 40 min of moderate-intensity exercise at 60% V̇O2 peak on three separate days. The within-person standard deviation (SDw) in plasma glucose response was analysed both during and 1 h after exercise using the two visits per participant most closely matched by pre-exercise plasma glucose level. RESULTS When the two closest matched visits per individual were included for analysis, mean (±SD) change in plasma glucose level was -1.8 ± 1.1 mmoL/L during exercise and -0.6 ± 1.0 mmoL/L during recovery, with the SDw of these changes being 0.5 mmol (95% CI 0.2, 0.8) during exercise and 0.8 mmoL/L (95% CI 0.4, 1.3) during recovery. The median intra-individual difference in plasma glucose level change was 0.3 mmoL/L [IQR 0.1, 0.7] during exercise and 0.8 mmoL/L [IQR 0.4, 1.0] during recovery. CONCLUSION Within-person plasma glucose responses to moderate-intensity exercise may be reproducible under fasting and basal insulin conditions and similar pre-exercise plasma glucose levels. This finding may assist the design of future studies investigating both the reproducibility of glycaemic responses to exercise and blood glucose management for individuals with type 1 diabetes.
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Affiliation(s)
- Wayne H K Soon
- Division of Paediatrics, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, Western Australia, Australia
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Paul A Fournier
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, Western Australia, Australia
| | - Mary B Abraham
- Division of Paediatrics, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Grant J Smith
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Nirubasini Paramalingam
- Division of Paediatrics, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, Western Australia, Australia
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Vinutha B Shetty
- Division of Paediatrics, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, Western Australia, Australia
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Kym J Guelfi
- School of Human Sciences (Exercise and Sport Science), The University of Western Australia, Perth, Western Australia, Australia
| | - Timothy W Jones
- Division of Paediatrics, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Elizabeth A Davis
- Division of Paediatrics, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
- Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, Western Australia, Australia
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Shetty VB, Soon WHK, Roberts AG, Fried L, Roby HC, Smith GJ, Fournier PA, Jones TW, Davis EA. A Novel Mobile Health App to Educate and Empower Young People With Type 1 Diabetes to Exercise Safely: Prospective Single-Arm Mixed Methods Pilot Study. JMIR Diabetes 2021; 6:e29739. [PMID: 34647896 PMCID: PMC8554675 DOI: 10.2196/29739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/19/2021] [Accepted: 09/09/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Empowering young people with type 1 diabetes (T1D) to manage their blood glucose levels during exercise is a complex challenge faced by health care professionals due to the unpredictable nature of exercise and its effect on blood glucose levels. Mobile health (mHealth) apps would be useful as a decision-support aid to effectively contextualize a blood glucose result and take appropriate action to optimize glucose levels during and after exercise. A novel mHealth app acT1ve was recently developed, based on expert consensus exercise guidelines, to provide real-time support for young people with T1D during exercise. OBJECTIVE Our aim was to pilot acT1ve in a free-living setting to assess its acceptability and functionality, and gather feedback on the user experience before testing it in a larger clinical trial. METHODS A prospective single-arm mixed method design was used. Ten participants with T1D (mean age 17.7 years, SD 4.2 years; mean HbA1c, 54 mmol/mol, SD 5.5 mmol/mol [7.1%, SD 0.5%]) had acT1ve installed on their phones, and were asked to use the app to guide their exercise management for 6 weeks. At the end of 6 weeks, participants completed both a semistructured interview and the user Mobile Application Rating Scale (uMARS). All semistructured interviews were transcribed. Thematic analysis was conducted whereby interview transcripts were independently analyzed by 2 researchers to uncover important and relevant themes. The uMARS was scored for 4 quality subscales (engagement, functionality, esthetics, and information), and a total quality score was obtained from the weighted average of the 4 subscales. Scores for the 4 objective subscales were determined by the mean score of each of its individual questions. The perceived impact and subjective quality of acT1ve for each participant were calculated by averaging the scores of their related questions, but were not considered in the total quality score. All scores have a maximal possible value of 5, and they are presented as medians, IQRs, and ranges. RESULTS The main themes arising from the interview analysis were "increased knowledge," "increased confidence to exercise," and "suitability" for people who were less engaged in exercise. The uMARS scores for acT1ve were high (out of 5) for its total quality (median 4.3, IQR 4.2-4.6), engagement (median 3.9, IQR 3.6-4.2), functionality (median 4.8, IQR 4.5-4.8), information (median 4.6, IQR 4.5-4.8), esthetics (median 4.3, IQR 4.0-4.7), subjective quality (median 4.0, IQR 3.8-4.2), and perceived impact (median 4.3, IQR 3.6-4.5). CONCLUSIONS The acT1ve app is functional and acceptable, with a high user satisfaction. The efficacy and safety of this app will be tested in a randomized controlled trial in the next phase of this study. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12619001414101; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378373.
