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Farrell CM, McNeilly AD, Hapca S, Fournier PA, Jones TW, Facchinetti A, Cappon G, West DJ, McCrimmon RJ. High intensity interval training as a novel treatment for impaired awareness of hypoglycaemia in people with type 1 diabetes (HIT4HYPOS): a randomised parallel-group study. Diabetologia 2024; 67:392-402. [PMID: 38010533 PMCID: PMC10789679 DOI: 10.1007/s00125-023-06051-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/23/2023] [Indexed: 11/29/2023]
Abstract
AIMS/HYPOTHESIS Impaired awareness of hypoglycaemia (IAH) in type 1 diabetes may develop through a process referred to as habituation. Consistent with this, a single bout of high intensity interval exercise as a novel stress stimulus improves counterregulatory responses (CRR) to next-day hypoglycaemia, referred to as dishabituation. This longitudinal pilot study investigated whether 4 weeks of high intensity interval training (HIIT) has sustained effects on counterregulatory and symptom responses to hypoglycaemia in adults with type 1 diabetes and IAH. METHODS HIT4HYPOS was a single-centre, randomised, parallel-group study. Participants were identified using the Scottish Diabetes Research Network (SDRN) and from diabetes outpatient clinics in NHS Tayside, UK. The study took place at the Clinical Research Centre, Ninewells Hospital and Medical School, Dundee, UK. Participants were aged 18-55 years with type 1 diabetes of at least 5 years' duration and HbA1c levels <75 mmol/mol (<9%). They had IAH confirmed by a Gold score ≥4, modified Clarke score ≥4 or Dose Adjustment For Normal Eating [DAFNE] hypoglycaemia awareness rating of 2 or 3, and/or evidence of recurrent hypoglycaemia on flash glucose monitoring. Participants were randomly allocated using a web-based system to either 4 weeks of real-time continuous glucose monitoring (RT-CGM) or RT-CGM+HIIT. Participants and investigators were not masked to group assignment. The HIIT programme was performed for 20 min on a stationary exercise bike three times a week. Hyperinsulinaemic-hypoglycaemic (2.5 mmol/l) clamp studies with assessment of symptoms, hormones and cognitive function were performed at baseline and after 4 weeks of the study intervention. The predefined primary outcome was the difference in hypoglycaemia-induced adrenaline (epinephrine) responses from baseline following RT-CGM or RT-CGM+HIIT. RESULTS Eighteen participants (nine men and nine women) with type 1 diabetes (median [IQR] duration 27 [18.75-32] years) and IAH were included, with nine participants randomised to each group. Data from all study participants were included in the analysis. During the 4 week intervention there were no significant mean (SEM) differences between RT-CGM and RT-CGM+HIIT in exposure to level 1 (28 [7] vs 22 [4] episodes, p=0.45) or level 2 (9 [3] vs 4 [1] episodes, p=0.29) hypoglycaemia. The CGM-derived mean glucose level, SD of glucose and glucose management indicator (GMI) did not differ between groups. During the hyperinsulinaemic-hypoglycaemic clamp studies, mean (SEM) change from baseline was greater for the noradrenergic responses (RT-CGM vs RT-CGM+HIIT: -988 [447] vs 514 [732] pmol/l, p=0.02) but not the adrenergic responses (-298 [687] vs 1130 [747] pmol/l, p=0.11) in those participants who had undergone RT-CGM+HIIT. There was a benefit of RT-CGM+HIIT for mean (SEM) change from baseline in the glucagon CRR to hypoglycaemia (RT-CGM vs RT-CGM+HIIT: 1 [4] vs 16 [6] ng/l, p=0.01). Consistent with the hormone response, the mean (SEM) symptomatic response to hypoglycaemia (adjusted for baseline) was greater following RT-CGM+HIIT (RT-CGM vs RT-CGM+HIIT: -4 [2] vs 0 [2], p<0.05). CONCLUSIONS/INTERPRETATION In this pilot clinical trial in people with type 1 diabetes and IAH, we found continuing benefits of HIIT for overall hormonal and symptomatic CRR to subsequent hypoglycaemia. Our findings also suggest that HIIT may improve the glucagon response to insulin-induced hypoglycaemia. TRIAL REGISTRATION ISRCTN15373978. FUNDING Sir George Alberti Fellowship from Diabetes UK (CMF) and the Juvenile Diabetes Research Foundation.
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Affiliation(s)
- Catriona M Farrell
- Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Alison D McNeilly
- Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Simona Hapca
- Computing Science and Mathematics, Faculty of Natural Sciences, University of Stirling, Stirling, UK
| | | | | | - Andrea Facchinetti
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Giacomo Cappon
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Daniel J West
- Population Health Sciences Institute, Faculty of Medical Science, Newcastle University, Newcastle upon Tyne, UK
| | - Rory J McCrimmon
- Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, UK.
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D’Souza NC, Kesibi D, Yeung C, Shakeri D, D’Souza AI, Macpherson AK, Riddell MC. The Impact of Sex, Body Mass Index, Age, Exercise Type and Exercise Duration on Interstitial Glucose Levels during Exercise. SENSORS (BASEL, SWITZERLAND) 2023; 23:9059. [PMID: 38005447 PMCID: PMC10674905 DOI: 10.3390/s23229059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023]
Abstract
The impact of age, sex and body mass index on interstitial glucose levels as measured via continuous glucose monitoring (CGM) during exercise in the healthy population is largely unexplored. We conducted a multivariable generalized estimating equation (GEE) analysis on CGM data (Dexcom G6, 10 days) collected from 119 healthy exercising individuals using CGM with the following specified covariates: age; sex; BMI; exercise type and duration. Females had lower postexercise glycemia as compared with males (92 ± 18 vs. 100 ± 20 mg/dL, p = 0.04) and a greater change in glycemia during exercise from pre- to postexercise (p = 0.001) or from pre-exercise to glucose nadir during exercise (p = 0.009). Younger individuals (i.e., <20 yrs) had higher glucose during exercise as compared with all other age groups (all p < 0.05) and less CGM data in the hypoglycemic range (<70 mg/dL) as compared with those aged 20-39 yrs (p < 0.05). Those who were underweight, based on body mass index (BMI: <18.5 kg/m2), had higher pre-exercise glycemia than the healthy BMI group (104 ± 20 vs. 97 ± 17 mg/dL, p = 0.02) but similar glucose levels after exercise. Resistance exercise was associated with less of a drop in glycemia as compared with aerobic or mixed forms of exercise (p = 0.008) and resulted in a lower percent of time in the hypoglycemic (p = 0.04) or hyperglycemic (glucose > 140 mg/dL) (p = 0.03) ranges. In summary, various factors such as age, sex and exercise type appear to have subtle but potentially important influence on CGM measurements during exercise in healthy individuals.
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Affiliation(s)
- Ninoschka C. D’Souza
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, ON M3J 1P3, Canada; (N.C.D.); (D.K.); (C.Y.); (D.S.); (A.K.M.)
| | - Durmalouk Kesibi
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, ON M3J 1P3, Canada; (N.C.D.); (D.K.); (C.Y.); (D.S.); (A.K.M.)
| | - Christopher Yeung
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, ON M3J 1P3, Canada; (N.C.D.); (D.K.); (C.Y.); (D.S.); (A.K.M.)
| | - Dorsa Shakeri
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, ON M3J 1P3, Canada; (N.C.D.); (D.K.); (C.Y.); (D.S.); (A.K.M.)
| | | | - Alison K. Macpherson
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, ON M3J 1P3, Canada; (N.C.D.); (D.K.); (C.Y.); (D.S.); (A.K.M.)
| | - Michael C. Riddell
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, ON M3J 1P3, Canada; (N.C.D.); (D.K.); (C.Y.); (D.S.); (A.K.M.)
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Macon EL, Devore MH, Lin YK, Music MB, Wooten M, McMullen CA, Woodcox AM, Marksbury AR, Beckner Z, Patel BV, Schoeder LA, Iles AN, Fisher SJ. Current and future therapies to treat impaired awareness of hypoglycemia. Front Pharmacol 2023; 14:1271814. [PMID: 37942482 PMCID: PMC10628050 DOI: 10.3389/fphar.2023.1271814] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/05/2023] [Indexed: 11/10/2023] Open
Abstract
In order to achieve optimal glycemic control, intensive insulin regimes are needed for individuals with Type 1 Diabetes (T1D) and insulin-dependent Type 2 Diabetes (T2D). Unfortunately, intensive glycemic control often results in insulin-induced hypoglycemia. Moreover, recurrent episodes of hypoglycemia result in both the loss of the characteristic warning symptoms associated with hypoglycemia and an attenuated counterregulatory hormone responses. The blunting of warning symptoms is known as impaired awareness of hypoglycemia (IAH). Together, IAH and the loss of the hormonal response is termed hypoglycemia associated autonomic failure (HAAF). IAH is prevalent in up to 25% in people with T1D and up to 10% in people with T2D. IAH and HAAF increase the risk of severe hypoglycemia 6-fold and 25-fold, respectively. To reduce this risk for severe hypoglycemia, multiple different therapeutic approaches are being explored that could improve awareness of hypoglycemia. Current therapies to improve awareness of hypoglycemia include patient education and psychoeducation, the use of novel glycemic control technology, pancreas/islet transplantation, and drug therapy. This review examines both existing therapies and potential therapies that are in pre-clinical testing. Novel treatments that improve awareness of hypoglycemia, via improving the counterregulatory hormone responses or improving hypoglycemic symptom recognition, would also shed light on the possible neurological mechanisms that lead to the development of IAH. To reduce the risk of severe hypoglycemia in people with diabetes, elucidating the mechanism behind IAH, as well as developing targeted therapies is currently an unmet need for those that suffer from IAH.
