1
|
Riddell MC, Li Z, Gal RL, Calhoun P, Jacobs PG, Clements MA, Martin CK, Doyle III FJ, Patton SR, Castle JR, Gillingham MB, Beck RW, Rickels MR. Examining the Acute Glycemic Effects of Different Types of Structured Exercise Sessions in Type 1 Diabetes in a Real-World Setting: The Type 1 Diabetes and Exercise Initiative (T1DEXI). Diabetes Care 2023; 46:704-713. [PMID: 36795053 PMCID: PMC10090894 DOI: 10.2337/dc22-1721] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/27/2022] [Indexed: 02/10/2023]
Abstract
OBJECTIVE Maintenance of glycemic control during and after exercise remains a major challenge for individuals with type 1 diabetes. Glycemic responses to exercise may differ by exercise type (aerobic, interval, or resistance), and the effect of activity type on glycemic control after exercise remains unclear. RESEARCH DESIGN AND METHODS The Type 1 Diabetes Exercise Initiative (T1DEXI) was a real-world study of at-home exercise. Adult participants were randomly assigned to complete six structured aerobic, interval, or resistance exercise sessions over 4 weeks. Participants self-reported study and nonstudy exercise, food intake, and insulin dosing (multiple daily injection [MDI] users) using a custom smart phone application and provided pump (pump users), heart rate, and continuous glucose monitoring data. RESULTS A total of 497 adults with type 1 diabetes (mean age ± SD 37 ± 14 years; mean HbA1c ± SD 6.6 ± 0.8% [49 ± 8.7 mmol/mol]) assigned to structured aerobic (n = 162), interval (n = 165), or resistance (n = 170) exercise were analyzed. The mean (± SD) change in glucose during assigned exercise was -18 ± 39, -14 ± 32, and -9 ± 36 mg/dL for aerobic, interval, and resistance, respectively (P < 0.001), with similar results for closed-loop, standard pump, and MDI users. Time in range 70-180 mg/dL (3.9-10.0 mmol/L) was higher during the 24 h after study exercise when compared with days without exercise (mean ± SD 76 ± 20% vs. 70 ± 23%; P < 0.001). CONCLUSIONS Adults with type 1 diabetes experienced the largest drop in glucose level with aerobic exercise, followed by interval and resistance exercise, regardless of insulin delivery modality. Even in adults with well-controlled type 1 diabetes, days with structured exercise sessions contributed to clinically meaningful improvement in glucose time in range but may have slightly increased time below range.
Collapse
Affiliation(s)
| | - Zoey Li
- Jaeb Center for Health Research, Tampa, FL
| | | | | | - Peter G. Jacobs
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | | | - Corby K. Martin
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA
| | - Francis J. Doyle III
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA
| | | | - Jessica R. Castle
- Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR
| | - Melanie B. Gillingham
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, OR
| | | | - Michael R. Rickels
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
2
|
Adolfsson P, Taplin CE, Zaharieva DP, Pemberton J, Davis EA, Riddell MC, McGavock J, Moser O, Szadkowska A, Lopez P, Santiprabhob J, Frattolin E, Griffiths G, DiMeglio LA. ISPAD Clinical Practice Consensus Guidelines 2022: Exercise in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:1341-1372. [PMID: 36537529 PMCID: PMC10107219 DOI: 10.1111/pedi.13452] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Peter Adolfsson
- Department of Pediatrics, Kungsbacka Hospital, Kungsbacka, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Craig E Taplin
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, 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
| | - Dessi P Zaharieva
- Division of Endocrinology, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California, USA
| | - John Pemberton
- Department of Endocrinology and Diabetes, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, 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
| | - Michael C Riddell
- Muscle Health Research Centre, York University, Toronto, Ontario, Canada
| | - Jonathan McGavock
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada.,Diabetes Research Envisioned and Accomplished in Manitoba (DREAM) Theme, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada.,Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada.,Diabetes Action Canada SPOR Network, Toronto, Ontario, Canada
| | - Othmar Moser
- Division Exercise Physiology and Metabolism, Department of Sport Science, University of Bayreuth, Bayreuth, Germany.,Interdisciplinary Metabolic Medicine Trials Unit, Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Agnieszka Szadkowska
- Department of Pediatrics, Diabetology, Endocrinology & Nephrology, Medical University of Lodz, Lodz, Poland
| | - Prudence Lopez
- Department of Paediatrics, John Hunter Children's Hospital, Newcastle, New South Wales, Australia.,University of Newcastle, Newcastle, New South Wales, Australia
| | - Jeerunda Santiprabhob
- Siriraj Diabetes Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Division of Endocrinology and Metabolism, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Linda A DiMeglio
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetology, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA
| |
Collapse
|
3
|
Gwizdala KL, Ferguson DP, Kovan J, Novak V, Pontifex MB. Placebo controlled phase II clinical trial: Safety and efficacy of combining intranasal insulin & acute exercise. Metab Brain Dis 2021; 36:1289-1303. [PMID: 33856613 DOI: 10.1007/s11011-021-00727-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/31/2021] [Indexed: 10/21/2022]
Abstract
A growing number of investigations are exploring the utility of intranasal insulin as a means of mitigating cognitive decline. However, as a basic tenant of dementia prevention programs is increasing physical activity, it is essential to obtain a preliminary assessment of the safety profile of combining intranasal insulin with physical activity; to ensure that undue risks are not incurred. Utilizing a randomized double-blind placebo-controlled design, a sample of 116 non-diabetic, fasted college-aged adults were randomly assigned to receive a dose of 0-to-120 IU of NovoLog (Insulin Aspart) before being randomized to 20 min of exercise or sitting control condition. The safety of intranasal insulin was assessed by examining the incidence of potential symptoms of hypoglycemia and changes in peripheral blood glucose. The efficacy of a combination therapeutic approach was assessed using behavioral measures of inhibition and sustained attention alongside neuroelectric indices of attentional engagement. The frequency of symptoms reported following administration of intranasal insulin were not observed to interact with exercise so as to make their occurrence any more or less prominent, nor was the frequency observed to relate to the dose of intranasal insulin. However, doses of intranasal insulin of 100 IU or more were observed to result in a 7-fold increase in the likelihood of a level 1 hypoglycemic event for those individuals in the exercise condition. This study provides preliminary evidence to suggest that exercise is not associated with an increase in risk when combined with lower doses of intranasal insulin.Clinical trial registration The trial is registered at ClinicalTrials.gov, number NCT04292535.
Collapse
Affiliation(s)
- Kathryn L Gwizdala
- Department of Kinesiology, Michigan State University, 126E IM Sports Circle, East Lansing, MI, 48824-1049, USA
| | - David P Ferguson
- Department of Kinesiology, Michigan State University, 126E IM Sports Circle, East Lansing, MI, 48824-1049, USA
| | - Jeffery Kovan
- Department of Intercollegiate Athletics, Michigan State University, East Lansing, MI, USA
| | - Vera Novak
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Matthew B Pontifex
- Department of Kinesiology, Michigan State University, 126E IM Sports Circle, East Lansing, MI, 48824-1049, USA.
| |
Collapse
|
4
|
Valli G, Minnock D, Tarantino G, Neville RD. Delayed effect of different exercise modalities on glycaemic control in type 1 diabetes mellitus: A systematic review and meta-analysis. Nutr Metab Cardiovasc Dis 2021; 31:705-716. [PMID: 33549457 DOI: 10.1016/j.numecd.2020.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 12/02/2020] [Accepted: 12/07/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Despite the crucial role of exercise in the prevention of comorbidities and complications in type 1 diabetes mellitus (T1DM), people living with the disease are often insufficiently physically active, mainly due to the fear of hypoglycaemia. Research using continuous glucose monitoring (CGM) devices has shown that exercise affects glycaemic control in T1DM for over 24 h. The aim of this systematic review and meta-analysis is, therefore, to investigate the delayed effects of different exercise modalities on glycaemic control in adults with T1DM. METHODS AND RESULTS The literature search of experimental studies was conducted on PubMed, SPORTDiscus and EMBASE from January 2000 to September 2019. Twelve studies using CGM devices were included. Compared to endurance, intermittent exercise increased the time spent in hypoglycaemia (0.62, 0.07 to 1.18; standardised effect size, 95% CI) and reduced the mean interstitial glucose concentration (-0.88, -1.45 to -0.33). No differences emerged in the time spent in hyperglycaemia (-0.07, -0.58 to 0.45) or in the proportion of exercisers experiencing hypoglycaemic events (0.82, 0.45 to 1.49; proportion ratio, 95% CI) between conditions. The systematic review also found a reduced risk of hypoglycaemia if exercise is performed in the morning rather than in the afternoon, and with a 50% rapid-acting insulin reduction. It was not possible to determine the benefits of resistance exercise. CONCLUSIONS For the first time, we systematically investigated the delayed effect of exercise in adults with T1DM, highlighted undetected effects, shortcomings in the existing literature, and provided suggestions to design future comparable studies.