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Affiliation(s)
- Vinutha B Shetty
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia.,Telethon Kids Institute, Children's Diabetes Centre, The University of Western Australia, Perth, Australia.,Division of Pediatrics, The University of Western Australia, Perth, Australia
| | - Wayne H K Soon
- Telethon Kids Institute, Children's Diabetes Centre, The University of Western Australia, Perth, Australia
| | - Alison G Roberts
- Telethon Kids Institute, Children's Diabetes Centre, The University of Western Australia, Perth, Australia
| | - Leanne Fried
- Telethon Kids Institute, Children's Diabetes Centre, The University of Western Australia, Perth, Australia
| | - Heather C Roby
- Telethon Kids Institute, Children's Diabetes Centre, The University of Western Australia, Perth, Australia
| | - Grant J Smith
- Telethon Kids Institute, Children's Diabetes Centre, The University of Western Australia, Perth, Australia
| | - Paul A Fournier
- Telethon Kids Institute, Children's Diabetes Centre, The University of Western Australia, Perth, Australia.,Exercise and Health, School of Human Sciences, The University of Western Australia, Perth, Australia
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia.,Telethon Kids Institute, Children's Diabetes Centre, The University of Western Australia, Perth, Australia.,Division of Pediatrics, The University of Western Australia, Perth, Australia
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia.,Telethon Kids Institute, Children's Diabetes Centre, The University of Western Australia, Perth, Australia.,Division of Pediatrics, The University of Western Australia, Perth, Australia
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Shetty VB, Fournier PA, Paramalingam N, Soon W, Roby HC, Jones TW, Davis EA. Effect of Exercise Intensity on Exogenous Glucose Requirements to Maintain Stable Glycemia At High Insulin Levels in Type 1 Diabetes. J Clin Endocrinol Metab 2021; 106:e83-e93. [PMID: 33097945 DOI: 10.1210/clinem/dgaa768] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Indexed: 01/17/2023]
Abstract
CONTEXT Under basal insulin levels, there is an inverted U relationship between exercise intensity and exogenous glucose requirements to maintain stable blood glucose levels in type 1 diabetes (T1D), with no glucose required for intense exercise (80% V̇O2 peak), implying that high-intensity exercise is not conducive to hypoglycemia. OBJECTIVE This work aimed to test the hypothesis that a similar inverted U relationship exists under hyperinsulinemic conditions, with high-intensity aerobic exercise not being conducive to hypoglycemia. METHODS Nine young adults with T1D (mean ± SD age, 22.6 ± 4.7 years; glycated hemoglobin, 61 ± 14 mmol/mol; body mass index, 24.0 ± 3.3 kg/m2, V̇O2 peak, 36.6 ± 8.0 mL·kg-1 min-1) underwent a hyperinsulinemic-euglycemic clamp to maintain stable glycemia (5-6 mmol·L-1), and exercised for 40 minutes at 4 intensities (35%, 50%, 65%, and 80% V̇O2peak) on separate days following a randomized counterbalanced study design. MAIN OUTCOME MEASURES Glucose infusion rates (GIR) and glucoregulatory hormones levels were measured. RESULTS The GIR (± SEM) to maintain euglycemia was 4.4 ± 0.4 mg·kg-1 min-1 prior to exercise, and increased significantly by 1.8 ± 0.4, 3.0 ± 0.4, 4.2 ± 0.7, and 3.5 ± 0.7 mg·kg-1 min-1 during exercise at 35%, 50%, 65%, and 80% V̇O2 peak, respectively, with no significant differences between the 2 highest exercise intensities (P > .05), despite differences in catecholamine levels (P < .05). During the 2-hour period after exercise at 65% and 80% V̇O2 peak, GIRs did not differ from those during exercise (P > .05). CONCLUSIONS Under hyperinsulinemic conditions, the exogenous glucose requirements to maintain stable glycemia during and after exercise increase with exercise intensity then plateau with exercise performed at above moderate intensity ( > 65% V̇O2 peak). High-intensity exercise confers no protection against hypoglycemia.