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Affiliation(s)
- Erica L. Macon
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Micah H. Devore
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Yu Kuei Lin
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Megan B. Music
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Mason Wooten
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Colleen A. McMullen
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Andrea M. Woodcox
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Ashlee R. Marksbury
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Zachary Beckner
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Bansi V. Patel
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Lily A. Schoeder
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Ashley N. Iles
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Simon J. Fisher
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
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Armstrong M, Colberg SR, Sigal RJ. Where to Start? Physical Assessment, Readiness, and Exercise Recommendations for People With Type 1 or Type 2 Diabetes. Diabetes Spectr 2023; 36:105-113. [PMID: 37193205 PMCID: PMC10182968 DOI: 10.2337/dsi22-0016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Exercise plays an important role in the management of diabetes and is associated with many benefits such as decreased morbidity and mortality. For people exhibiting signs and symptoms of cardiovascular disease, pre-exercise medical clearance is warranted; however, requiring broad screening requirements can lead to unnecessary barriers to initiating an exercise program. Robust evidence supports the promotion of both aerobic and resistance training, with evidence emerging on the importance of reducing sedentary time. For people with type 1 diabetes, there are special considerations, including hypoglycemia risk and prevention, exercise timing (including prandial status), and differences in glycemic responses based on biological sex.
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Affiliation(s)
- Marni Armstrong
- Medicine Strategic Clinical Network, Alberta Health Services, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sheri R. Colberg
- Human Movement Sciences Department, Old Dominion University, Norfolk, VA
| | - Ronald J. Sigal
- Departments of Medicine, Cardiac Sciences, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Abstract
Regular physical activity improves cardiometabolic and musculoskeletal health, helps with weight management, improves cognitive and psychosocial functioning, and is associated with reduced mortality related to cancer and diabetes mellitus. However, turnover rates of glucose in the blood increase dramatically during exercise, which often results in either hypoglycaemia or hyperglycaemia as well as increased glycaemic variability in individuals with type 1 diabetes mellitus (T1DM). A complex neuroendocrine response to an acute exercise session helps to maintain circulating levels of glucose in a fairly tight range in healthy individuals, while several abnormal physiological processes and limitations of insulin therapy limit the capacity of people with T1DM to exercise in a normoglycaemic state. Knowledge of the acute and chronic effects of exercise and regular physical activity is critical for the formulation of clinical strategies for the management of insulin and nutrition for active patients with T1DM. Emerging diabetes-related technologies, such as continuous glucose monitors, automated insulin delivery systems and the administration of solubilized glucagon, are demonstrating efficacy for preserving glucose homeostasis during and after exercise in this population of patients. This Review highlights the beneficial effects of regular exercise and details the complex endocrine and metabolic responses to different types of exercise for adults with T1DM. An overview of basic clinical strategies for the preservation of glucose homeostasis using emerging technologies is also provided.
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Affiliation(s)
- Michael C Riddell
- Muscle Health Research Centre, School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada.
- LMC Diabetes and Endocrinology, Toronto, Ontario, Canada.
| | - Anne L Peters
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Hagelqvist PG, Andersen A, Maytham KB, Andreasen CR, Engberg S, Lindhardt TB, Faber J, Holst JJ, Forman JL, Pedersen-Bjergaard U, Knop FK, Vilsbøll T. Exercise-related hypoglycaemia induces QTc-interval prolongation in individuals with type 1 diabetes. Diabetes Obes Metab 2023; 25:1186-1195. [PMID: 36593718 DOI: 10.1111/dom.14964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/20/2022] [Accepted: 12/30/2022] [Indexed: 01/04/2023]
Abstract
AIMS To investigate changes in cardiac repolarisation during exercise-related hypoglycaemia compared to hypoglycaemia induced at rest in people with type 1 diabetes. MATERIAL AND METHODS In a randomised crossover study, 15 men with type 1 diabetes underwent two separate hyperinsulinaemic euglycaemic-hypoglycaemic clamp experiments during Holter-ECG monitoring. One experiment included a bout of moderate-intensity cycling exercise (60 min) along with declining plasma glucose (PG; Clamp-exercise). In the other experiment, hypoglycaemia was induced with the participants at rest (Clamp-rest). We studied QTc interval, T-peak to T-end (Tpe) interval and hormonal responses during three steady-state phases: (i) baseline (PG 4.0-8.0 mmol/L); (ii) hypoglycaemic phase (PG <3.0 mmol/L); and (iii) recovery phase (PG 4.0-8.0 mmol/L). RESULTS Both QTc interval and Tpe interval increased significantly from baseline during the hypoglycaemic phase but with no significant difference between test days. These changes were accompanied by an increase in plasma adrenaline and a decrease in plasma potassium on both days. During the recovery phase, ΔQTc interval was longer during Clamp-rest compared to Clamp-exercise, whereas ΔTpe interval remained similar on the two test days. CONCLUSIONS We found that both exercise-related hypoglycaemia and hypoglycaemia induced at rest can cause QTc-interval prolongation and Tpe-interval prolongation in people with type 1 diabetes. Thus, both scenarios may increase susceptibility to ventricular arrhythmias.
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Affiliation(s)
- Per G Hagelqvist
- Clinical Research, Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Andreas Andersen
- Clinical Research, Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Kaisar B Maytham
- Clinical Research, Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Christine R Andreasen
- Clinical Research, Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Susanne Engberg
- Clinical Research, Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Tommi B Lindhardt
- Department of Cardiology, Nordsjaellands Hospital Hillerød, University of Copenhagen, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens Faber
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Endocrinology, Herlev Hospital, Herlev, Denmark
| | - Jens J Holst
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Julie L Forman
- Section of Biostatistics, Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ulrik Pedersen-Bjergaard
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Endocrinology and Nephrology, Nordsjaellands Hospital Hillerød, University of Copenhagen, Hillerød, Denmark
| | - Filip K Knop
- Clinical Research, Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tina Vilsbøll
- Clinical Research, Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Center for Clinical Metabolic Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Sanchez-Rangel E, Deajon-Jackson J, Hwang JJ. Pathophysiology and management of hypoglycemia in diabetes. Ann N Y Acad Sci 2022; 1518:25-46. [PMID: 36202764 DOI: 10.1111/nyas.14904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In the century since the discovery of insulin, diabetes has changed from an early death sentence to a manageable chronic disease. This change in longevity and duration of diabetes coupled with significant advances in therapeutic options for patients has fundamentally changed the landscape of diabetes management, particularly in patients with type 1 diabetes mellitus. However, hypoglycemia remains a major barrier to achieving optimal glycemic control. Current understanding of the mechanisms of hypoglycemia has expanded to include not only counter-regulatory hormonal responses but also direct changes in brain glucose, fuel sensing, and utilization, as well as changes in neural networks that modulate behavior, mood, and cognition. Different strategies to prevent and treat hypoglycemia have been developed, including educational strategies, new insulin formulations, delivery devices, novel technologies, and pharmacologic targets. This review article will discuss current literature contributing to our understanding of the myriad of factors that lead to the development of clinically meaningful hypoglycemia and review established and novel therapies for the prevention and treatment of hypoglycemia.
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Affiliation(s)
- Elizabeth Sanchez-Rangel
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jelani Deajon-Jackson
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Janice Jin Hwang
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA.,Division of Endocrinology, Department of Internal Medicine, University of North Carolina - Chapel Hill, Chapel Hill, North Carolina, USA
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Lin YK, Fisher SJ, Pop‐Busui R. Hypoglycemia unawareness and autonomic dysfunction in diabetes: Lessons learned and roles of diabetes technologies. J Diabetes Investig 2020; 11:1388-1402. [PMID: 32403204 PMCID: PMC7610104 DOI: 10.1111/jdi.13290] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/01/2020] [Accepted: 05/07/2020] [Indexed: 12/18/2022] Open
Abstract
Impaired awareness of hypoglycemia (IAH) is a reduction in the ability to recognize low blood glucose levels that would otherwise prompt an appropriate corrective therapy. Identified in approximately 25% of patients with type 1 diabetes, IAH has complex pathophysiology, and might lead to serious and potentially lethal consequences in patients with diabetes, particularly in those with more advanced disease and comorbidities. Continuous glucose monitoring systems can provide real-time glucose information and generate timely alerts on rapidly falling or low blood glucose levels. Given their improvements in accuracy, affordability and integration with insulin pump technology, continuous glucose monitoring systems are emerging as critical tools to help prevent serious hypoglycemia and mitigate its consequences in patients with diabetes. This review discusses the current knowledge on IAH and effective diagnostic methods, the relationship between hypoglycemia and cardiovascular autonomic neuropathy, a practical approach to evaluating cardiovascular autonomic neuropathy for clinicians, and recent evidence from clinical trials assessing the effects of the use of CGM technologies in patients with type 1 diabetes with IAH.