Collapse
Affiliation(s)
- Giacomo Valli
- Neuromuscular Physiology Laboratory, Department of Biomedical Sciences, University of Padova, Italy.
| | - Dean Minnock
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Ireland
| | - Giampiero Tarantino
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Ireland
| | - Ross D Neville
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Ireland
| |
Collapse
|
5
|
Adolfsson P, Riddell MC, Taplin CE, Davis EA, Fournier PA, Annan F, Scaramuzza AE, Hasnani D, Hofer SE. ISPAD Clinical Practice Consensus Guidelines 2018: Exercise in children and adolescents with diabetes. Pediatr Diabetes 2018; 19 Suppl 27:205-226. [PMID: 30133095 DOI: 10.1111/pedi.12755] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 07/16/2018] [Indexed: 12/17/2022] Open
Affiliation(s)
- Peter Adolfsson
- Department of Pediatrics, Kungsbacka Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Craig E Taplin
- Division of Endocrinology and Diabetes, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Princess Margaret Hospital; Telethon Kids Institute, University of Western Australia, Crawley, Australia
| | - Paul A Fournier
- School of Human Sciences, University of Western Australia, Perth, Australia
| | - Francesca Annan
- Children and Young People's Diabetes Service, University College London Hospitals NHS, Foundation Trust, London, UK
| | - Andrea E Scaramuzza
- Division of Pediatrics, ASST Cremona, "Ospedale Maggiore di Cremona", Cremona, Italy
| | - Dhruvi Hasnani
- Diacare-Diabetes Care and Hormone Clinic, Ahmedabad, India
| | - Sabine E Hofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| |
Collapse
|
6
|
Commentaries on Viewpoint: A time for exercise: the exercise window. J Appl Physiol (1985) 2017; 122:210-213. [DOI: 10.1152/japplphysiol.00938.2016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 10/25/2016] [Indexed: 11/22/2022] Open
|
7
|
Pedersen BK, Saltin B. Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports 2016; 25 Suppl 3:1-72. [PMID: 26606383 DOI: 10.1111/sms.12581] [Citation(s) in RCA: 1671] [Impact Index Per Article: 208.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2015] [Indexed: 12/12/2022]
Abstract
This review provides the reader with the up-to-date evidence-based basis for prescribing exercise as medicine in the treatment of 26 different diseases: psychiatric diseases (depression, anxiety, stress, schizophrenia); neurological diseases (dementia, Parkinson's disease, multiple sclerosis); metabolic diseases (obesity, hyperlipidemia, metabolic syndrome, polycystic ovarian syndrome, type 2 diabetes, type 1 diabetes); cardiovascular diseases (hypertension, coronary heart disease, heart failure, cerebral apoplexy, and claudication intermittent); pulmonary diseases (chronic obstructive pulmonary disease, asthma, cystic fibrosis); musculo-skeletal disorders (osteoarthritis, osteoporosis, back pain, rheumatoid arthritis); and cancer. The effect of exercise therapy on disease pathogenesis and symptoms are given and the possible mechanisms of action are discussed. We have interpreted the scientific literature and for each disease, we provide the reader with our best advice regarding the optimal type and dose for prescription of exercise.
Collapse
Affiliation(s)
- B K Pedersen
- The Centre of Inflammation and Metabolism and The Center for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - B Saltin
- The Copenhagen Muscle Research Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
8
|
Abstract
Exercise is a significant physiological challenge with markedly increased cardiac output, respiration and fuel mobilisation. Whilst the cardio-respiratory response to exercise is similar in type 1 diabetes to that seen in non-diabetic subjects, the response to mobilisation of fuel source to support exercise is impaired. This effect, when combined with the difficulties of nutrition and insulin therapy in type 1 diabetes may negatively impact on the performance of the athlete with diabetes. Hypoglycaemia both during and following exercise, is a significant risk. Furthermore, hyperglycaemia prior to and following some types of exercises can also be problematic. The effect on blood glucose of varying sports can be predicted, and therefore, pro-active adjustments of insulin therapy and nutrition can be made. This article outlines the important differences seen with exercise in type 1 diabetes and discusses appropriate strategies to normalise performance and reduce the risk of hypoglycaemia.
Collapse
Affiliation(s)
- Ian W Gallen
- Diabetes Centre, Wycombe Hospital, High Wycombe, Buckinghamshire, HP11 2TT, UK,
| |
Collapse
|
9
|
Leclair E, Liggins RT, Peckett AJ, Teich T, Coy DH, Vranic M, Riddell MC. Glucagon responses to exercise-induced hypoglycaemia are improved by somatostatin receptor type 2 antagonism in a rat model of diabetes. Diabetologia 2016; 59:1724-31. [PMID: 27075449 DOI: 10.1007/s00125-016-3953-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 03/18/2016] [Indexed: 12/18/2022]
Abstract
AIMS/HYPOTHESIS Regular exercise is at the cornerstone of care in type 1 diabetes. However, relative hyperinsulinaemia and a blunted glucagon response to exercise promote hypoglycaemia. Recently, a selective antagonist of somatostatin receptor 2, PRL-2903, was shown to improve glucagon counterregulation to hypoglycaemia in resting streptozotocin-induced diabetic rats. The aim of this study was to test the efficacy of PRL-2903 in enhancing glucagon counterregulation during repeated hyperinsulinaemic exercise. METHODS Diabetic rats performed daily exercise for 1 week and were then exposed to saline (154 mmol/l NaCl) or PRL-2903, 10 mg/kg, before hyperinsulinaemic exercise on two separate occasions spaced 1 day apart. In the following week, animals crossed over to the alternate treatment for a third hyperinsulinaemic exercise protocol. RESULTS Liver glycogen content was lower in diabetic rats compared with control rats, despite daily insulin therapy (p < 0.05). Glucagon levels failed to increase during exercise with saline but increased three-to-six fold with PRL-2903 (all p < 0.05). Glucose concentrations tended to be higher during exercise and early recovery with PRL-2903 on both days of treatment; this difference did not achieve statistical significance (p > 0.05). CONCLUSIONS/INTERPRETATION PRL-2903 improves glucagon counterregulation during exercise. However, liver glycogen stores or other factors limit the prevention of exercise-induced hypoglycaemia in rats with streptozotocin-induced diabetes.
Collapse
Affiliation(s)
- Erwan Leclair
- School of Kinesiology and Health Science, York University, Toronto, ON, M3J 1P3, Canada
| | | | - Ashley J Peckett
- School of Kinesiology and Health Science, York University, Toronto, ON, M3J 1P3, Canada
| | - Trevor Teich
- School of Kinesiology and Health Science, York University, Toronto, ON, M3J 1P3, Canada
| | - David H Coy
- Department of Medicine, Peptide Research Labs, Tulane University Medical Center, New Orleans, LA, USA
| | - Mladen Vranic
- Departments of Physiology and Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael C Riddell
- School of Kinesiology and Health Science, York University, Toronto, ON, M3J 1P3, Canada.
| |
Collapse
|
10
|
Abstract
Although not curable, type 1 diabetes is eminently controllable. IIT, as guided by the results of landmark studies such as the DCCT, provides primary care providers with a blueprint for reducing the frequency of the devastating complications of diabetes that were all too common in the recent past. Considering the remarkable advances in contemporary therapy, including MDI and CSII, the likelihood of even greater future improvements in quality of life and survivability can be anticipated. Success requires patient engagement and education, an informed primary care provider, and an interdisciplinary team to maximize the benefits of insulin therapy and avoid the risks of hypoglycemia.
