Weight Management in Youth with Type 1 Diabetes and Obesity: Challenges and Possible Solutions

The Interplay between Dietary Habits and Glycemic Control in Type 1 Diabetes: A Comprehensive Prospective FGM Study

Type 1 diabetes has become prevalent among the adult population, who have increasingly gained access to sensing technology. This study delved into the impact of diet, nutritional status, and the use of a continuous glucose monitoring system (CGM) on glycemic regulation among adults diagnosed with T1D. Employing a prospective design, data were gathered from 151 participants aged 18-60 across multiple cycles. Participants utilized the FreeStyle Libre (FSL) Flash Glucose Monitoring (FGM) System and provided dietary details via questionnaires and diaries. The findings unveiled correlations between dietary patterns and glycemic control, with higher protein intake associated with improved glycated hemoglobin A1C values (p = 0.019), yet elevated fat and protein consumption was linked to heightened rates of hyperglycemia. Conversely, no significant relationship was observed between dietary variables and hypoglycemia occurrence. Interestingly, subjects with more readings of glucose levels consumed fewer carbohydrates (p = 0.004) and more proteins (p = 0.000). Furthermore, physical activity and marital status correlated with glycemic stability, while higher education was associated with enhanced glycemic control (p = 0.021). This study confirmed the importance of structured education on glycemic regulation and the importance of dietary patterns in glucose management. Also, the educational role of the FGM system in changing dietary habits was confirmed, which is one of the key factors for improving glycemic regulation in continuous glucose monitoring system users.

Change in Body Mass Index in Youth in the First 5 Years After Type 1 Diabetes Mellitus Diagnosis

OBJECTIVE

Examine body mass index (BMI) trajectories in American youth with type 1 diabetes (T1D) over the first 5 years following diagnosis.

METHODS

Retrospective record review of BMI trajectories in youth with T1D diagnosed in 2015 to 2016.

RESULTS

Near the time of diabetes diagnosis, 35.5% of youth had BMIs in the overweight/obesity range. These rates increased over time (P < .001), with 52.8% having overweight/obesity 5 years after diagnosis. Average age when BMI rose from healthy to overweight/obese or overweight to obese (rise group) was at 12.7 years, occurring 2.5 years after diagnosis. There were no differences between hemoglobin A1c, use of continuous glucose monitors, or use of insulin pumps between the rise group and those with healthy BMI throughout the study period.

CONCLUSIONS

Alarmingly high rates of overweight/obesity in youth were observed within 5 years following T1D diagnosis. Awareness and further research are necessary to address this independent risk factor for morbidities.

Weight Management Behaviors are Associated with Elevated Glycemic Outcomes in Adolescents and Young Adults with Type 1 Diabetes

Many adolescents and young adults (AYAs) with type 1 diabetes (T1D) engage in weight management behaviors (i.e., trying to lose weight), and efforts to manage weight may impact glycemic control. We assessed objective/subjective weight status and weight management behaviors in a diverse sample of 76 AYAs with T1D, and examined differences in sociodemographic characteristics and A1c levels by the following categories: (1) Overweight BMI/weight management (n = 21), (2) overweight BMI/no weight management (n = 6), (3) in/below-range BMI/weight management (n = 25), (4) in/below-range BMI/no weight management (n = 24). Subjective overweight status was more common among late adolescents and females; female gender was associated with weight management behaviors. AYAs endorsing weight management behaviors evidenced higher A1c values than those who did not. Clinicians working with AYAs should be aware of associations among weight management and glycemic indicators and routinely screen for weight management behaviors. Future research should explore interventions to promote healthy lifestyle behaviors among AYAs.