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Affiliation(s)
- Yu Kuei Lin
- Division of Metabolism, Endocrinology and DiabetesDepartment of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Simon J Fisher
- Division of Endocrinology, Metabolism and DiabetesDepartment of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Rodica Pop‐Busui
- Division of Metabolism, Endocrinology and DiabetesDepartment of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
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Diabetic Cardiomyopathy and Ischemic Heart Disease: Prevention and Therapy by Exercise and Conditioning. Int J Mol Sci 2020; 21:ijms21082896. [PMID: 32326182 PMCID: PMC7215312 DOI: 10.3390/ijms21082896] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/14/2020] [Accepted: 04/18/2020] [Indexed: 02/06/2023] Open
Abstract
Metabolic syndrome, diabetes, and ischemic heart disease are among the leading causes of death and disability in Western countries. Diabetic cardiomyopathy is responsible for the most severe signs and symptoms. An important strategy for reducing the incidence of cardiovascular disease is regular exercise. Remote ischemic conditioning has some similarity with exercise and can be induced by short periods of ischemia and reperfusion of a limb, and it can be performed in people who cannot exercise. There is abundant evidence that exercise is beneficial in diabetes and ischemic heart disease, but there is a need to elucidate the specific cardiovascular effects of emerging and unconventional forms of exercise in people with diabetes. In addition, remote ischemic conditioning may be considered among the options to induce beneficial effects in these patients. The characteristics and interactions of diabetes and ischemic heart disease, and the known effects of exercise and remote ischemic conditioning in the presence of metabolic syndrome and diabetes, are analyzed in this brief review.
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Rhyu YA, Jang JY, Park S, An JH, Kim DL, Kim SK, Song KH. Impaired Cortisol and Growth Hormone Counterregulatory Responses among Severe Hypoglycemic Patients with Type 2 Diabetes Mellitus. Endocrinol Metab (Seoul) 2019; 34:187-194. [PMID: 31257746 PMCID: PMC6599906 DOI: 10.3803/enm.2019.34.2.187] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 04/11/2019] [Accepted: 04/16/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Elevated levels of cortisol and growth hormone are critical counterregulatory responses to severe hypoglycemia. However, the proportion and clinical characteristics of patients with type 2 diabetes mellitus (DM) who fail to show appropriate cortisol and/or growth hormone secretion in response to severe hypoglycemia have not been investigated. METHODS We measured plasma cortisol and growth hormone levels in type 2 DM patients with severe hypoglycemia who visited the emergency department between 2006 and 2015. RESULTS Of 112 hypoglycemic patients, 23 (20.5%) had an impaired cortisol response (<18 μg/dL) and 82 patients (73.2%) had an impaired growth hormone response (<5 ng/mL). Nineteen patients (17.0%) had impaired responses to both cortisol and growth hormone. The patients with impaired responses of cortisol, growth hormone, and both hormones were significantly older and more likely to be female, and had higher admission rates, lower growth hormone levels, and lower adrenocorticotropic hormone levels than the patients with a normal hormonal response. Multivariate logistic regression analysis indicated that an impaired growth hormone response was significantly associated with advanced age, shorter DM duration, a higher admission rate, and a higher body mass index (BMI). An impaired cortisol response was significantly associated with growth hormone levels. Patients with an impaired growth hormone response had higher admission rates than patients with a normal response. CONCLUSION A considerable number of type 2 DM patients had impaired cortisol and/or growth hormone responses to severe hypoglycemia. Advanced age, shorter DM duration, and higher BMI were independently associated with an abnormal growth hormone response.
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Affiliation(s)
- Young A Rhyu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Ju Young Jang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Sooyoun Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Jee Hyun An
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Dong Lim Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Suk Kyeong Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Kee Ho Song
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea.
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Nistor M, Schmidt M, Graul I, Rakers F, Schiffner R. A Systematic Review of Neuroprotective Strategies in the Management of Hypoglycemia. Int J Mol Sci 2019; 20:ijms20030550. [PMID: 30696060 PMCID: PMC6386855 DOI: 10.3390/ijms20030550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 01/18/2019] [Accepted: 01/24/2019] [Indexed: 02/07/2023] Open
Abstract
Severe hypogylcemia has been found to induce cerebral damage. While a number of illnesses can lead to hypoglycemic episodes, antidiabetic medications prescribed for glycemic control are a common cause. Considering the rising prevalence of diabetes mellitus in the population, we investigated neuroprotective strategies during hypoglycemia in the form of a systematic review in adherence to the PRISMA statement. A review protocol was registered in the PROSPERO database. A systematic literature search of PubMed, Web of Science, and CENTRAL was performed in September 2018. Based on a predefined inclusion protocol, results were screened and evaluated by two researchers. Both animal experiments and human studies were included, and their risk of bias was assessed with SYRCLE’s and the Cochrane risk of bias tools, respectively. Of a total of 16,230 results, 145 were assessed in full-text form: 27 articles adhered to the inclusion criteria and were qualitatively analyzed. The retrieved neuroprotective strategies could be categorized into three subsets: (1) Energy substitution, (2) hypoglycemia unawareness, and (3) other neuroprotective strategies. While on a study level, the individual results appeared promising, more research is required to investigate not only specific neuroprotective strategies against hypoglycemic cerebral damage, but also its underlying pathophysiological mechanisms.
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Affiliation(s)
- Marius Nistor
- Department of Neurology, Jena University Hospital - Friedrich Schiller University, Jena 07747, Germany.
| | - Martin Schmidt
- Institute for Biochemistry II, Jena University Hospital - Friedrich Schiller University, Jena 07743, Germany.
| | - Isabel Graul
- Orthopedic Department, Jena University Hospital - Friedrich Schiller University, Campus Eisenberg, Klosterlausnitzer Straße 81, Eisenberg 07607, Germany.
| | - Florian Rakers
- Department of Neurology, Jena University Hospital - Friedrich Schiller University, Jena 07747, Germany.
| | - René Schiffner
- Department of Neurology, Jena University Hospital - Friedrich Schiller University, Jena 07747, Germany.
- Orthopedic Department, Jena University Hospital - Friedrich Schiller University, Campus Eisenberg, Klosterlausnitzer Straße 81, Eisenberg 07607, Germany.
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12
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Exercise Prescription in Patients with Different Combinations of Cardiovascular Disease Risk Factors: A Consensus Statement from the EXPERT Working Group. Sports Med 2018; 48:1781-1797. [DOI: 10.1007/s40279-018-0930-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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13
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Roberto S, Crisafulli A. Consequences of Type 1 and 2 Diabetes Mellitus on the Cardiovascular Regulation During Exercise: A Brief Review. Curr Diabetes Rev 2017; 13:560-565. [PMID: 27306960 PMCID: PMC5684785 DOI: 10.2174/1573399812666160614123226] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 06/08/2016] [Accepted: 06/10/2016] [Indexed: 01/26/2023]
Abstract
INTRODUCTION One challenging problem in patients suffering from Diabetes Mellitus (DM) is the elevate incidence of cardiovascular events. Exercise has been proved useful in reducing cardiovascular risks in these patients. However, both type 1 and 2 DM significantly affect the cardiovascular response during exercise. Therefore, on one side exercise is considered to be a valid therapeutic tool for DM, whereas on the other side during exercise these patients may experience troubles in the cardiovascular regulation. BACKGROUND Several impairments at central and at peripheral level have been reported during exercise in both types of DM. For example, sympathetic dysfunctions have been demonstrated in type 1 and 2 DM. Furthermore, impairments in hemodynamics have been often reported. The purpose of the present paper is to briefly review the latest data on the role played by type 1 and 2 DM in the cardiovascular regulation during dynamic exercise. CONCLUSION Hemodynamic dysfunctions may develop in both type 1 and 2 DM during exercise. However, these cardiovascular dys-regulations are different between the two kinds of diabetes.
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Affiliation(s)
| | - Antonio Crisafulli
- Address correspondence to this author at the Department of Medical
Sciences, Sports Physiology Lab., University of Cagliari, Via Porcell 4, 09124 Cagliari, Italy; Tel: +390706758937; Fax: +390706758917;
E-mail:
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14
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Paramalingam N, Fournier PA, Davey RJ, Roby HC, Smith GJ, Shetty VB, Guelfi KJ, Davis EA, Jones TW. A 10-second sprint does not blunt hormonal counter-regulation to subsequent hypoglycaemia. Diabet Med 2017; 34:1440-1446. [PMID: 28586510 DOI: 10.1111/dme.13396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2017] [Indexed: 11/30/2022]
Abstract
AIM To investigate whether a 10-second (s) sprint impairs the counter-regulatory response to subsequent hypoglycaemia. METHODS Nine people (five male, four female) with Type 1 diabetes, aged 21.1 ± 4.5 years, performed a 10-s rest or a 10-s maximum-effort sprint in random order on different days, while subjected to an euinsulinaemic-euglycaemic clamp. This was followed by a hyperinsulinaemic-hypoglycaemic glucose clamp 2.5 h later to induce hypoglycaemia for 40 min. At timed intervals, the counter-regulatory hormonal responses to hypoglycaemia were measured. Blood pressure, heart rate and hypoglycaemic symptoms were also assessed. RESULTS During the hypoglycaemic clamp, epinephrine, norepinephrine, growth hormone and cortisol levels increased significantly from baseline, and their responses were similar after both rest and sprint conditions. In particular, plasma epinephrine rose eightfold, from 197 ± 103 pmol/l to 1582 ± 1118 pmol/l after the rest condition, and from 219 ± 119 pmol/l to 1900 ± 898 pmol/l after the sprint condition. CONCLUSION A 10-s sprint is unlikely to blunt the subsequent hormonal counter-regulation to hypoglycaemia in individuals with Type 1 diabetes.