Collapse
Affiliation(s)
- Elizabeth Stephens
- Providence Medical Group NE-Medical Education, 5050 Northeast Hoyt, Suite 540, Portland, OR 97213, USA; Department of Internal Medicine, Oregon Health and Sciences University, Portland, OR, USA.
| |
Collapse
|
11
|
Robertson K, Riddell MC, Guinhouya BC, Adolfsson P, Hanas R. ISPAD Clinical Practice Consensus Guidelines 2014. Exercise in children and adolescents with diabetes. Pediatr Diabetes 2014; 15 Suppl 20:203-23. [PMID: 25182315 DOI: 10.1111/pedi.12176] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 06/11/2014] [Indexed: 12/25/2022] Open
Affiliation(s)
- Kenneth Robertson
- Greater Glasgow & Clyde Children's Diabetes Service, Royal Hospital for Sick Children, Glasgow, UK
| | | | | | | | | | | |
Collapse
|
12
|
Stenerson M, Cameron F, Wilson DM, Harris B, Payne S, Bequette BW, Buckingham BA. The Impact of Accelerometer and Heart Rate Data on Hypoglycemia Mitigation in Type 1 Diabetes. J Diabetes Sci Technol 2014; 8:64-69. [PMID: 24876539 PMCID: PMC4454114 DOI: 10.1177/1932296813516208] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aerobic exercise can lower blood glucose levels and alter insulin sensitivity both during and several hours after exercise, creating challenges for a closed-loop artificial pancreas. Predictive low glucose suspend (PLGS) algorithms are a first step toward an artificial pancreas, but few of these have been successfully applied to exercise. This study incorporates physical activity measurements from a combined accelerometer/heart rate monitor (HRM) to improve the performance of an existing PLGS algorithm at mitigating exercise-associated hypoglycemia in participants with type 1 diabetes. In all, 22 subjects with type 1 diabetes on insulin pump therapy were provided a combined accelerometer/HRM and (if not already using one) a continuous glucose monitor (CGM), then instructed to go about their everyday lives while wearing the devices. After the monitoring period, each subject's insulin pump, CGM, and accelerometer/HRM were downloaded and the data were used to augment an existing PLGS algorithm to incorporate activity. Using a computer simulator, the accelerometer-augmented algorithm was compared to the HRM-augmented algorithm to determine which was most effective at mitigating hypoglycemia. Mean length of monitoring was 4.9 days. Across all subjects, 11 061 CGM readings were recorded during the monitoring period. In the simulator analysis, the PLGS algorithm reduced hypoglycemia by 62%, compared to 71% and 74% reductions for the HRM-augmented and accelerometer-augmented algorithms, respectively; combined accelerometer and HRM augmentation provided a 76% reduction. In a simulated setting, the accelerometer-augmented pump suspension algorithm decreases the incidence of exercise-related hypoglycemia by a meaningful amount compared to the PLGS algorithm alone. Results also failed to justify the additional user burden of a HRM.
Collapse
Affiliation(s)
- Matthew Stenerson
- Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
| | - Fraser Cameron
- Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, NY, USA
| | - Darrell M Wilson
- Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
| | - Breanne Harris
- Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
| | - Shelby Payne
- Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
| | - B Wayne Bequette
- Department of Chemical and Biological Engineering, Rensselaer Polytechnic Institute, Troy, NY, USA
| | - Bruce A Buckingham
- Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
| |
Collapse
|
13
|
Abstract
Physical exercise is firmly incorporated in the management of type 1 diabetes (T1DM), due to multiple recognized beneficial health effects (cardiovascular disease prevention being preeminent). When glycemic values are not excessively low or high at the time of exercise, few absolute contraindications exist; practical guidelines regarding amount, type, and duration of age-appropriate exercise are regularly updated by entities such as the American Diabetes Association and the International Society for Pediatric and Adolescent Diabetes. Practical implementation of exercise regimens, however, may at times be problematic. In the poorly controlled patient, specific structural changes may occur within skeletal muscle fiber, which is considered by some to be a disease-specific myopathy. Further, even in well-controlled patients, several homeostatic mechanisms regulating carbohydrate metabolism often become impaired, causing hypo- or hyperglycemia during and/or after exercise. Some altered responses may be related to inappropriate exogenous insulin administration, but are often also partly caused by the "metabolic memory" of prior glycemic events. In this context, prior hyperglycemia correlates with increased inflammatory and oxidative stress responses, possibly modulating key exercise-associated cardio-protective pathways. Similarly, prior hypoglycemia correlates with impaired glucose counterregulation, resulting in greater likelihood of further hypoglycemia to develop. Additional exercise responses that may be altered in T1DM include growth factor release, which may be especially important in children and adolescents. These multiple alterations in the exercise response should not discourage physical activity in patients with T1DM, but rather should stimulate the quest for the identification of the exercise formats that maximize beneficial health effects.
Collapse
Affiliation(s)
- Pietro Galassetti
- Department of Pediatrics, University of California Irvine, Irvine, California, USA.
| | | |
Collapse
|
14
|
Dubé MC, Lavoie C, Weisnagel SJ. Glucose or intermittent high-intensity exercise in glargine/glulisine users with T1DM. Med Sci Sports Exerc 2013; 45:3-7. [PMID: 22895370 DOI: 10.1249/mss.0b013e31826c6ad3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The effects of glargine/glulisine insulin regimen on exercise blood glucose (BG) and strategies to limit exercise-induced hypoglycemia are not well documented. Intermittent high-intensity exercise has been proposed to prevent hypoglycemia, but its effect in participants with type 1 diabetes using glargine/glulisine is unknown. METHODS The study used a repeated-measures design with three randomly ordered exercise conditions. Eleven participants completed 60 min of moderate-intensity exercise at 50% VO(2peak) for all conditions. These conditions varied as follows: participants ingested 0 g of glucose preexercise (0G + MOD), 30 g of glucose preexercise (30G + MOD), or 0 g of glucose preexercise but performed brief high-intensity intervals interspersed every 2 min (0G + MOD/INT) during exercise. If BG fell <4 mmol·L(-1), a 20% dextrose solution was started to maintain BG between 4 and 5 mmol·L(-1). RESULTS Consuming 30 g of glucose before exercise (30G + MOD) resulted in a higher preexercise BG (11.7 ± 2.7 mmol·L(-1)) compared with 0 g of glucose before exercise (0G + MOD, 7.8 ± 4.0, and 0G + MOD/INT, 9.2 ± 3.5mmol·L(-1)), P < 0.05. A dextrose infusion was required in 7/11, 4/11, and 1/11 participants for 0G + MOD, 0G + MOD/INT, 30G + MOD conditions, respectively, P < 0.02. The duration and the quantity of dextrose infused were greatest in the 0G + MOD condition, moderate in the to 0G + MOD/INT condition, and minimal in the 30G + MOD condition, P < 0.01. CONCLUSION Our results suggest that both moderate-intensity exercise with a 30-g preexercise glucose beverage or interspersed with intermittent high-intensity sprints may be safe strategies to prevent hypoglycemia in glargine/glulisine users.
Collapse
Affiliation(s)
- Marie-Christine Dubé
- Diabetes Research Unit, Université Laval Medical Center, Quebec City, QC, Canada
| | | | | |
Collapse
|
15
|
Francescato MP, Geat M, Accardo A, Blokar M, Cattin L, Noacco C. Exercise and glycemic imbalances: a situation-specific estimate of glucose supplement. Med Sci Sports Exerc 2011; 43:2-11. [PMID: 20473219 DOI: 10.1249/mss.0b013e3181e6d6a1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE The purposes of this study were to describe a newly developed algorithm that estimates the glucose supplement on a patient- and situation-specific basis and to test whether these amounts would be appropriate for maintaining blood glucose levels within the recommended range in exercising type 1 diabetic patients. METHODS The algorithm first estimates the overall amount of glucose oxidized during exercise on the basis of the patient's physical fitness, exercise intensity, and duration. The amount of supplemental CHO to be consumed before or during the effort represents a fraction of the burned quantity depending on the patient's usual therapy and insulin sensitivity and on the time of day the exercise is performed. The algorithm was tested in 27 patients by comparing the estimated amounts of supplemental CHO with the actual amounts required to complete 1-h constant-intensity walks. Each patient performed three trials, each of which started at different time intervals after insulin injection (81 walks were performed overall). Glycemia was tested every 15 min. RESULTS In 70.4% of the walks, independent of the time of day, the amount of CHO estimated by the algorithm would be adequate to allow the patients to complete the exercise with a glucose level within the selected thresholds (i.e., 3.9-10 mmol·L(-1)). CONCLUSIONS The algorithm provided a satisfactory estimate of the CHO needed to complete the exercises. Although the performance of the algorithm still requires testing for different exercise intensities, durations, and modalities, the results indicate its potential usefulness as a tool for preventing immediate exercise-induced glycemic imbalances (i.e., during exercise) in type 1 diabetic patients, in particular for spontaneous physical activities not planned in advance, thus allowing all insulin-dependent patients to safely enjoy the benefits of exercise.