An Overview of Diet and Physical Activity for Healthy Weight in Adolescents and Young Adults with Type 1 Diabetes: Lessons Learned from the ACT1ON Consortium

The prevalence of overweight and obesity in young people with type 1 diabetes (T1D) now parallels that of the general population. Excess adiposity increases the risk of cardiovascular disease, which is already elevated up to 10-fold in T1D, underscoring a compelling need to address weight management as part of routine T1D care. Sustainable weight management requires both diet and physical activity (PA). Diet and PA approaches must be optimized towards the underlying metabolic and behavioral challenges unique to T1D to support glycemic control throughout the day. Diet strategies for people with T1D need to take into consideration glycemic management, metabolic status, clinical goals, personal preferences, and sociocultural considerations. A major barrier to weight management in this high-risk population is the challenge of integrating regular PA with day-to-day management of T1D. Specifically, exercise poses a substantial challenge due to the increased risk of hypoglycemia and/or hyperglycemia. Indeed, about two-thirds of individuals with T1D do not engage in the recommended amount of PA. Hypoglycemia presents a serious health risk, yet prevention and treatment often necessitates the consumption of additional calories, which may prohibit weight loss over time. Exercising safely is a concern and challenge with weight management and maintaining cardiometabolic health for individuals living with T1D and many healthcare professionals. Thus, a tremendous opportunity exists to improve exercise participation and cardiometabolic outcomes in this population. This article will review dietary strategies, the role of combined PA and diet for weight management, current resources for PA and glucose management, barriers to PA adherence in adults with T1D, as well as findings and lessons learned from the Advancing Care for Type 1 Diabetes and Obesity Network (ACT1ON).

The impact of physical activity, quality of life and eating habits on cardiometabolic profile and adipokines in youth with T1D

PURPOSE

Individuals with Type-1-Diabetes (T1D) are at higher risk of having premature cardiovascular-disease (CVD). Physical activity and healthy lifestyle are major components in the prevention of diabetes' related comorbidities and complications. The aim of this study was to investigate the impact of physical activity, eating habits and quality of life in children and adolescents with T1D on diabetic control, cardiovascular and biochemical profile, infection indices, and adipokine levels.

METHODS

This cross-sectional study involved 80 participants (36 boys/44 girls) with T1D, aged (mean ± SD) 14.9 ± 3.4 years, who attended the Diabetes and Metabolism Clinic of a University Children's Hospital, using anthropometric studies, lipid profile, high-sensitivity-C-Reactive-Protein(hs-CRP), Interleukin-6(IL6), leptin and adiponectin levels. Physical activity was assessed with pedometers (total-steps/week) and questionnaire.

RESULTS

In 20(25%) children the level of exercise was >75th percentile, in 20(25%) <25th percentile and in 40(50%) children ranged between 25-75th percentile, respectively. Higher levels of physical activity were associated with weight (beta = -0.053, p < 0.001), waist circumference (beta = -0.077, p < 0.001), BMI (beta = -0.167, p = 0.009), muscle mass (beta = -0.0619, p = 0.001) and HDL-C (beta = 0.039, p = 0.033). Quality of life was positively related to weight (beta = 5.49511, p = 0.002), waist circumference (beta = 6.593345, p = 0.012), muscle mass (beta = 7.324088, p < 0.001) and T1D duration (beta = 19.22442, p = 0.005). Lipid profile was positively associated with sweets and chocolate consumption (beta = 0.348, p < 0.05), while vegetable (beta = -0.245, p < 0.05) and white milk consumption (beta = -0.2295, p < 0.05) were negatively associated with waist/height ratio.

CONCLUSIONS

In the present study, higher levels of physical activity were associated with improved lipid profile (HDL-C, triglycerides) and body composition [waist circumference, Body-Mass-Index (BMI] of children and adolescents with T1D. Higher scoring in quality-of-life questionnaires were related to older children with longer diabetes duration. Unhealthy eating habits unfavorably affected lipid profile and body composition in T1D youth.

Body composition and physical fitness improve after 8 weeks of high-intensity circuit training using body weight in obese women

BACKGROUND

We examined the effects of an 8-week modified high-intensity circuit training using body weight as resistance (HICT^BW) on health-related physical fitness in sedentary obese women.

METHODS

Twenty-four sedentary obese women were allocated into the HICT^BW or a non-training control group (CG). The modified HICT^BW was performed for eight weeks (three times per week). Training consisted of a 30-second workout and 10-second rest for 12 exercise poses per one circuit (one circuit in the first week), with an increase of one circuit every two weeks. Body weight and body composition included skeletal muscle mass (SMM), body fat mass (BFM), body fat percentage (BF%), visceral fat area (VFA), and skeletal muscle mass to visceral fat area ratio (MFR) were measured. Physical fitness included flexibility of the lower back and hamstrings (Flex<inf>LH</inf>), and leg and handgrip muscle strength (Strength<inf>Leg</inf>, Strength<inf>HG</inf>). Cardiovascular endurance included the Åstrand-Rhyming heart rate (HR<inf>Åstrand</inf>), relative maximum oxygen uptake (relative V̇O<inf>2max</inf>), and workload.