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Affiliation(s)
- N Paramalingam
- Telethon Kids Institute, Perth, WA, Australia
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia
- Division of Paediatrics, within the Medical School, University of Western Australia, Perth, WA, Australia
- School of Human Sciences, University of Western Australia, Perth, WA, Australia
| | - P A Fournier
- School of Human Sciences, University of Western Australia, Perth, WA, Australia
| | - R J Davey
- Telethon Kids Institute, Perth, WA, Australia
- Division of Paediatrics, within the Medical School, University of Western Australia, Perth, WA, Australia
| | - H C Roby
- Telethon Kids Institute, Perth, WA, Australia
| | - G J Smith
- Telethon Kids Institute, Perth, WA, Australia
| | - V B Shetty
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia
- Division of Paediatrics, within the Medical School, University of Western Australia, Perth, WA, Australia
| | - K J Guelfi
- School of Human Sciences, University of Western Australia, Perth, WA, Australia
| | - E A Davis
- Telethon Kids Institute, Perth, WA, Australia
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia
- Division of Paediatrics, within the Medical School, University of Western Australia, Perth, WA, Australia
| | - T W Jones
- Telethon Kids Institute, Perth, WA, Australia
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia
- Division of Paediatrics, within the Medical School, University of Western Australia, Perth, WA, Australia
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15
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Rooijackers HM, Wiegers EC, van der Graaf M, Thijssen DH, Kessels RPC, Tack CJ, de Galan BE. A Single Bout of High-Intensity Interval Training Reduces Awareness of Subsequent Hypoglycemia in Patients With Type 1 Diabetes. Diabetes 2017; 66:1990-1998. [PMID: 28420673 DOI: 10.2337/db16-1535] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 04/11/2017] [Indexed: 11/13/2022]
Abstract
High-intensity interval training (HIIT) has gained increasing popularity in patients with diabetes. HIIT acutely increases plasma lactate levels. This may be important, since the administration of lactate during hypoglycemia suppresses symptoms and counterregulation while preserving cognitive function. We tested the hypothesis that, in the short term, HIIT reduces awareness of hypoglycemia and attenuates hypoglycemia-induced cognitive dysfunction. In a randomized crossover trial, patients with type 1 diabetes and normal awareness of hypoglycemia (NAH), patients with impaired awareness of hypoglycemia (IAH), and healthy participants (n = 10 per group) underwent a hyperinsulinemic-hypoglycemic (2.6 mmol/L) clamp, either after a HIIT session or after seated rest. Compared with rest, HIIT reduced symptoms of hypoglycemia in patients with NAH but not in healthy participants or patients with IAH. HIIT attenuated hypoglycemia-induced cognitive dysfunction, which was mainly driven by changes in the NAH subgroup. HIIT suppressed cortisol and growth hormone responses, but not catecholamine responses to hypoglycemia. The present findings demonstrate that a single HIIT session rapidly reduces awareness of subsequent hypoglycemia in patients with type 1 diabetes and NAH, but does not in patients with IAH, and attenuates hypoglycemia-induced cognitive dysfunction. The role of exercise-induced lactate in mediating these effects, potentially serving as an alternative fuel for the brain, should be further explored.
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Affiliation(s)
- Hanne M Rooijackers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Evita C Wiegers
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marinette van der Graaf
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Pediatrics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Dick H Thijssen
- Department of Physiology, Radboud University Medical Center, Nijmegen, the Netherlands
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, U.K
| | - Roy P C Kessels
- Department of Medical Psychology, Radboud University Medical Center, Nijmegen, the Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, the Netherlands
| | - Cees J Tack
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bastiaan E de Galan
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
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16
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McCrimmon RJ. RD Lawrence Lecture 2015 Old habits are hard to break: lessons from the study of hypoglycaemia. Diabet Med 2017; 34:148-155. [PMID: 27770582 DOI: 10.1111/dme.13277] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2016] [Indexed: 11/29/2022]
Abstract
Despite the introduction of newer technologies and improved insulin formulations, recurrent hypoglycaemia continues to affect the lives of many people with Type 1 and Type 2 diabetes. Developing strategies or therapies designed to prevent or minimize hypoglycaemia risk is of utmost importance to help individuals safely achieve glycaemic targets. Novel, educational or behavioural approaches need to be based on a clear understanding of the mechanisms underpinning both the detection of hypoglycaemia and why repeated exposure to hypoglycaemia leads to the development of a clinical syndrome referred to as impaired awareness of hypoglycaemia. In the present review, I propose that impaired awareness of hypoglycaemia may represent a form of learning called habituation, a response that, at a cellular level, represents a biological adaptation designed to protect the organism from future exposure to that stressor. In diabetes, this survival response to low glucose is, however, overwhelmed by high systemic insulin levels resulting from exogenous insulin therapy, leading to progressively more severe hypoglycaemia. A recognition of the underlying mechanism means that the development of impaired awareness of hypoglycaemia can perhaps be better understood and explained to individuals with diabetes, and novel therapeutic approaches such as dishabituation or cognitive behavioural therapies can be considered.
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Affiliation(s)
- R J McCrimmon
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
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17
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Eshghi SR, Fletcher K, Myette-Côté É, Durrer C, Gabr RQ, Little JP, Senior P, Steinback C, Davenport MH, Bell GJ, Brocks DR, Boulé NG. Glycemic and Metabolic Effects of Two Long Bouts of Moderate-Intensity Exercise in Men with Normal Glucose Tolerance or Type 2 Diabetes. Front Endocrinol (Lausanne) 2017; 8:154. [PMID: 28744255 PMCID: PMC5504214 DOI: 10.3389/fendo.2017.00154] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/20/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The glycemic and insulinemic responses following 30-60 min of exercise have been extensively studied, and a dose-response has been proposed between exercise duration, or volume, and improvements in glucose tolerance or insulin sensitivity. However, few studies have examined the effects of longer bouts of exercise in type 2 diabetes (T2D). Longer bouts may have a greater potential to affect glucagon, interleukin-6 (IL-6) and incretin hormones [i.e., glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP)]. AIM To examine the effect of two bouts of long-duration, moderate-intensity exercise on incretins, glucagon, and IL-6 responses before and after exercise, as well as in response to an oral glucose tolerance test (OGTT) conducted the following day. METHODS Twelve men, six with and six without T2D, participated in two separate conditions (i.e., exercise vs. rest) according to a randomized crossover design. On day 1, participants either rested or performed two 90 min bouts of treadmill exercise (separated by 3.5 h) at 80% of their ventilatory threshold. All participants received standardized meals on day 1. On day 2 of each condition, glucose and hormonal responses were measured during a 4-h OGTT. RESULTS On day 1, exercise increased IL-6 at the end of the first bout of exercise (exercise by time interaction p = 0.03) and GIP overall (main effect of exercise p = 0.004). Glucose was reduced to a greater extent in T2D following exercise (exercise by T2D interaction p = 0.03). On day 2, GIP and active GLP-1 were increased in the fasting state (p = 0.05 and p = 0.03, respectively), while plasma insulin and glucagon concentrations were reduced during the OGTT (p = 0.01 and p = 0.02, respectively) in the exercise compared to the rest condition for both healthy controls and T2D. Postprandial glucose was elevated in T2D compared to healthy control (p < 0.05) but was not affected by exercise. CONCLUSION Long-duration, moderate-intensity aerobic exercise can increase IL-6. On the day following exercise, fasting incretins remained increased but postprandial insulin and glucagon were decreased without affecting postprandial glucose. This long duration of exercise may not be appropriate for some people, and further research should investigate why next day glucose tolerance was unchanged.