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Affiliation(s)
- Vinutha B Shetty
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia
- Division of Pediatrics within the Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Paul A Fournier
- School of Human Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Nirubasini Paramalingam
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Wayne Soon
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Heather C Roby
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia
- Division of Pediatrics within the Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia
- Division of Pediatrics within the Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
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Shetty VB, Fournier PA, Davey RJ, Retterath AJ, Paramalingam N, Roby HC, Davis EA, Jones TW. The time lag prior to the rise in glucose requirements to maintain stable glycaemia during moderate exercise in a fasted insulinaemic state is of short duration and unaffected by the level at which glycaemia is maintained in Type 1 diabetes. Diabet Med 2018; 35:1404-1411. [PMID: 29939421 DOI: 10.1111/dme.13771] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2018] [Indexed: 11/28/2022]
Abstract
AIMS To determine the duration of the low hypoglycaemia risk period after the start of moderate-intensity exercise performed under basal insulinaemic conditions and whether this period is affected by the level at which glycaemia is maintained under these conditions. METHODS This was a prospective, randomized counterbalanced study. Eight participants with Type 1 diabetes (mean ± sd age 21.5 ± 4.0 years) underwent either a euglycaemic (5-6 mmol/l) or hyperglycaemic clamp (9-10 mmol/l) on separate days and were infused with insulin at basal rates and [6,6-2 H]glucose while cycling for 40 min at 50% maximum oxygen consumption rate. The main outcome measures were the glucose infusion rates required to maintain stable glycaemia and glucoregulatory hormone levels, and rates of glucose appearance and disappearance. RESULTS During the first 20 min of exercise, the glucose infusion rate did not increase significantly, irrespective of the level at which glycaemia was maintained, but increased acutely between 20 and 25 min under both conditions. Maintaining higher glycaemia resulted in higher glucose infusion rate during, but not early post-exercise. With the exception of epinephrine, the glucoregulatory hormone levels and rates of glucose appearance and disappearance were similar between conditions. CONCLUSION Irrespective of the levels at which glycaemia is maintained, there is a 20-min low exogenous glucose demand period during which the exogenous glucose requirements to maintain stable glycaemia do not increase during moderate exercise performed at basal insulin level.