RESULTS

All variables were obtained at baseline, week 4, and week 8. The HICT^BW improved Flex<inf>LH</inf>, Strength<inf>Leg</inf>, and relative V̇O<inf>2max</inf> from baseline to week 4 (All P<0.05). Improvements from baseline to week 8 were observed for SMM, BFM, BF%, VFA and MFR, Flex<inf>LH</inf>, Strength<inf>Leg</inf>, HR<inf>Åstrand</inf>, relative V̇O<inf>2max</inf>, and workload (All P<0.05). Furthermore, the HICT^BW elicited a higher change in SMM (+2.9%), BFM (-3.4%), BF% (-3.2%), MFR (+9.5%), Flex<inf>LH</inf> (+145.7%) and relative V̇O<inf>2max</inf> (+32.3%) than the CG at week-8 (All P<0.05).

CONCLUSIONS

An eight-week modified HICT^BW program thrice a week is an effective training modality to influence health-related physical fitness in sedentary obese women.

Body mass index, basal insulin and glycemic control in children with type 1 diabetes treated with the advanced hybrid closed loop system remain stable - 1-year prospective, observational, two-center study

BACKGROUND

Information on the influence of insulin treatment using advanced hybrid closed loop systems (AHCL) on body weight of young patients with type 1 diabetes (T1D) is scarce. The aim of this study was to observe whether there were any changes in body mass index (BMI) of children and adolescents with T1D treated using the Medtronic Minimed 780G AHCL after 1 year of follow up and to analyze potential associations between these changes and the insulin doses.

MATERIALS AND METHODS

For 50 children and adolescents (age 5.4-16.8 years, 24 (48%) boys, T1D for 3.9 ± 2.56 years) using an AHCL system anthropometric and AHCL data were collected prospectively. BMI Z-scores and two-week AHCL records obtained after AHCL enrollment were compared with data after 6 months and also 1 year after starting AHCL.

RESULTS

The BMI Z-score of the patients at 1 year follow-up did not change from time of AHCL initiation (0.51 ± 2.79 vs 0.57 ± 2.85, p>0.05). There was a slight increase in total daily insulin per kg of body weight (0.67 ± 0.21 U/kg vs 0.80 ± 0.21 U/kg, p <0.001), but the percent of basal insulin was unchanged (34.88 ± 6.91% vs 35.08 ± 6.30%, p>0.05). We observed also no change (AHCL start vs after 1 year) in glycemic control parameters: average sensor glucose (131.36± 11.04 mg/dL vs 132.45 ± 13.42 mg/dL, p>0.05), coefficient of variation (34.99± 5.17% vs 34.06 ± 5.38%, p>0.05), glucose management indicator (6.45 ± 0.26% vs 6.48 ± 0.32%, p>0.05), and time spent in the range of 70-180 mg/dL (79.28 ± 8.12% vs 80.40 ± 8.25%, p>0.05).

CONCLUSION

During the 1 year of follow-up the BMI of children and adolescents with T1D treated with an AHCL system remained stable. Although there was a slight increase in the total daily insulin dose, the percent of basal insulin was unchanged. The patients maintained recommended glycemic control.

Multi-Faceted Influence of Obesity on Type 1 Diabetes in Children - From Disease Pathogenesis to Complications

The prevalence of overweight and obesity among youth patients with diabetes type 1 is increasing. It is estimated, that even up to 35% of young patients with this type of diabetes, considered so far to be characteristic for slim figure, are overweight or even obese. General increase of obesity in children's population complicates differential diagnosis of the type of diabetes in youths. Coexistence of obesity has clinical implications for all stages of diabetes course. It is confirmed that obesity is the risk factor for autoimmune diabetes, and is connected with the earlier onset of diabetes in predisposed patients. Many diabetic patients with obesity present additional risk factors for macroangiopathy, and are recognised to present metabolic syndrome, insulin resistance, and typical for diabetes type 2 - polycystic ovary syndrome, or non-alcoholic fatty liver disease. The prevalence of obesity rises dramatically in adolescence of diabetic child, more often in girls. It has negative impact on metabolic control, glycaemic variability and insulin demand. The risk for microangiopathic complications increases as well. The treatment is difficult and includes not only insulinotherapy and non-pharmacological trials. Recently treatment of insulin resistance with biguanids, and treatment with typical for type 2 new diabetes drugs like GLP-1 analogues, SGLT-2 receptor inhibitors, or even cases of bariatric surgery also has been reported.