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Affiliation(s)
- Saeed Reza Eshghi
- Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Kevin Fletcher
- Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Étienne Myette-Côté
- Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Cody Durrer
- School of Health and Exercise Sciences, University of British Columbia, Kelowna, BC, Canada
| | - Raniah Q. Gabr
- National Organization for Drug Control and Research (NODCAR), Giza, Egypt
| | - Jonathan P. Little
- School of Health and Exercise Sciences, University of British Columbia, Kelowna, BC, Canada
| | - Peter Senior
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Craig Steinback
- Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Margie H. Davenport
- Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Gordon J. Bell
- Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Dion R. Brocks
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Normand G. Boulé
- Faculty of Physical Education and Recreation, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
- *Correspondence: Normand G. Boulé,
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18
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Cade WT, Khoury N, Nelson S, Shackleford A, Semenkovich K, Krauss MJ, Arbeláez AM. Hypoglycemia during moderate intensity exercise reduces counterregulatory responses to subsequent hypoglycemia. Physiol Rep 2016; 4:4/17/e12848. [PMID: 27597762 PMCID: PMC5027337 DOI: 10.14814/phy2.12848] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 06/09/2016] [Indexed: 11/24/2022] Open
Abstract
Hypoglycemia, which occurs commonly during and following exercise in people with diabetes, is thought to be due to attenuated counterregulation in the setting of therapeutic insulin excess. To better understand the pathophysiology of counterregulation, we aimed to determine if dextrose administration to maintain euglycemia during moderate intensity exercise alters the attenuation of counterregulatory responses to subsequent hypoglycemia in healthy adults. Counterregulatory responses to hypoglycemia were assessed in 18 healthy adults after bed rest and following exercise with (n = 9) and without (n = 9) dextrose infusion. Responses were measured during a stepped euglycemic‐hypoglycemic clamp 24 h after either bed rest or two 90‐min bouts of exercise at 70% peak oxygen uptake. Hypoglycemia occurred during the second bout of exercise without dextrose infusion. Plasma glucagon and epinephrine responses to stepped hypoglycemia after antecedent exercise without dextrose infusion were significantly lower at the 45 mg/dL glycemic level compared to after bed rest. However, no attenuation of the counterregulatory responses to hypoglycemia was evident after antecedent exercise when dextrose was infused. This study suggests that the attenuation of the counterregulatory responses during hypoglycemia after exercise is likely due to the hypoglycemia that occurs during moderate prolonged exercise and not solely due to exercise or its intensity.
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Affiliation(s)
- W Todd Cade
- Program in Physical Therapy, Washington University School of Medicine, Saint Louis, Missouri
| | - Nadia Khoury
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Suzanne Nelson
- Division of Biostatistics, Washington University School of Medicine, Saint Louis, Missouri
| | - Angela Shackleford
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri
| | - Katherine Semenkovich
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri
| | - Melissa J Krauss
- Division of Biostatistics, Washington University School of Medicine, Saint Louis, Missouri
| | - Ana María Arbeláez
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri
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19
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Abrahamsson N, Börjesson JL, Sundbom M, Wiklund U, Karlsson FA, Eriksson JW. Gastric Bypass Reduces Symptoms and Hormonal Responses in Hypoglycemia. Diabetes 2016; 65:2667-75. [PMID: 27313315 DOI: 10.2337/db16-0341] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/10/2016] [Indexed: 11/13/2022]
Abstract
Gastric bypass (GBP) surgery, one of the most common bariatric procedures, induces weight loss and metabolic effects. The mechanisms are not fully understood, but reduced food intake and effects on gastrointestinal hormones are thought to contribute. We recently observed that GBP patients have lowered glucose levels and frequent asymptomatic hypoglycemic episodes. Here, we subjected patients before and after undergoing GBP surgery to hypoglycemia and examined symptoms and hormonal and autonomic nerve responses. Twelve obese patients without diabetes (8 women, mean age 43.1 years [SD 10.8] and BMI 40.6 kg/m(2) [SD 3.1]) were examined before and 23 weeks (range 19-25) after GBP surgery with hyperinsulinemic-hypoglycemic clamp (stepwise to plasma glucose 2.7 mmol/L). The mean change in Edinburgh Hypoglycemia Score during clamp was attenuated from 10.7 (6.4) before surgery to 5.2 (4.9) after surgery. There were also marked postsurgery reductions in levels of glucagon, cortisol, and catecholamine and the sympathetic nerve responses to hypoglycemia. In addition, growth hormone displayed a delayed response but to a higher peak level. Levels of glucagon-like peptide 1 and gastric inhibitory polypeptide rose during hypoglycemia but rose less postsurgery compared with presurgery. Thus, GBP surgery causes a resetting of glucose homeostasis, which reduces symptoms and neurohormonal responses to hypoglycemia. Further studies should address the underlying mechanisms as well as their impact on the overall metabolic effects of GBP surgery.
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Affiliation(s)
| | - Joey Lau Börjesson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden
| | - Magnus Sundbom
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Urban Wiklund
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | | | - Jan W Eriksson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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20
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Dagogo-Jack S. Philip E. Cryer, MD: Seminal Contributions to the Understanding of Hypoglycemia and Glucose Counterregulation and the Discovery of HAAF (Cryer Syndrome). Diabetes Care 2015; 38:2193-9. [PMID: 26604275 PMCID: PMC4876742 DOI: 10.2337/dc15-0533] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Optimized glycemic control prevents and slows the progression of long-term complications in patients with type 1 and type 2 diabetes. In healthy individuals, a decrease in plasma glucose below the physiological range triggers defensive counterregulatory responses that restore euglycemia. Many individuals with diabetes harbor defects in their defenses against hypoglycemia, making iatrogenic hypoglycemia the Achilles heel of glycemic control. This Profile in Progress focuses on the seminal contributions of Philip E. Cryer, MD, to our understanding of hypoglycemia and glucose counterregulation, particularly his discovery of the syndrome of hypoglycemia-associated autonomic failure (HAAF).
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Affiliation(s)
- Samuel Dagogo-Jack
- Division of Endocrinology, Diabetes and Metabolism, The University of Tennessee Health Science Center, Memphis, TN
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Abstract
While being physically active bestows many health benefits on individuals with type 1 diabetes, their overall blood glucose control is not enhanced without an effective balance of insulin dosing and food intake to maintain euglycemia before, during, and after exercise of all types. At present, a number of technological advances are already available to insulin users who desire to be physically active with optimal blood glucose control, although a number of limitations to those devices remain. In addition to continued improvements to existing technologies and introduction of new ones, finding ways to integrate all of the available data to optimize blood glucose control and performance during and following exercise will likely involve development of "smart" calculators, enhanced closed-loop systems that are able to use additional inputs and learn, and social aspects that allow devices to meet the needs of the users.
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Affiliation(s)
- Sheri R Colberg
- Human Movement Sciences Department, Old Dominion University, Norfolk, VA, USA
| | - Remmert Laan
- William Sansum Diabetes Center, Santa Barbara, CA, USA
| | - Eyal Dassau
- Department of Chemical Engineering, University of California, Santa Barbara, CA, USA
| | - David Kerr
- William Sansum Diabetes Center, Santa Barbara, CA, USA
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22
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Gomez AM, Gomez C, Aschner P, Veloza A, Muñoz O, Rubio C, Vallejo S. Effects of performing morning versus afternoon exercise on glycemic control and hypoglycemia frequency in type 1 diabetes patients on sensor-augmented insulin pump therapy. J Diabetes Sci Technol 2015; 9:619-24. [PMID: 25555390 PMCID: PMC4604526 DOI: 10.1177/1932296814566233] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Although physical exercise (PE) is recommended for individuals with type 1 diabetes (DM1), participation in exercise is challenging because it increases the risk of severe hypoglycemia and the available therapeutic options to prevent it frequently result in hyperglycemia. There is no clear recommendation about the best timing for exercise. The aim of this study was to compare the risk of hypoglycemia after morning or afternoon exercise sessions up to 36 hours postworkout. METHODS This randomized crossover study enrolled subjects with DM1, older than 18 years of age, on sensor-augmented insulin pump (SAP) therapy. Participants underwent 2 moderate-intensity exercise sessions; 1 in the morning and 1 in the afternoon, separated by a 7 to 14 day wash-out period. Continuous glucose monitoring (CGM) data were collected 24 hours before, during and 36 hours after each session. RESULTS Thirty-five subjects (mean age 30.31 ± 12.66 years) participated in the study. The rate of hypoglycemia was significantly lower following morning versus afternoon exercise sessions (5.6 vs 10.7 events per patient, incidence rate ratio, 0.52; 95% CI, 0.43-0.63; P < .0001). Most hypoglycemic events occurred 15-24 hours after the session. On days following morning exercise sessions, there were 20% more CGM readings in near-euglycemic range (70-200 mg/dL) than on days prior to morning exercise (P = .003). CONCLUSIONS Morning exercise confers a lower risk of late-onset hypoglycemia than afternoon exercise and improves metabolic control on the subsequent day.
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Affiliation(s)
- Ana Maria Gomez
- Pontificia Universidad Javeriana, Bogota, Colombia Hospital Universitario San Ignacio, Bogota, Colombia
| | - Claudia Gomez
- Pontificia Universidad Javeriana, Bogota, Colombia Hospital Universitario San Ignacio, Bogota, Colombia
| | - Pablo Aschner
- Pontificia Universidad Javeriana, Bogota, Colombia Hospital Universitario San Ignacio, Bogota, Colombia
| | | | - Oscar Muñoz
- Pontificia Universidad Javeriana, Bogota, Colombia Hospital Universitario San Ignacio, Bogota, Colombia
| | - Claudia Rubio
- Hospital Universitario San Ignacio, Bogota, Colombia
| | - Santiago Vallejo
- Pontificia Universidad Javeriana, Bogota, Colombia Hospital Universitario San Ignacio, Bogota, Colombia
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Aveseh M, Nikooie R, Sheibani V, Esmaeili-Mahani S. Endurance training increases brain lactate uptake during hypoglycemia by up regulation of brain lactate transporters. Mol Cell Endocrinol 2014; 394:29-36. [PMID: 25004253 DOI: 10.1016/j.mce.2014.06.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 06/26/2014] [Accepted: 06/30/2014] [Indexed: 10/25/2022]
Abstract
The capacity of the brain to metabolize non-glucose substrates under hypoglycemic state maintains its energy requirements. We hypothesized that exercise-induced increase in capacity for brain utilization of lactate by up regulation of the monocarboxylate transporters (MCTs) may contribute metabolic substrates during hypoglycemia in diabetic rats induced by streptozotocin. The induced diabetes increased MCT1 and MCT2 expression in the cortex and the hippocampus in the sedentary diabetic animals. There were exercise-induced increases in MCT1 in the cortex and the hippocampus and MCT2 expression in the cortex in trained diabetic animals; whereas, no changes were found in the healthy trained animals. Both diabetic and healthy trained animals showed higher values for brain lactate uptake during insulin-induced hypoglycemia when animals were intraperitoneally injected by L(+)-lactic acid. However, the response of counterregulatory hormones during hypoglycemia were blunted in the diabetic trained animals which indicates to carefully monitoring of glycemic targets both during and following prolonged exercise.