Collapse
|
16
|
Iscoe KE, Riddell MC. Continuous moderate-intensity exercise with or without intermittent high-intensity work: effects on acute and late glycaemia in athletes with Type 1 diabetes mellitus. Diabet Med 2011; 28:824-32. [PMID: 21388440 DOI: 10.1111/j.1464-5491.2011.03274.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIMS Individuals with Type 1 diabetes mellitus are susceptible to hypoglycaemia during and after continuous moderate-intensity exercise, but hyperglycaemia during intermittent high-intensity exercise. The combination of both forms of exercise may have a moderating effect on glycaemia in recovery. The aims of this study were to compare the physiological responses and associated glycaemic changes to continuous moderate-intensity exercise vs. continuous moderate-intensity exercise + intermittent high-intensity exercise in athletes with Type 1 diabetes. METHODS Interstitial glucose levels were measured in a blinded fashion in 11 trained athletes with Type 1 diabetes during two sedentary days and during 2 days in which 45 min of afternoon continuous moderate-intensity exercise occurred either with or without intermittent high-intensity exercise. The total amount of work performed and the duration of exercise was identical between sessions. RESULTS During exercise, heart rate, respiratory exchange ratio, oxygen utilization, ventilation and blood lactate levels were higher during continuous moderate-intensity + intermittent high-intensity exercise vs. continuous moderate-intensity exercise (all P < 0.05). Despite these marked cardiorespiratory differences between trials, there was no difference in the reduction of interstitial glucose or plasma glucose levels between the exercise trials. Nocturnal glucose levels were higher in continuous moderate-intensity + intermittent high-intensity exercise and in sedentary vs. continuous moderate-intensity exercise (P < 0.05). Compared with continuous moderate-intensity exercise alone, continuous moderate-intensity + intermittent high-intensity exercise was associated with less post-exercise hypoglycaemia (5.2 vs. 1.5% of the time spent with glucose < 4.0 mmol/l) and more post-exercise hyperglycaemia (33.8 vs. 20.4% of time > 11.0 mmol/l). CONCLUSIONS Although the decreases in glucose level during continuous moderate-intensity exercise and continuous moderate-intensity + intermittent high-intensity exercise are similar, the latter form of exercise protects against nocturnal hypoglycaemia in athletes with Type 1 diabetes.
Collapse
Affiliation(s)
- K E Iscoe
- Department of Kinesiology and Health Science, Muscle Health Research Centre York University, 4700 Keele Street, Toronto, ON, Canada, M3J 1P3
| | | |
Collapse
|
17
|
West DJ, Stephens JW, Bain SC, Kilduff LP, Luzio S, Still R, Bracken RM. A combined insulin reduction and carbohydrate feeding strategy 30 min before running best preserves blood glucose concentration after exercise through improved fuel oxidation in type 1 diabetes mellitus. J Sports Sci 2011; 29:279-89. [DOI: 10.1080/02640414.2010.531753] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
18
|
Abstract
Current recommendations are that people with Type 1 and Type 2 diabetes mellitus exercise regularly. However, in cases in which insulin or insulin secretagogues are used to manage diabetes, patients have an increased risk of developing hypoglycemia, which is amplified during and after exercise. Repeated episodes of hypoglycemia blunt autonomic nervous system, neuroendocrine and metabolic defenses (counter-regulatory responses) against subsequent episodes of falling blood glucose levels during exercise. Likewise, antecedent exercise blunts counter-regulatory responses to subsequent hypoglycemia. This can lead to a vicious cycle, by which each episode of either exercise or hypoglycemia further blunts counter-regulatory responses. Although contemporary insulin therapies cannot fully mimic physiologic changes in insulin secretion, people with diabetes have several management options to avoid hypoglycemia during and after exercise, including regularly monitoring blood glucose, reducing basal and/or bolus insulin, and consuming supplemental carbohydrates.
Collapse
Affiliation(s)
- Lisa M Younk
- Department of Medicine, University of Maryland School of Medicine, 10-055 Bressler Research Building, 655 West Baltimore Street, Baltimore, MD 21201, USA
| | - Maia Mikeladze
- Department of Medicine, University of Maryland School of Medicine, 10-055 Bressler Research Building, 655 West Baltimore Street, Baltimore, MD 21201, USA
| | - Donna Tate
- Department of Medicine, University of Maryland School of Medicine, 10-055 Bressler Research Building, 655 West Baltimore Street, Baltimore, MD 21201, USA
| | - Stephen N Davis
- Department of Medicine, University of Maryland School of Medicine, 22 South Greene Street, Room N3W42, Baltimore, MD 21201, USA
| |
Collapse
|
19
|
Robertson K, Adolfsson P, Scheiner G, Hanas R, Riddell MC. Exercise in children and adolescents with diabetes. Pediatr Diabetes 2009; 10 Suppl 12:154-68. [PMID: 19754626 DOI: 10.1111/j.1399-5448.2009.00567.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
|
20
|
Perry E, Gallen IW. Guidelines on the current best practice for the management of type 1 diabetes, sport and exercise. ACTA ACUST UNITED AC 2009. [DOI: 10.1002/pdi.1351] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
21
|
Exercise and glycemic control in diabetes: benefits, challenges, and adjustments to pharmacotherapy. Phys Ther 2008; 88:1297-321. [PMID: 18801852 DOI: 10.2522/ptj.20080114] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Exercise, along with dietary intervention, represents first-line therapy for diabetes mellitus. Aerobic exercise is recommended for its beneficial effects on glucose control as well as its abilities to retard the progression of other comorbidities common in patients with diabetes, such as cardiovascular disease. The capability of aerobic exercise to improve glycemic control in diabetes is well documented, although adherence to exercise regimens is problematic. More recently, the glucose-lowering effects of resistance training have also been documented; this form of exercise has additional benefits, such as the capability to counteract sarcopenia, which is common in older people with type 2 diabetes. Exercise in people with diabetes, however, also can present significant challenges to glycemic control. Excessive glucose lowering can occur under certain conditions, enhancing the threat of hypoglycemia; in other situations, hyperglycemia can be accentuated. An understanding of the interactions between specific antidiabetic medications and various forms and intensities of exercise is essential to optimizing glycemic control while minimizing the potential for acute derangements in plasma glucose levels. Exogenous forms of insulin and agents that stimulate insulin secretion in a glucose-independent manner (such as sulfonylureas and glinides) increase the propensity for hypoglycemia during low- to moderate-intensity aerobic exercise. In contrast, exercise protocols characterized by high intensity are more likely to result in episodes of hyperglycemia. Strategies to minimize inappropriate swings in glycemic control are reviewed.
Collapse
|
22
|
Sáez de la Fuente J, Granja Berna V, Ferrari Piquero JM, Valero Zanuy MA, Herreros de Tejada López-Coterilla A. [Types of insulin therapy]. Rev Clin Esp 2008; 208:76-86. [PMID: 18261394 DOI: 10.1157/13115203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Diabetes mellitus is a chronic disease associated with a series of long-term microvascular and macrovascular complications that requires continuing therapeutic control. In recent years, the pharmaceutical industry has developed new types of insulin and administration systems in order to more closely mimic human insulin secretion. In this way, insulin therapy is divided into conventional and intensive regimens according to their complexity. In type 1 diabetes mellitus (T1DM) patients, the treatment of choice is the one which achieves intensive glycemic control. In type 2 diabetes mellitus, we can start with a simplified conventional regimen which could progress into an intensive one similar to that of T1DM treatment. Both types of diabetes require an individualized treatment prescription based on the needs and characteristics of each patient.
Collapse
Affiliation(s)
- J Sáez de la Fuente
- Servicio de Farmacia, Hospital Universitario Doce de Octubre, Madrid, España.
| | | | | | | | | |
Collapse
|
23
|
Shalitin S, Phillip M. Hypoglycemia in type 1 diabetes: a still unresolved problem in the era of insulin analogs and pump therapy. Diabetes Care 2008; 31 Suppl 2:S121-4. [PMID: 18227471 DOI: 10.2337/dc08-s228] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The Diabetes Control and Complications Trial demonstrated that in patients with type 1 diabetes, tight metabolic control achieved with intensive insulin therapy can reduce the risk of long-term microvascular complications. However, strict glycemic control carries an increased risk of severe hypoglycemia. Recurrent episodes of hypoglycemia, especially at young ages, can lead to hypoglycemia unawareness, exert adverse effects on neurocognitive function, and cause significant emotional morbidity in the child and parents. Although the introduction of the new insulin analogs in diabetes therapy and the use of continuous subcutaneous insulin infusion raised hopes for a solution to this problem, these modalities have not been associated with the expected reduction in hypoglycemic episodes. The findings suggest that the prevention of hypoglycemia in patients with type 1 diabetes lies in biologically controlled insulin secretion, as in islet transplantation, or the development of an autonomous closed-loop system that efficiently mimics the action of the pancreatic beta-cells and maintains blood glucose levels within the desired range.