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Affiliation(s)
- V B Shetty
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia
- Division of Paediatrics, Medical School, Perth, WA, Australia
- Telethon Kids Institute, Children's Diabetes Centre, University of Western Australia, Perth, WA, Australia
| | - P A Fournier
- School of Human Sciences, Perth, WA, Australia
- Telethon Kids Institute, Children's Diabetes Centre, University of Western Australia, Perth, WA, Australia
| | - R J Davey
- Telethon Kids Institute, Children's Diabetes Centre, University of Western Australia, Perth, WA, Australia
| | - A J Retterath
- Telethon Kids Institute, Children's Diabetes Centre, University of Western Australia, Perth, WA, Australia
| | - N Paramalingam
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia
- Telethon Kids Institute, Children's Diabetes Centre, University of Western Australia, Perth, WA, Australia
| | - H C Roby
- Telethon Kids Institute, Children's Diabetes Centre, University of Western Australia, Perth, WA, Australia
| | - E A Davis
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia
- Division of Paediatrics, Medical School, Perth, WA, Australia
- Telethon Kids Institute, Children's Diabetes Centre, University of Western Australia, Perth, WA, Australia
| | - T W Jones
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia
- Division of Paediatrics, Medical School, Perth, WA, Australia
- Telethon Kids Institute, Children's Diabetes Centre, University of Western Australia, Perth, WA, Australia
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Paramalingam N, Fournier PA, Davey RJ, Roby HC, Smith GJ, Shetty VB, Guelfi KJ, Davis EA, Jones TW. A 10-second sprint does not blunt hormonal counter-regulation to subsequent hypoglycaemia. Diabet Med 2017; 34:1440-1446. [PMID: 28586510 DOI: 10.1111/dme.13396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2017] [Indexed: 11/30/2022]
Abstract
AIM To investigate whether a 10-second (s) sprint impairs the counter-regulatory response to subsequent hypoglycaemia. METHODS Nine people (five male, four female) with Type 1 diabetes, aged 21.1 ± 4.5 years, performed a 10-s rest or a 10-s maximum-effort sprint in random order on different days, while subjected to an euinsulinaemic-euglycaemic clamp. This was followed by a hyperinsulinaemic-hypoglycaemic glucose clamp 2.5 h later to induce hypoglycaemia for 40 min. At timed intervals, the counter-regulatory hormonal responses to hypoglycaemia were measured. Blood pressure, heart rate and hypoglycaemic symptoms were also assessed. RESULTS During the hypoglycaemic clamp, epinephrine, norepinephrine, growth hormone and cortisol levels increased significantly from baseline, and their responses were similar after both rest and sprint conditions. In particular, plasma epinephrine rose eightfold, from 197 ± 103 pmol/l to 1582 ± 1118 pmol/l after the rest condition, and from 219 ± 119 pmol/l to 1900 ± 898 pmol/l after the sprint condition. CONCLUSION A 10-s sprint is unlikely to blunt the subsequent hormonal counter-regulation to hypoglycaemia in individuals with Type 1 diabetes.
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Affiliation(s)
- N Paramalingam
- Telethon Kids Institute, Perth, WA, Australia
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia
- Division of Paediatrics, within the Medical School, University of Western Australia, Perth, WA, Australia
- School of Human Sciences, University of Western Australia, Perth, WA, Australia
| | - P A Fournier
- School of Human Sciences, University of Western Australia, Perth, WA, Australia
| | - R J Davey
- Telethon Kids Institute, Perth, WA, Australia
- Division of Paediatrics, within the Medical School, University of Western Australia, Perth, WA, Australia
| | - H C Roby
- Telethon Kids Institute, Perth, WA, Australia
| | - G J Smith
- Telethon Kids Institute, Perth, WA, Australia
| | - V B Shetty
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia
- Division of Paediatrics, within the Medical School, University of Western Australia, Perth, WA, Australia
| | - K J Guelfi
- School of Human Sciences, University of Western Australia, Perth, WA, Australia
| | - E A Davis
- Telethon Kids Institute, Perth, WA, Australia
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia
- Division of Paediatrics, within the Medical School, University of Western Australia, Perth, WA, Australia
| | - T W Jones
- Telethon Kids Institute, Perth, WA, Australia
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia
- Division of Paediatrics, within the Medical School, University of Western Australia, Perth, WA, Australia
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Abraham MB, Larkins N, Choong CS, Shetty VB. Transient pseudohypoaldosteronism in infancy secondary to urinary tract infection. J Paediatr Child Health 2017; 53:458-463. [PMID: 28233358 DOI: 10.1111/jpc.13481] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 11/03/2016] [Accepted: 11/10/2016] [Indexed: 11/29/2022]
Abstract
AIM Hyponatraemia with hyperkalaemia in infancy is a typical presentation of congenital adrenal hyperplasia. In the presence of pyelonephritis, the same biochemical picture can occur with transient type 1 pseudohypoaldosteronism (PHA-1) also termed type 4 renal tubular acidosis. Recognition of PHA-1 enables appropriate management thus avoiding unnecessary investigations and treatment. To improve awareness of this condition, we present a case series to highlight the clinical and biochemical features of PHA-1. METHODS A retrospective chart review of patients diagnosed with transient PHA-1 at a tertiary children's hospital in Western Australia was conducted. RESULTS Five male infants (32 days to 6 months) with transient PHA-1 were identified. Failure to thrive was the most common symptom with hyponatraemia on presentation. Two infants had antenatally diagnosed bilateral hydronephrosis and urinary tract infection (UTI) on admission. Two infants were treated for congenital adrenal hyperplasia and received hydrocortisone. All infants had UTI and required parenteral antibiotics. The condition was transient and hyponatraemia corrected by day 4 in all infants. There was no correlation between plasma sodium and aldosterone levels. The severity of PHA-1 was independent of the underlying renal anomaly. Four infants had hydronephrosis and vesicoureteric reflux. Surgical intervention was required in two infants. CONCLUSIONS PHA-1 may be precipitated by UTI or urinary tract anomalies in early infancy. Urine analysis should be performed in infants with hyponatraemia. Diagnosis of PHA-1 facilitates appropriate renal investigations to reduce long-term morbidity.