Beyond Two Cultures: Cultural Infrastructure for Data-driven Decision Support

In the twenty years since Dr. Leo Breiman's incendiary paper Statistical Modeling: The Two Cultures was first published, algorithmic modeling techniques have gone from controversial to commonplace in the statistical community. While the widespread adoption of these methods as part of the contemporary statistician's toolkit is a testament to Dr. Breiman's vision, the number of high-profile failures of algorithmic models suggests that Dr. Breiman's final remark that "the emphasis needs to be on the problem and the data" has been less widely heeded. In the spirit of Dr. Breiman, we detail an emerging research community in statistics - data-driven decision support. We assert that to realize the full potential of decision support, broadly and in the context of precision health, will require a culture of social awareness and accountability, in addition to ongoing attention towards complex technical challenges.

Preventing Cardiovascular Complications in Type 1 Diabetes: The Need for a Lifetime Approach

Cardiovascular disease (CVD) remains the main cause of morbidity and mortality in individuals with type 1 diabetes (T1D). Adolescence appears to be a critical time for the development of early subclinical manifestations of CVD, with these changes likely driven by a deterioration in glycemic control during the progression through puberty, combined with the emergence of numerous other traditional cardiometabolic risk factors (e.g., hypertension, dyslipidemia, smoking, alcohol use, obesity, etc.) which emerge at this age. Although hemoglobin A1C has long been the primary focus of screening and treatment strategies, glycemic control remains poor in youth with T1D. Furthermore, screening for cardiovascular risk factors-which are often elevated in youth with T1D-is suboptimal, and use of pharmacological interventions for hypertension and dyslipidemia remains low. As such, there is a clear need not only for better screening strategies for CVD risk factors in youth, but also early interventions to reduce these, if future CVD events have to be prevented. Accumulating evidence has recently suggested that early increases in urinary albumin excretion, even within the normal range, may identify adolescents with T1D who are at an increased risk of complications, and results from pharmacological intervention with statins and ACE inhibitors in these individuals have been encouraging. These data join a growing evidence highlighting the need for a whole-life approach to prevention starting from childhood if efforts to improve CVD outcomes and related mortality in T1D are to be maintained.

Obesity in Patients with Type 1 Diabetes: Links, Risks and Management Challenges

Obesity affects large numbers of patients with type 1 diabetes (T1D) across their lifetime, with rates ranging between 2.8% and 37.1%. Patients with T1D and obesity are characterized by the presence of insulin resistance, of high insulin requirements, have a greater cardiometabolic risk and an enhanced risk of developing chronic complications when compared to normal-weight persons with T1D. Dual treatment of obesity and T1D is challenging and no specific guidelines for improving outcomes of both glycemic control and weight management have been established for this population. Nevertheless, although evidence is scarce, a comprehensive approach based on a balanced hypocaloric diet, physical activity and cognitive behavioral therapy by a multidisciplinary team, expert in both obesity and diabetes, remains as the best clinical practice. However, weight loss responses with lifestyle changes alone are limited, so in the "roadmap" of the treatment of obesity in T1D, it will be helpful to include anti-obesity pharmacotherapy despite at present there is a lack of evidence since T1D patients have been excluded from anti-obesity drug clinical trials. In case of severe obesity, bariatric surgery has proven to be of benefit in obtaining a substantial and long-term weight loss and reduction in cardiovascular risk. The near future looks promising with the development of new and more effective anti-obesity treatments and strategies to improve insulin resistance and oxidative stress. Advances in precision medicine may help individualize and optimize the medical management and care of these patients. This review, by gathering current evidence, highlights the need of solid knowledge in all facets of the treatment of patients with obesity and T1D that can only be obtained through high quality well-designed studies.