Collapse
Affiliation(s)
- Shlomit Shalitin
- Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, 14 Kaplan St., Petach Tikva 49202, Israel
| | | |
Collapse
|
24
|
Robertson K, Adolfsson P, Riddell MC, Scheiner G, Hanas R. Exercise in children and adolescents with diabetes. Pediatr Diabetes 2008; 9:65-77. [PMID: 18211636 DOI: 10.1111/j.1399-5448.2007.00362.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
25
|
Kavookjian J, Elswick BM, Whetsel T. Interventions for being active among individuals with diabetes: a systematic review of the literature. DIABETES EDUCATOR 2008; 33:962-88; discussion 989-90. [PMID: 18057265 DOI: 10.1177/0145721707308411] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this systematic review is to assess and summarize evidence and gaps in the literature regarding the intervention for being active (exercise) among individuals with diabetes. METHODS Twelve electronic databases were searched. Publications eligible for inclusion specifically studied learning, behavioral, clinical, and humanistic outcomes for exercise interventions in adult patients with type 1 and type 2 diabetes. RESULTS Seven reviews (2 systematic reviews, 3 meta-analyses, 2 technical reviews) and 34 individual, nonreview studies (18 randomized controlled trials, 16 nonrandomized trials) met inclusion criteria. For type 2 diabetes, findings suggested that exercise had a positive effect on glycemic control and decreased cardiovascular risk, but the impact of exercise on behavioral and humanistic outcomes was unclear; long-term outcomes and adherence to exercise interventions is unknown because most studies were of short duration. The overall impact of varied types of exercise in type 1 diabetes was unclear, especially regarding glycemic control. Potential benefits of exercise in type 1 may include improved cardiovascular health. CONCLUSION The review did not identify specific successful intervention details because of the heterogeneity of studies, subjects, and research gaps. General findings suggest that physical activity is better than no exercise at all; intensive regimens, if tolerated by patients, achieved better clinical outcomes than less intensive regimens. Reviewed studies using structured exercise regimens exhibited a more significant impact on outcomes. Substantial gaps in the literature include studies measuring direct effects of exercise in the US minority populations most affected by type 2 diabetes and economic evaluations of exercise interventions. Interventions must be tailored to individual patient needs to succeed.
Collapse
Affiliation(s)
- Jan Kavookjian
- The Department of Pharmacy Care Systems, Harrison School of Pharmacy, Auburn, Alabama (Dr Kavookjian)
| | - Betsy M Elswick
- The Clinical Pharmacy Department, West Virginia University School of Pharmacy, Morgantown (Dr Elswick, Dr Whetsel)
| | - Tara Whetsel
- The Clinical Pharmacy Department, West Virginia University School of Pharmacy, Morgantown (Dr Elswick, Dr Whetsel)
| |
Collapse
|
26
|
Iscoe KE, Corcoran M, Riddell MC. High Rates of Nocturnal Hypoglycemia in a Unique Sports Camp for Athletes with Type 1 Diabetes: Lessons Learned from Continuous Glucose Monitoring Systems. Can J Diabetes 2008. [DOI: 10.1016/s1499-2671(08)23008-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
27
|
Wallymahmed ME, Morgan C, Gill GV, MacFarlane IA. Aerobic fitness and hand grip strength in Type 1 diabetes: relationship to glycaemic control and body composition. Diabet Med 2007; 24:1296-9. [PMID: 17956456 DOI: 10.1111/j.1464-5491.2007.02257.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To clarify the relationship of aerobic fitness and handgrip strength with glycaemic control (HbA1c), body composition and lipid profile in Type 1 diabetes. METHODS Aerobic capacity (Chester Step Test), handgrip strength and body composition (bioelectrical impedance) were measured in 141 patients with Type 1 diabetes. RESULTS Aerobic capacity correlated positively with HbA1c and lean body mass and negatively with body mass index and fat mass. Handgrip strength correlated positively with aerobic capacity and negatively with HbA1c and fat mass. In addition, there was a positive correlation between HbA1c and total cholesterol. CONCLUSION Patients with Type 1 diabetes who have good aerobic capacity have poorer glycaemic control. However, this was an observational study and the results must be interpreted with caution. Further investigation into how these patients manage blood glucose during exercise is required.
Collapse
Affiliation(s)
- M E Wallymahmed
- University Department of Diabetes and Endocrinology, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK.
| | | | | | | |
Collapse
|
28
|
Chokkalingam K, Tsintzas K, Snaar JEM, Norton L, Solanky B, Leverton E, Morris P, Mansell P, Macdonald IA. Hyperinsulinaemia during exercise does not suppress hepatic glycogen concentrations in patients with type 1 diabetes: a magnetic resonance spectroscopy study. Diabetologia 2007; 50:1921-1929. [PMID: 17639304 DOI: 10.1007/s00125-007-0747-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Accepted: 05/28/2007] [Indexed: 11/26/2022]
Abstract
AIMS/HYPOTHESIS We compared in vivo changes in liver glycogen concentration during exercise between patients with type 1 diabetes and healthy volunteers. METHODS We studied seven men with type 1 diabetes (mean +/- SEM diabetes duration 10 +/- 2 years, age 33 +/- 3 years, BMI 24 +/- 1 kg/m(2), HbA(1c) 8.1 +/- 0.2% and VO(2) peak 43 +/- 2 ml [kg lean body mass](-1) min(-1)) and five non-diabetic controls (mean +/- SEM age 30 +/- 3 years, BMI 22 +/- 1 kg/m(2), HbA(1c) 5.4 +/- 0.1% and VO(2) peak 52 +/- 4 ml [kg lean body mass](-1) min(-1), before and after a standardised breakfast and after three bouts (EX1, EX2, EX3) of 40 min of cycling at 60% VO(2) peak. (13)C Magnetic resonance spectroscopy of liver glycogen was acquired in a 3.0 T magnet using a surface coil. Whole-body substrate oxidation was determined using indirect calorimetry. RESULTS Blood glucose and serum insulin concentrations were significantly higher (p < 0.05) in the fasting state, during the postprandial period and during EX1 and EX2 in subjects with type 1 diabetes compared with controls. Serum insulin concentration was still different between groups during EX3 (p < 0.05), but blood glucose concentration was similar. There was no difference between groups in liver glycogen concentration before or after the three bouts of exercise, despite the relative hyperinsulinaemia in type 1 diabetes. There were also no differences in substrate oxidation rates between groups. CONCLUSIONS/INTERPRETATION In patients with type 1 diabetes, hyperinsulinaemic and hyperglycaemic conditions during moderate exercise did not suppress hepatic glycogen concentrations. These findings do not support the hypothesis that exercise-induced hypoglycaemia in patients with type 1 diabetes is due to suppression of hepatic glycogen mobilisation.
Collapse
Affiliation(s)
- K Chokkalingam
- Centre for Integrated Systems Biology and Medicine, School of Biomedical Sciences, University of Nottingham, Nottingham, UK
- Queen's Medical Centre, Nottingham, UK
| | - K Tsintzas
- Centre for Integrated Systems Biology and Medicine, School of Biomedical Sciences, University of Nottingham, Nottingham, UK
| | - J E M Snaar
- Sir Peter Mansfield Magnetic Resonance Centre, University of Nottingham, Nottingham, UK
| | - L Norton
- Centre for Integrated Systems Biology and Medicine, School of Biomedical Sciences, University of Nottingham, Nottingham, UK
| | - B Solanky
- Sir Peter Mansfield Magnetic Resonance Centre, University of Nottingham, Nottingham, UK
| | - E Leverton
- Sir Peter Mansfield Magnetic Resonance Centre, University of Nottingham, Nottingham, UK
| | - P Morris
- Sir Peter Mansfield Magnetic Resonance Centre, University of Nottingham, Nottingham, UK
| | - P Mansell
- Queen's Medical Centre, Nottingham, UK
| | - I A Macdonald
- Centre for Integrated Systems Biology and Medicine, School of Biomedical Sciences, University of Nottingham, Nottingham, UK.