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Affiliation(s)
- Mary B Abraham
- Department of Endocrinology and Diabetes, The University of Western Australia, Perth, Western Australia, Australia.,School of Child Health and Paediatrics, The University of Western Australia, Perth, Western Australia, Australia
| | - Nicholas Larkins
- Department of Nephrology, Princess Margaret Hospital, The University of Western Australia, Perth, Western Australia, Australia
| | - Catherine S Choong
- Department of Endocrinology and Diabetes, The University of Western Australia, Perth, Western Australia, Australia.,School of Child Health and Paediatrics, The University of Western Australia, Perth, Western Australia, Australia
| | - Vinutha B Shetty
- Department of Endocrinology and Diabetes, The University of Western Australia, Perth, Western Australia, Australia.,School of Child Health and Paediatrics, The University of Western Australia, Perth, Western Australia, Australia
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Abstract
BACKGROUND The etiology of primary adrenal insufficiency has implications for further management of the condition. CASE CHARACTERISTICS A 5-year-old boy presented in adrenal crisis with glucocorticoid and mineralocorticoid deficiency. OBSERVATION Investigations confirmed primary adrenal insufficiency and ruled out the common etiologies. Genetic testing identified a novel NR0B1/DAX gene mutation. MESSAGE A genetic diagnosis in children with primary adrenal insufficiency is useful to provide genetic counselling.
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Affiliation(s)
- Mary B Abraham
- Department of Endocrinology, Princess Margaret Hospital,; #School of Paediatrics and Child Health, The University of Western Australia; and $Genetic Services of Western Australia, Princess Margaret Hospital and King Edward Memorial Hospital; Perth, Australia. Correspondence to: Dr Mary B Abraham, Department of Endocrinology and Diabetes, Princess Margaret Hospital, Perth, Australia.
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Shetty VB, Fournier PA, Davey RJ, Retterath AJ, Paramalingam N, Roby HC, Cooper MN, Davis EA, Jones TW. Effect of Exercise Intensity on Glucose Requirements to Maintain Euglycemia During Exercise in Type 1 Diabetes. J Clin Endocrinol Metab 2016; 101:972-80. [PMID: 26765581 DOI: 10.1210/jc.2015-4026] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
CONTEXT No recommendations exist to inform the carbohydrate amount required to prevent hypoglycemia associated with exercise of different intensities in individuals with type 1 diabetes (T1D). OBJECTIVE The relationship between exercise intensity and carbohydrate requirements to maintain stable euglycemia in individuals with T1D remains to be determined. It was predicted that an "inverted-U" relationship exists between exercise intensity and the amount of glucose required to prevent hypoglycemia during exercise at basal insulinemia. Our objective was to investigate this relationship and elucidate the underlying glucoregulatory mechanisms. DESIGN, PARTICIPANTS, AND INTERVENTION We subjected nine individuals (mean ± SD age, 21.5 ± 4.0 years; duration of disease, 11.4 ± 6.4 years; glycated hemoglobin, 7.9 ± 0.8% [60 mmol/mol]; body mass index, 25.4 ± 5.5 kg/m(2); VO2peak, 34.8 ± 5.1 mL·kg(-1)·min(-1); and lactate threshold, 59.9 ± 5.9% VO2peak) with T1D to a euglycemic clamp, whereby euglycemia was maintained by infusing basal insulin rates with concomitant infusion of [6,6-(2)H2]glucose for determining glucose kinetics. Glucose was infused to maintain euglycemia during and for 2 hours after exercise of different intensities (35, 50, 65, and 80% VO2peak). MAIN OUTCOME MEASURES The glucose infusion rate (GIR), levels of glucoregulatory hormones, and rates of endogenous glucose appearance and disappearance were compared between conditions. RESULTS The mean GIR to maintain euglycemia during exercise increased with intensity up to 50% (4.0 ± 1.6 g/h; P < .05) and 65% (4.1 ± 1.7 g/h), but no glucose was required at 80% VO2peak. Glucose rate of appearance and disappearance increased with intensity and, together with plasma catecholamines, reached higher levels at 80% VO2peak. CONCLUSION Our findings support the predicted inverted-U relationship between exercise intensity and glucose requirement. However, the relationship between iv and oral glucose requirements needs to be investigated to translate these GIR data to clinical practice.