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Affiliation(s)
- Malihe Aveseh
- Neuroscience Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran; Department of Exercise Physiology, Faculty of Physical Education and Sport Science, Shahid Bahonar University of Kerman, Kerman, Iran
| | - Rohollah Nikooie
- Department of Exercise Physiology, Faculty of Physical Education and Sport Science, Shahid Bahonar University of Kerman, Kerman, Iran.
| | - Vahid Sheibani
- Neuroscience Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Saeed Esmaeili-Mahani
- Department of Biology, Faculty of Sciences, Shahid Bahonar University of Kerman, Kerman, Iran
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Davey RJ, Bussau VA, Paramalingam N, Ferreira LD, Lim EM, Davis EA, Jones TW, Fournier PA. A 10-s sprint performed after moderate-intensity exercise neither increases nor decreases the glucose requirement to prevent late-onset hypoglycemia in individuals with type 1 diabetes. Diabetes Care 2013; 36:4163-5. [PMID: 24130362 PMCID: PMC3836164 DOI: 10.2337/dc12-2198] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine whether performing a 10-s sprint after moderate-intensity exercise increases the amount of carbohydrate required to maintain euglycemia and prevent late-onset postexercise hypoglycemia relative to moderate-intensity exercise alone. RESEARCH DESIGN AND METHODS Seven individuals with type 1 diabetes underwent a hyperinsulinemic-euglycemic clamp and performed 30 min of moderate-intensity exercise on two separate occasions followed by either a 10-s maximal sprint effort or no sprint. During the following 8 h, glucose infusion rate to maintain euglycemia and rates of glucose appearance and disappearance were measured continuously. RESULTS In response to exercise and throughout the 8-h recovery period, there were no differences in glucose infusion rate, blood glucose levels, plasma insulin concentrations, and rates of glucose appearance and disappearance between the two experimental conditions (P > 0.05). CONCLUSIONS A 10-s sprint performed after 30 min of moderate-intensity exercise does not affect the amount of carbohydrate required to maintain euglycemia postexercise in individuals with type 1 diabetes.
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Reno CM, Litvin M, Clark AL, Fisher SJ. Defective counterregulation and hypoglycemia unawareness in diabetes: mechanisms and emerging treatments. Endocrinol Metab Clin North Am 2013; 42:15-38. [PMID: 23391237 PMCID: PMC3568263 DOI: 10.1016/j.ecl.2012.11.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
For people with diabetes, hypoglycemia remains the limiting factor in achieving glycemic control. This article reviews recent advances in how the brain senses and responds to hypoglycemia. Novel mechanisms by which individuals with insulin-treated diabetes develop hypoglycemia unawareness and impaired counterregulatory responses are outlined. Prevention strategies for reducing the incidence of hypoglycemia are discussed.
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Affiliation(s)
- Candace M. Reno
- Division of Endocrinology, Metabolism, & Lipid Research, Department of Medicine, Washington University, St. Louis, MO
| | - Marina Litvin
- Division of Endocrinology, Metabolism, & Lipid Research, Department of Medicine, Washington University, St. Louis, MO
| | - Amy L. Clark
- Division of Endocrinology and Diabetes, Department of Pediatrics, Washington University, St. Louis, MO
| | - Simon J. Fisher
- Division of Endocrinology, Metabolism, & Lipid Research, Department of Medicine, Washington University, St. Louis, MO
- Department of Cell Biology and Physiology, Washington University, St. Louis, MO
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Roberto S, Marongiu E, Pinna M, Angius L, Olla S, Bassareo P, Tocco F, Concu A, Milia R, Crisafulli A. Altered hemodynamics during muscle metaboreflex in young type 1 diabetes patients. J Appl Physiol (1985) 2012; 113:1323-31. [PMID: 22700802 DOI: 10.1152/japplphysiol.00280.2012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A reduction in catecholamine levels during exercise has been described in young subjects with type 1 diabetes mellitus (DM1). It has been suggested that type 1 diabetes per se is associated with the loss of sympathetic response before any clinical evidence. Considering that an increase in sympathetic drive is required for normal cardiovascular response to muscle metaboreflex, the aim of this study was to assess the hemodynamics during metaboreflex in DM1 patients. Impedance cardiography was used to measure hemodynamics during metaboreflex activation, obtained through postexercise ischemia in 14 DM1 patients and in 11 healthy controls (CTL). Principal results were: 1) blunted blood pressure response during metaboreflex was observed in DM1 patients compared with the CTL; 2) reduced capacity to increase systemic vascular resistance was also witnessed in DM1 subjects; 3) DM1 subjects reported higher stroke volumes as a consequence of reduced cardiac afterload compared with the CTL, which led to a more evident cardiac output response, which partially compensated for the lack of vasoconstriction. These facts suggest that cardiovascular regulation was altered in DM1 patients and that there was a reduced capacity to increase sympathetic tone, even in the absence of any overt clinical sign. The metaboreflex test appears to be a valid tool to detect early signs of this cardiovascular dysregulation.
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Affiliation(s)
- Silvana Roberto
- Department of Medical Sciences, Sports Physiology Laboratory, University of Cagliari, Via Porcell 4, Cagliari, Italy
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Milman S, Leu J, Shamoon H, Vele S, Gabriely I. Opioid receptor blockade prevents exercise-associated autonomic failure in humans. Diabetes 2012; 61:1609-15. [PMID: 22522612 PMCID: PMC3357274 DOI: 10.2337/db11-1622] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Hypoglycemia and exercise both induce the release of β-endorphin, which plays an important role in the modulation of the autonomic response during subsequent events. Because opioid receptor (OR) blockade during antecedent hypoglycemia has been shown to prevent hypoglycemia-associated autonomic failure, we hypothesized that OR blockade during exercise would prevent exercise-associated autonomic failure (EAAF). We studied 8 healthy subjects on 2 consecutive days, each of whom participated in three different studies in random order. The protocol on day 1 involved one of the following: 1) two 90-min hyperinsulinemic-euglycemic clamps plus naloxone infusion (control); 2) two 90-min hyperinsulinemic-euglycemic clamps with exercise at 60% Vo(2max), plus naloxone infusion (N+); or 3) same protocol as in the N+ group, but with saline infusion only (N-). On day 2, all were studied with stepped hyperinsulinemic-hypoglycemic clamps, using hormone concentrations and glucose turnover as indicators of hypoglycemia counterregulation. Compared with control, N- studies resulted in significantly blunted epinephrine and norepinephrine responses to subsequent hypoglycemia. Conversely, the N+ group exhibited unimpaired hypoglycemia counterregulation, characterized by appropriate increases in epinephrine, norepinephrine, and endogenous glucose production. Thus, OR blockade with naloxone during antecedent exercise prevents the development of acute EAAF by improving the catecholamine responses and by restoring endogenous glucose production.
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Affiliation(s)
- Sofiya Milman
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Albert Einstein College of Medicine, Bronx, New York
| | - James Leu
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Albert Einstein College of Medicine, Bronx, New York
| | - Harry Shamoon
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Albert Einstein College of Medicine, Bronx, New York
- Institute for Clinical and Translational Research, Albert Einstein College of Medicine, Bronx, New York
| | - Septimiu Vele
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Albert Einstein College of Medicine, Bronx, New York
| | - Ilan Gabriely
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Albert Einstein College of Medicine, Bronx, New York
- Corresponding author: Ilan Gabriely,
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Oliver SR, Hingorani SR, Rosa JS, Zaldivar FP, Galassetti PR. Synergistic effect of obesity and lipid ingestion in suppressing the growth hormone response to exercise in children. J Appl Physiol (1985) 2012; 113:192-8. [PMID: 22518832 DOI: 10.1152/japplphysiol.01184.2011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Diet plays an important role in modulating exercise responses, including activation of the growth hormone (GH)/insulin-like growth factor-I (IGF-1) axis. Obesity and fat ingestion were separately shown to reduce exercise GH responses, but their combined effect, especially important in children, has not been studied. We therefore measured the GH response to exercise [30-min intermittent cycling, ten 2-min bouts at ~80% maximal aerobic capacity (Vo(2max)), separated by 1-min rest], started 45 min after ingestion of a high-fat meal (HFM) in 16 healthy [controls; body mass index percentile (BMI%ile) 51 ± 7], and 19 obese (Ob, BMI%ile 97 ± 0.4) children. Samples were drawn at baseline (premeal), and at start, peak, and 30 min postexercise. In the Ob group, a marked ~75% suppression of the GH response (ng/ml) to exercise was observed (2.4 ± 0.6 vs. 10.6 ± 2.1, P < 0.001). This level of suppression was also significantly greater compared with age-, fitness-, and BMI-matched historical controls that had performed identical exercise in fasting conditions. Our data indicate that the reduction in the GH response to exercise, already present in obese children vs. healthy controls, is considerably amplified by ingestion of fat nutrients shortly before exercise, implying a potentially downstream negative impact on growth factor homeostasis and long-term modulation of physiological growth.