- School of Biomedical Sciences, Queen's Medical Centre, University of Nottingham, Derby Road, Nottingham, NG7 2UH, UK.
| |
Collapse
|
29
|
Guelfi KJ, Ratnam N, Smythe GA, Jones TW, Fournier PA. Effect of intermittent high-intensity compared with continuous moderate exercise on glucose production and utilization in individuals with type 1 diabetes. Am J Physiol Endocrinol Metab 2007; 292:E865-70. [PMID: 17339500 DOI: 10.1152/ajpendo.00533.2006] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Previously, the decline in glycemia in individuals with type 1 diabetes has been shown to be less with intermittent high-intensity exercise (IHE) compared with continuous moderate-intensity exercise (MOD) despite the performance of a greater amount of total work. The purpose of the present study was to determine whether this lesser decline in glycemia can be attributed to a greater increment in endogenous glucose production (Ra) or attenuated glucose utilization (Rd). Nine individuals with type 1 diabetes were tested on two separate occasions, during which either a 30-min MOD or IHE protocol was performed under conditions of a euglycemic clamp in combination with the infusion of [6,6-(2)H]glucose. MOD consisted of continuous cycling at 40% VO2 peak, whereas IHE involved a combination of continuous exercise at 40% VO2 peak interspersed with additional 4-s maximal sprint efforts performed every 2 min to simulate the activity patterns of intermittent sports. During IHE, glucose Ra increased earlier and to a greater extent compared with MOD. Similarly, glucose Rd increased sooner during IHE, but the increase by the end of exercise was comparable with that elicited by MOD. During early recovery from IHE, Rd rapidly declined, whereas it remained elevated after MOD, a finding consistent with a lower glucose infusion rate during early recovery from IHE compared with MOD (P<0.05). The results suggest that the lesser decline in glycemia with IHE may be attributed to a greater increment in Ra during exercise and attenuated Rd during exercise and early recovery.
Collapse
Affiliation(s)
- K J Guelfi
- School of Human Movement and Exercise Science, University of Western Australia, 35 Stirling Highway, Crawley, and Department of Endocrinology and Diabetes, Princess Margaret Hospital, Subiaco, Western Australia, 6009, Australia.
| | | | | | | | | |
Collapse
|
30
|
Wallymahmed ME, Morgan C, Gill GV, MacFarlane IA. Does hypoglycaemic avoidance behaviour contribute to increased HbA1c levels in physically active people with type 1 diabetes? ACTA ACUST UNITED AC 2007. [DOI: 10.1002/pdi.1167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
31
|
Affiliation(s)
- Kathleen L Wyne
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA
| | | |
Collapse
|
32
|
Affiliation(s)
- Ian Gallen
- Diabetes Centre, Wycombe Hospital, High Wycombe, Buckinghamshire
| |
Collapse
|
33
|
Dubé MC, Weisnagel SJ, Prud'homme D, Lavoie C. Is early and late post-meal exercise so different in type 1 diabetic lispro users? Diabetes Res Clin Pract 2006; 72:128-34. [PMID: 16309777 DOI: 10.1016/j.diabres.2005.09.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2005] [Revised: 09/02/2005] [Accepted: 09/26/2005] [Indexed: 11/17/2022]
Abstract
To compare blood glucose (BG) responses during a 60 min moderate intensity exercise session performed in early or late postprandial periods. Nine generally well-controlled (HbA(1c): 7.3+/-0.1%) type 1 diabetic patients performed, at least one week apart, two exercise sessions, 60 (early exercise) and 180 min (late exercise) after a standardized breakfast. All subjects were using Humulin N (N) and Humalog (Lispro, LI) insulin. During exercise, the overall decrease in BG was 4.8+/-0.6 mmol/l and 3.6+/-0.8 mmol/l in early and late exercise, respectively (P=0.051). To prevent hypoglycemia, a dextrose infusion was initiated when BG reached 5 mmol/l. The quantity of dextrose infused was 6.2+/-3.0 g and 10.5+/-3.2g in early and late exercise, respectively (NS). The time free of dextrose infusion during exercise was 41.2+/-7.8 min and 31.7+/-7.5 min in early and late exercise, respectively (NS). In N-LI users, overall drop in BG during exercise tends to be greater in the early postprandial period. However, early and late exercise present similar quantity of dextrose infused and time free of dextrose infusion. Consequently, the similar risk of exercise-induced hypoglycemia suggests similar precautions in either exercise times.
Collapse
Affiliation(s)
- M-C Dubé
- Faculty of Medicine, Department of Physiology and Endocrinology, Laval University, Canada
| | | | | | | |
Collapse
|
34
|
Thompson R, Christie D, Hindmarsh PC. The role for insulin analogues in diabetes care. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/j.cupe.2005.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
35
|
Hindmarsh PC. The impact of hormone physiology on clinical practice with reference to two papers spanning 40 years of endocrinology. Arch Dis Child 2005; 90:1144-7. [PMID: 16243868 PMCID: PMC1720154 DOI: 10.1136/adc.2004.069682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Following the pioneering work of Roger Ekins in describing the methodology for radioimmunoassay of hormone concentrations in plasma a series of publications followed describing variation in plasma hormone concentrations in a number of diseases. Though fluctuations in hormonal concentrations had been suspected, it was not until Hunter and Rigal documented these for the GH axis that it became apparent that the preferred mode of signalling for many hormone systems and in particular the anterior-pituitary hormones was of a pulsatile nature.
Collapse
Affiliation(s)
- P C Hindmarsh
- Cobbold Laboratories, Middlesex Hospital, Mortimer Street, London W1T 3AA, UK.
| |
Collapse
|
36
|
Guelfi KJ, Jones TW, Fournier PA. The decline in blood glucose levels is less with intermittent high-intensity compared with moderate exercise in individuals with type 1 diabetes. Diabetes Care 2005; 28:1289-94. [PMID: 15920041 DOI: 10.2337/diacare.28.6.1289] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare the response of blood glucose levels to intermittent high-intensity exercise (IHE) and moderate-intensity exercise (MOD) in individuals with type 1 diabetes. RESEARCH DESIGN AND METHODS Seven healthy individuals with type 1 diabetes were tested on two separate occasions, during which either a 30-min MOD or IHE protocol was performed. MOD consisted of continuous exercise at 40% Vo(2peak), while the IHE protocol involved a combination of continuous exercise at 40% Vo(2peak) interspersed with 4-s sprints performed every 2 min to simulate the activity patterns of team sports. RESULTS Both exercise protocols resulted in a decline in blood glucose levels. However, the decline was greater with MOD (-4.4 +/- 1.2 mmol/l) compared with IHE (-2.9 +/- 0.8 mmol/l; P < 0.05), despite the performance of a greater amount of total work with IHE (P < 0.05). During 60 min of recovery from exercise, glucose levels remained higher in IHE compared with MOD (P < 0.05). Furthermore, glucose levels remained stable during recovery from IHE, while they continued to decrease after MOD (P < 0.05). The stabilization of blood glucose levels with IHE was associated with elevated levels of lactate, catecholamines, and growth hormone during early recovery from exercise (P < 0.05). There were no differences in free insulin, glucagon, cortisol, or free fatty acids between MOD and IHE. CONCLUSIONS The decline in blood glucose levels is less with IHE compared with MOD during both exercise and recovery in individuals with type 1 diabetes.
Collapse
Affiliation(s)
- Kym J Guelfi
- School of Human Movement and Exercise Science, University of Western Australia, 35 Stirling Hwy., Crawley, Western Australia 6009, Australia.
| | | | | |
Collapse
|
37
|
Guelfi KJ, Jones TW, Fournier PA. Intermittent high-intensity exercise does not increase the risk of early postexercise hypoglycemia in individuals with type 1 diabetes. Diabetes Care 2005; 28:416-8. [PMID: 15677802 DOI: 10.2337/diacare.28.2.416] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Kym J Guelfi
- School of Human Movement and Exercise Science, University of Western Australia, 35 Stirling Hwy., Crawley, Western Australia 6009, Australia.
| | | | | |
Collapse
|
38
|
Affiliation(s)
- Irl B Hirsch
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195-6176, USA.