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Affiliation(s)
- Vinutha B Shetty
- Department of Endocrinology and Diabetes (V.B.S., N.P., M.N.C., E.A.D., T.W.J.), Princess Margaret Hospital for Children, Perth, Western Australia 6840, Australia; and School of Paediatrics and Child Health (V.B.S., E.A.D., T.W.J.), School of Sport Science, Exercise, and Health (P.A.F.), and Telethon Kids Institute, The Centre for Child Health Research (R.J.D., A.J.R., N.P., H.C.R., M.N.C., E.A.D., T.W.J.), The University of Western Australia, Perth, Western Australia 6008, Australia
| | - Paul A Fournier
- Department of Endocrinology and Diabetes (V.B.S., N.P., M.N.C., E.A.D., T.W.J.), Princess Margaret Hospital for Children, Perth, Western Australia 6840, Australia; and School of Paediatrics and Child Health (V.B.S., E.A.D., T.W.J.), School of Sport Science, Exercise, and Health (P.A.F.), and Telethon Kids Institute, The Centre for Child Health Research (R.J.D., A.J.R., N.P., H.C.R., M.N.C., E.A.D., T.W.J.), The University of Western Australia, Perth, Western Australia 6008, Australia
| | - Raymond J Davey
- Department of Endocrinology and Diabetes (V.B.S., N.P., M.N.C., E.A.D., T.W.J.), Princess Margaret Hospital for Children, Perth, Western Australia 6840, Australia; and School of Paediatrics and Child Health (V.B.S., E.A.D., T.W.J.), School of Sport Science, Exercise, and Health (P.A.F.), and Telethon Kids Institute, The Centre for Child Health Research (R.J.D., A.J.R., N.P., H.C.R., M.N.C., E.A.D., T.W.J.), The University of Western Australia, Perth, Western Australia 6008, Australia
| | - Adam J Retterath
- Department of Endocrinology and Diabetes (V.B.S., N.P., M.N.C., E.A.D., T.W.J.), Princess Margaret Hospital for Children, Perth, Western Australia 6840, Australia; and School of Paediatrics and Child Health (V.B.S., E.A.D., T.W.J.), School of Sport Science, Exercise, and Health (P.A.F.), and Telethon Kids Institute, The Centre for Child Health Research (R.J.D., A.J.R., N.P., H.C.R., M.N.C., E.A.D., T.W.J.), The University of Western Australia, Perth, Western Australia 6008, Australia
| | - Nirubasini Paramalingam
- Department of Endocrinology and Diabetes (V.B.S., N.P., M.N.C., E.A.D., T.W.J.), Princess Margaret Hospital for Children, Perth, Western Australia 6840, Australia; and School of Paediatrics and Child Health (V.B.S., E.A.D., T.W.J.), School of Sport Science, Exercise, and Health (P.A.F.), and Telethon Kids Institute, The Centre for Child Health Research (R.J.D., A.J.R., N.P., H.C.R., M.N.C., E.A.D., T.W.J.), The University of Western Australia, Perth, Western Australia 6008, Australia
| | - Heather C Roby
- Department of Endocrinology and Diabetes (V.B.S., N.P., M.N.C., E.A.D., T.W.J.), Princess Margaret Hospital for Children, Perth, Western Australia 6840, Australia; and School of Paediatrics and Child Health (V.B.S., E.A.D., T.W.J.), School of Sport Science, Exercise, and Health (P.A.F.), and Telethon Kids Institute, The Centre for Child Health Research (R.J.D., A.J.R., N.P., H.C.R., M.N.C., E.A.D., T.W.J.), The University of Western Australia, Perth, Western Australia 6008, Australia
| | - Matthew N Cooper