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Affiliation(s)
- Stacy R Oliver
- Department of Pharmacology, School of Medicine, University of California-Irvine, CA, USA
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29
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Milman S, Leu J, Shamoon H, Vele S, Gabriely I. Magnitude of exercise-induced β-endorphin response is associated with subsequent development of altered hypoglycemia counterregulation. J Clin Endocrinol Metab 2012; 97:623-31. [PMID: 22170706 PMCID: PMC3275366 DOI: 10.1210/jc.2011-1391] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
CONTEXT β-Endorphin release in response to recurrent hypoglycemia is implicated in the pathogenesis of hypoglycemia-associated autonomic failure. OBJECTIVE We hypothesized that exercise-induced β-endorphin release will also result in the deterioration of subsequent hypoglycemia counterregulation and that the counterregulatory response will negatively correlate with the degree of antecedent β-endorphin elevation. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS Sixteen healthy subjects (six females, aged 26 ± 4.3 yr, body mass index 26.1 ± 5.6 kg/m(2)) were studied with three experimental paradigms on 2 consecutive days. Day 1 consisted of one of the following: 1) two 90-min hyperinsulinemic hypoglycemic clamps (3.3 mmol/liter); 2) two 90-min hyperinsulinemic euglycemic clamps while subjects exercised at 60% maximal oxygen uptake; or 3) two 90-min hyperinsulinemic euglycemic clamps (control). Day 2 followed with hyperinsulinemic (396 ± 7 pmol/liter) stepped hypoglycemic clamps (5.0, 4.4, 3.9, and 3.3 mmol/liter plasma glucose steps). MAIN OUTCOME MEASURES Day 2 hypoglycemia counterregulatory hormonal response and glucose turnover ([3-(3)H]-glucose) as indicators of recovery from hypoglycemia. RESULTS There was a significant inverse correlation between plasma β-endorphin levels during exercise and catecholamine release during subsequent hypoglycemia. Subjects with an exercise-induced rise in β-endorphin levels to above 25 pg/ml (n = 7) exhibited markedly reduced levels of plasma epinephrine and norepinephrine compared with control (2495 ± 306 vs. 4810 ± 617 pmol/liter and 1.9 ± 0.3 vs. 2.9 ± 0.4 nmol/liter, respectively, P < 0.01 for both). The rate of endogenous glucose production recovery in this group was also much lower than in controls (42 vs. 89%, P < 0.01). CONCLUSIONS The physiological increase in β-endorphin levels during exercise is associated with the attenuation of counterregulation during subsequent hypoglycemia.
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Affiliation(s)
- Sofiya Milman
- Department of Medicine, Division of Endocrinology and Metabolism, Albert Einstein College of Medicine, Bronx, New York 10461, USA
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30
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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.
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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
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31
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Abstract
The counterregulatory response to hypoglycemia is a complex and well-coordinated process. As blood glucose concentration declines, peripheral and central glucose sensors relay this information to central integrative centers to coordinate neuroendocrine, autonomic, and behavioral responses and avert the progression of hypoglycemia. Diabetes, both type 1 and type 2, can perturb these counterregulatory responses. Moreover, defective counterregulation in the setting of diabetes can progress to hypoglycemia unawareness. While the mechanisms that underlie the development of hypoglycemia unawareness are not completely known, possible causes include altered sensing of hypoglycemia by the brain and/or impaired coordination of responses to hypoglycemia. Further study is needed to better understand the intricacies of the counterregulatory response and the mechanisms contributing to the development of hypoglycemia unawareness.
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Affiliation(s)
- Nolawit Tesfaye
- Department of Medicine, Division of Endocrinology and Diabetes, University of Minnesota, 420 Delaware St. SE, Minneapolis, MN 55455, USA
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32
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Affiliation(s)
- Rory J McCrimmon
- Biomedical Research Institute, University of Dundee, Dundee, Scotland.
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33
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Oliver SR, Rosa JS, Minh TDC, Pontello AM, Flores RL, Barnett M, Galassetti PR. Dose-dependent relationship between severity of pediatric obesity and blunting of the growth hormone response to exercise. J Appl Physiol (1985) 2009; 108:21-7. [PMID: 19875716 DOI: 10.1152/japplphysiol.00589.2009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In children, exercise modulates systemic anabolism, muscle growth, and overall physiological development through the growth hormone (GH)-insulin-like growth factor I (IGF-I) axis. GH secretion, at rest and during exercise, changes with age and maturational status and can be blunted by hyperlipidemia and obesity, with possible negative effects on physiological growth. However, little is known about the effect of progressively more severe pediatric obesity on the GH response to exercise and its relationship to pubertal status. We therefore studied 48 early- or late-pubertal obese children [body mass index (BMI) >95th percentile, separated in tertiles with progressively greater BMI] and 42 matched controls (BMI <85th percentile), who performed ten 2-min cycling bouts at approximately 80% of maximal O2 consumption, separated by 1-min rest intervals. Plasma GH and IGF-I were measured at baseline and end exercise. GH responses were systematically blunted in obese children, with more pronounced blunting paralleling increasing BMI. Although overall the GH response to exercise was greater in late-pubertal than in younger children, this blunting pattern was observed in early- and late-pubertal children. Our results reveal insight into the interaction between pediatric obesity and key modulators of physiological growth and development and underscore the necessity of optimizing physical activity strategies for specific pediatric dysmetabolic conditions.
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Affiliation(s)
- Stacy R Oliver
- Department of Pharmacology, School of Medicine, University of California, Irvine, USA
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34
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Bao S, Briscoe VJ, Tate DB, Davis SN. Effects of differing antecedent increases of plasma cortisol on counterregulatory responses during subsequent exercise in type 1 diabetes. Diabetes 2009; 58:2100-8. [PMID: 19509020 PMCID: PMC2731524 DOI: 10.2337/db09-0382] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Antecedent hypoglycemia can blunt neuroendocrine and autonomic nervous system responses to next-day exercise in type 1 diabetes. The aim of this study was to determine whether antecedent increase of plasma cortisol is a mechanism responsible for this finding. RESEARCH DESIGN AND METHODS For this study, 22 type 1 diabetic subjects (11 men and 11 women, age 27 +/- 2 years, BMI 24 +/- 1 kg/m(2), A1C 7.9 +/- 0.2%) underwent four separate randomized 2-day protocols, with overnight normalization of blood glucose. Day 1 consisted of morning and afternoon 2-h hyperinsulinemic- (9 pmol x kg(-1) x min(-1)) euglycemic clamps (5.1 mmol/l), hypoglycemic clamps (2.9 mmol/l), or euglycemic clamps with a physiologic low-dose intravenous infusion of cortisol to reproduce levels found during hypoglycemia or a high-dose infusion, which resulted in further twofold greater elevations of plasma cortisol. Day 2 consisted of 90-min euglycemic cycling exercise at 50% Vo(2max). RESULTS During exercise, glucose levels were equivalently clamped at 5.1 +/- 0.1 mmol/l and insulin was allowed to fall to similar levels. Glucagon, growth hormone, epinephrine, norepinephrine, and pancreatic polypeptide responses during day 2 exercise were significantly blunted following antecedent hypoglycemia, low- and high-dose cortisol, compared with antecedent euglycemia. Endogenous glucose production and lipolysis were also significantly reduced following day 1 low- and high-dose cortisol. CONCLUSIONS Antecedent physiologic increases in cortisol (equivalent to levels occurring during hypoglycemia) resulted in blunted neuroendocrine, autonomic nervous system, and metabolic counterregulatory responses during subsequent exercise in subjects with type 1 diabetes. These data suggest that prior elevations of cortisol may play a role in the development of exercise-related counterregulatory failure in those with type 1 diabetes.
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Affiliation(s)
- Shichun Bao
- Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vanessa J. Briscoe
- Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Donna B. Tate
- Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen N. Davis
- Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee
- Veterans Administration Hospital, Nashville, Tennessee
- Corresponding author: Stephen N. Davis,
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35
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Affiliation(s)
- Philip E Cryer
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, Missouri, USA.