| |
Collapse
|
39
|
|
40
|
Davidson JA, Garber AJ, DiMarchi RD, Santiago JV. New advances in insulin treatment of diabetes: overcoming barriers. Endocr Pract 2004; 3:371-84. [PMID: 15251776 DOI: 10.4158/ep.3.6.371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To discuss the optimal role of insulin in the treatment of patients with diabetes mellitus. METHODS We review the complications of diabetes, highlight the attempts to improve control of plasma glucose, and summarize current recommendations for use of insulin in clinical practice. RESULTS With the strict new guidelines for the diagnosis of diabetes issued by the American Diabetes Association in July 1997--a plasma glucose level of 126 mg/dL (7 mmol/L) rather than 140 mg/dL (7.8 mmol/L)--an additional 8 million persons will be diagnosed this year, and diabetes and its complications will be at the forefront of public health concerns. Strong evidence indicates that with reduction of plasma glucose levels and tight control of glycohemoglobin, the rate of complications can be considerably decreased. Although insulin replacement therapy is well known to be both the best and the most cost-effective way to control glucose levels in patients with type 1 diabetes, studies have no shown that those with type 2 diabetes can likewise benefit from appropriate insulin therapy. Other investigations have indicated that coronary events are as likely to occur in patients with recently discovered impaired glucose tolerance as in patients with known diabetes (at a 2-hour postprandial glucose threshold of 96 mg/dL [5.3 mmol/L]). Such finding suggest that there may be no such thing as "borderline diabetes" and give impetus to the search for improved types of insulin to treat all patients with diabetes. A recent candidate is the new insulin analogue lispro, which was developed by recombinant DNA techniques, with its design influenced by the structural analogy to another endogenous hormone, insulin-like growth factor I. Lispro is a fast-acting, rapidly dissipating insulin formulation. This profile allows lispro to be given less than 15 minutes before a meal, yet with little risk of postprandial hypoglycemia because its high mealtime peak is followed by rapid disappearance from the bloodstream. CONCLUSION Lispro has been shown to improve postprandial control of plasma glucose and to decrease the occurrence of hypoglycemia episodes in comparison with regular insulin. Because of its stability and pharmacokinetic properties, lispro can also be used in insulin pump therapy.
Collapse
Affiliation(s)
- J A Davidson
- University of Texas Southwestern Medical School, Dallas, Texas, USA
| | | | | | | |
Collapse
|
41
|
DeWitt DE, Dugdale DC. Common problems in outpatient management of patients with diabetes in the age of insulin analogues. Prim Care 2003; 30:543-56, vi. [PMID: 14692200 DOI: 10.1016/s0095-4543(03)00037-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Most patients with diabetes are managed in an outpatient primary care setting. This article reviews common dilemmas in outpatient insulin therapy and presents the evidence regarding the rational use of insulin therapy and combination oral agent-insulin therapy.
Collapse
Affiliation(s)
- Dawn E DeWitt
- WWAMI Regional Community Based Education in Internal Medicine, Division of General Internal Medicine, University of Washington, General Internal Medicine Center, 4245 Roosevelt Way NE, Box 354760, Seattle, WA 98105, USA
| | | |
Collapse
|
42
|
Abstract
Insulin lispro, the first insulin analogue to be used clinically, was engineered to incorporate the pharmacological advantages of insulin-like growth factor-1 (IGF-1), which has a reduced tendency to self associate, compared to conventional soluble insulin. It is absorbed more quickly following a subcutaneous injection, reaching peak concentrations (approximately twice as much as conventional insulin) and then falls more rapidly. These more physiological insulin profiles are reflected in the results of clinical trials involving patients with Type 1 diabetes, which generally show comparable glycaemic control but reduced rates of hypoglycaemia, particularly at night. The reduction in the rate of hypoglycaemia in the early trials has been generally fairly modest, but more recent publications suggest that increasing experience and more individualised insulin adjustment may lead to a greater impact. Other indications include its use in continuous subcutaneous insulin infusion and postprandially in young children.
Collapse
Affiliation(s)
- Simon Heller
- University of Sheffield, Clinical Sciences Centre, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK.
| |
Collapse
|
43
|
McAulay V, Frier BM. Insulin analogues and other developments in insulin therapy for diabetes. Expert Opin Pharmacother 2003; 4:1141-56. [PMID: 12831339 DOI: 10.1517/14656566.4.7.1141] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Diabetes mellitus is a common chronic disorder, which is increasing in prevalence on a global scale. Insulin replacement therapy is required for all people with Type 1 diabetes and for many with Type 2 diabetes, to correct the metabolic abnormalities of these disorders. However, the pharmacokinetics and glucodynamics of available insulins have numerous limitations. Problems include delayed absorption from subcutaneous absorption sites (soluble [regular] insulin), and wide variability of absorption characteristics (insulin isophane suspension [NPH] and insulin lente) that is influenced by the adequacy of resuspension, and by a variable and insufficient duration of action, which usually requires intermediate-acting insulins to be administered twice-daily. All insulin preparations are associated with the common side effect of hypoglycaemia, and encourage weight gain.
Collapse
Affiliation(s)
- Vincent McAulay
- Department of Diabetes, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, Scotland, UK
| | | |
Collapse
|
44
|
Holcombe JH, Zalani S, Arora VK, Mast CJ. Comparison of insulin lispro with regular human insulin for the treatment of type 1 diabetes in adolescents. Clin Ther 2002; 24:629-38. [PMID: 12017407 DOI: 10.1016/s0149-2918(02)85138-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although insulin lispro (insulin LP) has been shown to improve postprandial blood glucose (BG) control and reduce hypoglycemic episodes in adult patients with type I diabetes, there appear to have been few clinical studies focusing on its use in adolescents. OBJECTIVE This study compared the effects of insulin LP with those of regular human insulin (insulin R) on postprandial BG control and hypoglycemia in adolescents with type diabetes. METHODS In this crossover, open-label study, adolescents between the ages of 9 and 18 years who had reached Tanner stage II puberty were randomized to receive either insulin LP immediately before meals or insulin R 30 to 45 minutes before meals, in addition to daily intermediate-acting insulin. After 4 months, patients were switched to the alternate treatment sequence. Eight-point BG profiles, hypoglycemia rate, and glycosylated hemoglobin (HbA1c) were measured at baseline and end point. RESULTS Four hundred eighty-one adolescents participated in the study at 53 investigative sites in 15 countries; 463 were randomized to treatment (228 insulin LP, 235 insulin R), and 457 completed the study. Insulin LP given before breakfast resulted in significantly lower mean (+/-SD) 2-hour postprandial BG levels compared with insulin R (9.7 +/- 4.0 mmol/L vs 10.6 +/- 4.3 mmol/L, respectively; P < 0.001). Insulin LP given before dinner resulted in significantly lower 2-hour postprandial BG levels compared with insulin R (8.6 +/- 3.5 mmol/L vs 9.3 +/- 3.7 mmol/L; P = 0.003). No differences were seen between treatments in 2-hour postprandial BG levels after the midday meal. Mean baseline HbA1c values were similar between sequence groups, and no between-group difference in HbA1c was observed at end point (insulin LP, 8.69% +/- 1.52%; insulin R, 8.70% +/- 1.65%). Treatment with insulin LP resulted in a significantly lower incidence of hypoglycemic episodes per patient per 30 days compared with insulin R (4.02 +/- 4.5 vs 4.37 +/- 4.5, respectively; P = 0.023) and significantly fewer hypoglycemic episodes between midnight and 6 AM (1.0 +/- 1.9 vs 1.7 +/- 2.6; P < 0.001). CONCLUSIONS In adolescents with type 1 diabetes, insulin LP significantly improved postprandial glycemic control and reduced episodes of nocturnal hypoglycemia compared with insulin R. Insulin LP was well tolerated and effective as part of an intensified insulin regimen in this study population.
Collapse
Affiliation(s)
- John H Holcombe
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, Indiana 46285, USA.
| | | | | | | |
Collapse
|
45
|
Madsbad S. Insulin analogues: have they changed insulin treatment and improved glycaemic control? Diabetes Metab Res Rev 2002; 18 Suppl 1:S21-8. [PMID: 11921426 DOI: 10.1002/dmrr.206] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
To improve insulin therapy, new insulin analogues have been developed. Two fast-acting analogues with a more rapid onset of effect and a shorter duration of action combined with a low day-to-day variation in absorption rate are now available. Despite this favourable time-action profile most studies have not been able to show any improvement in overall glycaemic control with the fast-acting analogues. A reduced post-prandial increase in blood glucose has been found in all studies, whereas between 3 and 5 h after the meal and during the night an increased blood glucose level is the normal course. This is probably the main explanation for the absence of improvement in overall glycaemic control when compared with regular human insulin. A tendency to a reduction in hypoglycaemic events during treatment with fast-acting analogues has been observed in most studies. Recent studies have indicated that NPH insulin administered several times daily at mealtimes can improve glycaemic control without increasing the risk of hypoglycaemia. The fast-acting analogues are now also available as insulin mixed with NPH. Insulin glargine is a new long-acting insulin which is soluble and precipitates after injection, resulting in a long half-life with a residual activity of about 50% 24 h after injection. Insulin glargine is a peakless insulin and studies in both type 1 and type 2 diabetic patients indicate that glargine improves fasting blood glucose control and reduces the incidence of nocturnal hypoglycaemia. Surprisingly, the new fast-acting analogues have not achieved the expected commercial success, which emphasises the need for new strategies for basal insulin supplementation, exercise, diet and blood glucose monitoring.