- Department of Endocrinology and Diabetes (V.B.S., N.P., M.N.C., E.A.D., T.W.J.), Princess Margaret Hospital for Children, Perth, Western Australia 6840, Australia; and School of Paediatrics and Child Health (V.B.S., E.A.D., T.W.J.), School of Sport Science, Exercise, and Health (P.A.F.), and Telethon Kids Institute, The Centre for Child Health Research (R.J.D., A.J.R., N.P., H.C.R., M.N.C., E.A.D., T.W.J.), The University of Western Australia, Perth, Western Australia 6008, Australia
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes (V.B.S., N.P., M.N.C., E.A.D., T.W.J.), Princess Margaret Hospital for Children, Perth, Western Australia 6840, Australia; and School of Paediatrics and Child Health (V.B.S., E.A.D., T.W.J.), School of Sport Science, Exercise, and Health (P.A.F.), and Telethon Kids Institute, The Centre for Child Health Research (R.J.D., A.J.R., N.P., H.C.R., M.N.C., E.A.D., T.W.J.), The University of Western Australia, Perth, Western Australia 6008, Australia
| | - Timothy W Jones
- Department of Endocrinology and Diabetes (V.B.S., N.P., M.N.C., E.A.D., T.W.J.), Princess Margaret Hospital for Children, Perth, Western Australia 6840, Australia; and School of Paediatrics and Child Health (V.B.S., E.A.D., T.W.J.), School of Sport Science, Exercise, and Health (P.A.F.), and Telethon Kids Institute, The Centre for Child Health Research (R.J.D., A.J.R., N.P., H.C.R., M.N.C., E.A.D., T.W.J.), The University of Western Australia, Perth, Western Australia 6008, Australia
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Abraham MB, Shetty VB, Price G, Smith N, Bock MD, Siafarikas A, Resnick S, Whan E, Ellard S, Flanagan SE, Davis EA, Jones TW, Hussain K, Choong CS. Efficacy and safety of sirolimus in a neonate with persistent hypoglycaemia following near-total pancreatectomy for hyperinsulinaemic hypoglycaemia. J Pediatr Endocrinol Metab 2015. [PMID: 26226122 DOI: 10.1515/jpem-2015-0094] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hyperinsulinaemic hypoglycaemia (HH) is characterised by inappropriate insulin secretion and is the most common cause for persistent neonatal hypoglycaemia. The only treatment available for medically unresponsive hypoglycaemia is a near-total pancreatectomy. A neonate with severe HH, due to a homozygous ABCC8 mutation, was not responsive to treatment with maximal doses of diazoxide and subcutaneous daily octreotide, and underwent a near-total pancreatectomy; however, hypoglycaemia persisted. Introduction of sirolimus, an mTOR (mammalian target of rapamycin) inhibitor, obviated the requirement for glucose infusion. Euglycaemia was achieved with no significant adverse events from the drug. Sirolimus therapy was ceased at 13 months of age. No episodes of persistent hypoglycaemia were observed after cessation of sirolimus. This report demonstrates the successful use of sirolimus for persistent hypoglycaemia in the critically ill infant post pancreatectomy. Sirolimus could be considered in patients with severe HH not responsive to conventional medical and surgical therapy. However, the long-term efficacy and safety with this immunosuppressive drug in very young patients are not assured.
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Shetty VB, Kiraly-Borri C, Lamont P, Bikker H, Choong CSY. NKX2-1 mutations in brain-lung-thyroid syndrome: a case series of four patients. J Pediatr Endocrinol Metab 2014; 27:373-8. [PMID: 24129101 DOI: 10.1515/jpem-2013-0109] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 08/21/2013] [Indexed: 11/15/2022]
Abstract
Brain-lung-thyroid syndrome (BLTS) characterized by congenital hypothyroidism, respiratory distress syndrome, and benign hereditary chorea is caused by thyroid transcription factor 1 (NKX2-1/TTF1) mutations. We report the clinical and molecular characteristics of four cases presenting with primary hypothyroidism, respiratory distress, and neurological disorder. Two of the four patients presenting with the triad of BLTS had NKX2-1 mutations, and one of these NKX2-1 [c.890_896del (p.Ala327Glyfs*52)] is a novel variant. The third patient without any identified NKX2-1 mutations was a carrier of mitochondrial mutation; this raises the possibility of mitochondrial mutations contributing to thyroid dysgenesis. Although rare, the triad of congenital hypothyroidism, neurological, and respiratory signs is highly suggestive of NKX2-1 anomalies. Screening for NKX2-1 mutations in patients with thyroid, lung, and neurological abnormalities will enable a unifying diagnosis and genetic counseling for the affected families. In addition, identification of an NKX2-1 defect would be helpful in allaying the concerns about inadequate thyroxine supplementation as the cause of neurological defects observed in some children with congenital hypothyroidism.
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Shetty VB, Bower C, Jones TW, Lewis BD, Davis EA. Ethnic and gender differences in rates of congenital adrenal hyperplasia in Western Australia over a 21 year period. J Paediatr Child Health 2012; 48:1029-32. [PMID: 23039988 DOI: 10.1111/j.1440-1754.2012.02584.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To evaluate the incidence, sex distribution, ethnicity, age at diagnosis, clinical presentation and morbidity of all childhood-onset congenital adrenal hyperplasia (CAH) cases in Western Australia (WA) between 1990 and 2010, a state where newborn screening for CAH is not in place. METHODS The total number of all known CAH cases was identified. Case files were reviewed retrospectively to determine clinical details. Classical CAH (C-CAH) was defined as patients presenting before 6 months of age and non-classical (NC-CAH) as presenting after 6 months. RESULTS Of the 41 CAH cases (26 female) born in WA, 5(12.2%) were of Aboriginal ethnicity. CAH was due to 21-hydroxylase deficiency in 40 cases. Of those with 21-hydroxylase deficiency, 37 were C-CAH (25 female) and 3 NC-CAH (all male). The incidence of C-CAH in WA was estimated to be 0.67 per 10, 000 live births (1:14, 869). The incidence rate ratio of Aboriginal compared with non-Aboriginal C-CAH was 2.45 (95% confidence interval 0.96-6.29). The mean age of diagnosis of C-CAH cases was lower in females (8.9 ± 2.5 days) compared to males (23.4 ± 9.8 days). Among these males, 72.7% presented initially with adrenal crisis. CONCLUSION The estimated incidence of classical CAH is similar to composite worldwide data. The increased female-to-male ratio is not in keeping with the expected sex distribution seen in a recessively inherited disease. The delayed diagnosis in males, with a significant proportion presenting with adrenal crisis, could be avoided with newborn screening. The higher rate of CAH in patients with Aboriginal ethnicity is a novel observation.
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Affiliation(s)
- Vinutha B Shetty
- Department of Endocrinology, The University of Western Australia, Perth, Western Australia, Australia
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Abstract
An 11 month old boy presented with gangrene of the extremities. He was found to have positive nuclear antibodies and antibodies to double stranded DNA, and negative Ro and La antibodies. The infant was started on oral prednisolone, which was discontinued after six months. At one year of follow up he was asymptomatic, with negative nuclear antibodies and antibodies to double stranded DNA.
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Affiliation(s)
- V B Shetty
- Department of Pediatrics, University Medical Centre, Kasturba Medical College, Mangalore 575 001, Karnataka, India.
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