Collapse
Affiliation(s)
- Sten Madsbad
- Department of Endocrinology, Hvidovre University Hospital, Hvidovre, Denmark.
| |
Collapse
|
46
|
Herz M, Profozic V, Arora V, Smircic-Duvnjak L, Kovacevic I, Boras J, Campaigne BN, Metelko Z. Effects of a fixed mixture of 25% insulin lispro and 75% NPL on plasma glucose during and after moderate physical exercise in patients with type 2 diabetes. Curr Med Res Opin 2002; 18:188-93. [PMID: 12201618 DOI: 10.1185/030079902125000615] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the plasma glucose (PG) response with a fixed mixture of 25% insulin lispro and 75% NPL (Mix25), prior to a meal and 3 h before exercise, to human insulin 30/70 (30/70) in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS Thirty-seven patients were treated in a randomized, open-label, 8-week, two-period crossover study. Mix25 was injected 5 min before breakfast and dinner throughout the study, as was 30/70 on inpatient test days and on outpatient dose titration days. Following the 4-week outpatient phase, patients were hospitalized, and exercised at a heart rate of 120 beats/min on a cycle ergometer two times for 30 min, separated by 30 min rest, starting 3 h after a 339 kcal breakfast. RESULTS The 2-h postprandial PG was significantly lower with Mix25 ((mean +/- SEM) 10.5 +/- 0.4 mmol/l vs 11.6 +/- 0.4 mmol/l; p = 0.016). Maximum decrease in PG from onset of exercise to end of exercise was significantly less with Mix25 (-3.6 +/- 0.29 mmol/l vs -4.7 +/- 0.31 mmol/l; p = 0.001). The maximum decrease in PG over 6 h, after exercise onset, was significantly less with Mix25 (-4.3 +/- 0.4 mmol/l vs -5.9 +/- 0.4 mmol/l; p < 0.001). The frequency of hypoglycemia (blood glucose (BG) < 3 mmol/l or symptoms) during the inpatient test was not different between treatments. During the outpatient phase, the frequency of patient-recorded hypoglycemia was significantly lower with Mix25 (0.7 +/- 0.2 episodes/30 d vs 1.2 +/- 0.3 episodes/30 d; p = 0.042). CONCLUSIONS Mix25 resulted in better postprandial PG control without an increase in exercise-induced hypoglycemia. The smaller decrease in PG during the postprandial phase after exercise may suggest a lower risk of exercise-induced hypoglycemia with Mix25 than with human insulin 30/70, especially for patients in tight glycemic control.
Collapse
Affiliation(s)
- M Herz
- Diabetes Product Team, El Lilly and Company, Indianapolis, Indiana, USA.
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Raskin P, Holcombe JH, Tamborlane WV, Malone JI, Strowig S, Ahern JA, Lavent F. A comparison of insulin lispro and buffered regular human insulin administered via continuous subcutaneous insulin infusion pump. J Diabetes Complications 2001; 15:295-300. [PMID: 11711322 DOI: 10.1016/s1056-8727(01)00168-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This study compared glycemic control achieved with insulin lispro or buffered regular human insulin in patients with Type 1 diabetes treated with continuous subcutaneous insulin infusion (CSII) using an external insulin pump. In this 24-week multicenter, randomized, two-way crossover, open-label trial, 58 patients on CSII with adequate glycemic control received either insulin lispro or buffered regular human insulin for 12 weeks, followed by the alternate treatment for another 12 weeks. Efficacy and safety measures included hemoglobin A(1c) (HbA(1c)) at baseline and endpoint, home blood glucose monitoring, hypoglycemia, and frequency of pump catheter occlusion. Patients consumed a standard test meal on three occasions, with determinations of fasting, 1- and 2-h postprandial glucose values. Insulin lispro use was associated with a significantly lower HbA(1c) than was buffered regular human insulin (7.41+/-0.97 vs. 7.65+/-0.85 mmol/l; P=.004). Fasting serum glucose values before the test meal were similar between the two therapies. The 1-h (11.16+/-4.29 vs. 13.20+/-4.68 mmol/l; P=.012) and 2-h (9.64+/-4.10 vs. 12.53+/-4.64 mmol/l; P=.001) postprandial glucose concentrations were significantly lower during treatment with insulin lispro. No differences between treatments were observed in basal or bolus insulin doses, weight gain, or the incidence and rate of hypoglycemia, hyperglycemia, or pump occlusions. When used in external pumps, insulin lispro provides better glycemic control than buffered regular human insulin with a similar adverse event profile.
Collapse
Affiliation(s)
- P Raskin
- Department of Internal Medicine, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, G5-238, Dallas, TX 75390-8858, USA
| | | | | | | | | | | | | |
Collapse
|
48
|
Abstract
The advent of insulin almost 80 years ago revolutionised treatment of diabetes and must be one of the most outstanding achievements of twentieth century medicine. Since then, there has been an ever-increasing awareness and acceptance of the need to achieve and sustain near-normoglycaemia to delay onset and retard progression of diabetic angiopathy. Physiological insulin replacement is therefore central to management of patients with diabetes who are unable to make [corrected] insulin. Insulin formulations, treatment strategies, and methods and routes of delivery have changed much, with more and more options for monitoring the effect on blood glucose concentrations. Patients with type 1 and type 2 diabetes need insulin much more aggressively than previously. Parallel developments in glucose-sensing technologies are welcomed as an integral part of safe and optimum implementation of insulin replacement therapy.
Collapse
Affiliation(s)
- D R Owens
- Diabetes Research Unit, Llandough Hospital, Penlan Road, Wales CF64 2XX, Penarth, UK.
| | | | | |
Collapse
|
49
|
Affiliation(s)
- T Forst
- Lilly Deutschland GmbH, Saalburgstrasse 153, 61350 Bad Homburg.
| |
Collapse
|
50
|
Rabasa-Lhoret R, Bourque J, Ducros F, Chiasson JL. Guidelines for premeal insulin dose reduction for postprandial exercise of different intensities and durations in type 1 diabetic subjects treated intensively with a basal-bolus insulin regimen (ultralente-lispro). Diabetes Care 2001; 24:625-30. [PMID: 11315820 DOI: 10.2337/diacare.24.4.625] [Citation(s) in RCA: 186] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate and validate appropriate premeal insulin dose reductions for postprandial exercises of different intensities and durations to minimize the risk of exercise-induced hypoglycemia in type 1 diabetic subjects. RESEARCH DESIGN AND METHODS Eight male type 1 diabetic patients on a basal-bolus insulin regimen of ultralente (UL) as basal insulin and lispro (LP) as premeal insulin were tested in a randomized, crossover fashion during postprandial exercise at 25% VO2max for 60 min, 50% VO2max for 30 and 60 min, and 75% VOmax for 30 min starting 90 min after a standardized mixed breakfast (600 kcal, 75 g carbohydrates). Each subject served as his own control and was rested after a full dose of insulin LP (LP 100%) and/or 50% (LP 50%) and/or 25% (LP 25%) of the current dose. RESULTS At all intensities, the full premeal insulin dose was associated with an increased risk of hypoglycemia. At 25% VO2max for 60 min, a 50% reduction in the premeal insulin dose resulted in plasma glucose of -0.62 mmol/l compared with baseline at the end of exercise. At 50% VO2max for 30 and 60 min, 50 and 75% reductions of the premeal insulin dose were associated with plasma glucose of -0.39 and +0.49 mmol/l, respectively, at the end of the exercise. At 75% VO2max, a 75% reduction of the premeal insulin dose was required to achieve appropriate postexercise plasma glucose (+0.71 mmol/l). Such reductions in the premeal insulin dose resulted in a 75% decrease in the incidence of exercise-induced hypoglycemia. CONCLUSIONS In well-controlled type 1 diabetic subjects on intensive insulin therapy with the basal-bolus (UL-LP) insulin regimen, risk of hypoglycemia can be minimized during postprandial exercises of different intensities and different durations by appropriate reduction of premeal insulin LP.
Collapse
Affiliation(s)
- R Rabasa-Lhoret
- Centre Hospitalier de l'Université de Montréal CHUM, Department of Medicine, University of Montreal, Québec, Canada
| | | | | | | |
Collapse
|