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36
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Nery M. [Hypoglycemia as a limiting factor in the management of type 1 diabetes]. ACTA ACUST UNITED AC 2009; 52:288-98. [PMID: 18438539 DOI: 10.1590/s0004-27302008000200016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2007] [Accepted: 12/03/2007] [Indexed: 01/31/2023]
Abstract
Type 1 diabetic patients frequently present hypoglycemic episodes during their insulinotherapy, which, besides the discomfort and constrains does not allow the ideal glycemic control. Further, hypoglycemic events lead to the deficiency of the counter-regulation mechanisms in the subsequent episode, with a decrease in the release of epinephrine and the symptoms of warming, with great risk of severe hypoglycemia. The occurrence of hypoglycemia during some risky activities, specially driving, could result in accidents with the patient and /or third parts including property damage, stressing here the need to advise diabetics against having the necessary caution while driving. Generally the connective recovery is total after correcting a hypoglycemic coma. However when these episodes are repetitive, particularly in children, they could result in definitive cognitive disturbances. Hypoglycemic events without a warning signal (hypoglycemic unawareness) are difficult to reverse, thus it is necessary to prevent their occurrence, adjusting the treatment with glycemic targets, using continuous glucose monitoring at home and teaching them how to have an early recognition of hypoglycemia.
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Affiliation(s)
- Márcia Nery
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil.
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37
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Abstract
Patients with type 2 diabetes experience hypoglycaemia less frequently than those with type 1 diabetes. Some protection against hypoglycaemia is afforded by the relatively intact glucose counter-regulatory pathways that characterize the pathophysiology of early type 2 diabetes. To some extent, this protection explains why hypoglycaemic episodes in intensively treated individuals with type 2 diabetes, when they occur, are rarely severe. As diabetes progresses and therapy intensifies to achieve recommended glycaemic goals, hypoglycaemia frequency and severity increase. Thus, when it comes to instituting intensive therapy, fear of hypoglycaemia may contribute to health-care providers' 'clinical inertia'. Because maintaining glycaemic control is so important to both public and individual health, many new therapies and technologies have been developed. This manuscript reviews and considers whether these advancements in therapy make glycaemic goals easier to achieve by minimizing hypoglycaemia. Putting the hypoglycaemia experienced by type 2 diabetes patients into appropriate clinical perspective, the impact of recent progress made in pharmacotherapy, drug delivery systems, and BG monitoring on hypoglycaemia incidence is largely positive. The extent to which this progress can effect improvement over traditional therapies will, however, depend upon patient (and provider) education, motivation and behaviour change.
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Affiliation(s)
- Patrick J Boyle
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico 87131, USA.
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38
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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]
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Novak BJ, Blake DR, Meinardi S, Rowland FS, Pontello A, Cooper DM, Galassetti PR. Exhaled methyl nitrate as a noninvasive marker of hyperglycemia in type 1 diabetes. Proc Natl Acad Sci U S A 2007; 104:15613-8. [PMID: 17895380 PMCID: PMC1994136 DOI: 10.1073/pnas.0706533104] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Recent technical advances allow detection of several hundred volatile organic compounds (VOCs) in human exhaled air, many of which reflect unidentified endogenous pathways. Our group has previously estimated plasma glucose levels in healthy adults during a standard oral glucose tolerance test via exhaled VOC analysis. As a result of the metabolic characteristics of hyperglycemia in the diabetic (low insulin and increased free fatty acids and ketones), we hypothesized that different exhaled VOC profiles may be present in children with type 1 diabetes mellitus (T1DM) during spontaneous hyperglycemia. Exhaled methyl nitrate strongly correlated specifically with the acute, spontaneous hyperglycemia of T1DM children. Eighteen experiments were conducted among 10 T1DM children. Plasma glucose and exhaled gases were monitored during either constant euglycemia (n = 5) or initial hyperglycemia with gradual correction (n = 13); all subjects received i.v. insulin and glucose as needed. Gas analysis was performed on 1.9-liter breath samples via gas chromatography using electron capture, flame ionization, and mass selective detection. Among the approximately 100 measured exhaled gases, the kinetic profile of exhaled methyl nitrate, commonly present in room air in the range of 5-10 parts per trillion, was most strongly statistically correlated with that of plasma glucose (P = 0.003-0.001). Indeed, the kinetic profiles of the two variables paralleled each other in 16 of 18 experiments, including repeat subjects who at different times displayed either euglycemia or hyperglycemia.
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Affiliation(s)
- B. J. Novak
- *Department of Chemistry, University of California, Irvine, CA 92697; and
| | - D. R. Blake
- *Department of Chemistry, University of California, Irvine, CA 92697; and
| | - S. Meinardi
- *Department of Chemistry, University of California, Irvine, CA 92697; and
| | - F. S. Rowland
- *Department of Chemistry, University of California, Irvine, CA 92697; and
- To whom correspondence may be addressed. E-mail:
| | - A. Pontello
- *Department of Chemistry, University of California, Irvine, CA 92697; and
- General Clinical Research Center, University of California at Irvine, Orange, CA 92868
| | - D. M. Cooper
- *Department of Chemistry, University of California, Irvine, CA 92697; and
- General Clinical Research Center, University of California at Irvine, Orange, CA 92868
| | - P. R. Galassetti
- *Department of Chemistry, University of California, Irvine, CA 92697; and
- General Clinical Research Center, University of California at Irvine, Orange, CA 92868
- To whom correspondence may be addressed at:
General Clinical Research Center, University of California at Irvine, Building 25, Second Floor, 101 The City Drive, Orange, CA 92868. E-mail:
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40
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Abstract
To assess the changes in counterregulatory hormones overnight after an afternoon of structured exercise or sedentary activity in children with type 1 diabetes mellitus (T1DM), the Diabetes Research in Children Network (DirecNet) studied 50 children (10 to <18 yr) with T1DM in five clinical research centers on two separate days (with and without an afternoon exercise session) using a crossover design. Glucose, epinephrine, norepinephrine, cortisol, growth hormone (GH), and glucagon concentrations were measured hourly overnight. Nocturnal hypoglycemia [plasma glucose concentrations < or =70 mg/dL (3.9 mmol/L)] occurred more frequently on the nights following exercise (56 vs. 36%; p = 0.008). Mean hourly concentrations of most hormones did not differ between sedentary or exercise nights or between nights with or without hypoglycemia. Spontaneous nocturnal hypoglycemia only stimulated small increases in plasma epinephrine and GH concentrations and failed to cause a rise in norepinephrine, cortisol, or glucagon levels in comparison with values during the hour before or after hypoglycemia or other times during those same nights. Counterregulatory hormone responses to spontaneous nocturnal hypoglycemia were markedly decreased regardless of whether there was antecedent afternoon exercise in children with T1DM. Sleep-induced impairments in counterregulatory hormone responses likely contribute to the increased risk of hypoglycemia during the entire overnight period in youth with T1DM.
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41
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Boyle PJ, Zrebiec J. Physiological and behavioral aspects of glycemic control and hypoglycemia in diabetes. South Med J 2007; 100:175-82. [PMID: 17330688 DOI: 10.1097/01.smj.0000242866.81791.70] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Homeostatic mechanisms that maintain blood glucose concentration within a narrow physiologic range are complex and redundant. Elaborate feedback loops involving insulin, glucagon, sympathoadrenal mediators, growth hormone, amylin, and incretins normally operate synchronously to keep blood glucose within a narrow set point. Individuals with diabetes have defects in glucose homeostatic pathways, including the counterregulatory pathways that oppose hypoglycemia and ensure sufficient glucose is available to serve the brain's metabolic needs. Because available interventions to manage hyperglycemia do not precisely mimic physiologic insulin secretion patterns, hypoglycemia can occur any time dosing exceeds demand. Focusing on the practical implications, we review the endocrinological principles underlying normal glucose homeostasis and the defects in regulation and counterregulation, including hypoglycemia unawareness, that occur with diabetes. Iatrogenic and behavioral factors that contribute to hypoglycemia risk and nocturnal hypoglycemia are discussed. A companion manuscript reviews the clinical symptoms and fundamentals of hypoglycemia prevention, recognition, and management.
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Affiliation(s)
- Patrick J Boyle
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA.
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42
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McMahon SK, Ferreira LD, Ratnam N, Davey RJ, Youngs LM, Davis EA, Fournier PA, Jones TW. Glucose requirements to maintain euglycemia after moderate-intensity afternoon exercise in adolescents with type 1 diabetes are increased in a biphasic manner. J Clin Endocrinol Metab 2007; 92:963-8. [PMID: 17118993 DOI: 10.1210/jc.2006-2263] [Citation(s) in RCA: 160] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
CONTEXT Exercise increases the risk of hypoglycemia in type 1 diabetes. OBJECTIVE This study aimed to investigate how the amount of glucose required to prevent an exercise-mediated fall in glucose level changes over time in adolescents with type 1 diabetes. SETTING The study took place at a tertiary pediatric referral center. DESIGN, PARTICIPANTS, AND INTERVENTION Nine adolescents with type 1 diabetes mellitus (five males, four females, aged 16 +/- 1.8 yr, diabetes duration 8.2 +/- 4.1 yr, hemoglobin A1c 7.8 +/- 0.8%, mean +/- SD) were subjected on two different occasions to a rest or 45 min of exercise at 95% of their lactate threshold. Insulin was administered iv at a rate based on their usual insulin dose, with similar plasma insulin levels for both studies (82.1 +/- 19.0, exercise vs. 82.7 +/- 16.4 pmol/liter, rest). Glucose was infused to maintain euglycemia for 18 h. MAIN OUTCOME MEASURES Glucose infusion rates required to maintain euglcycemia and levels of counterregulatory hormones were compared between rest and exercise study nights. RESULTS Glucose infusion rates to maintain stable glucose levels were elevated during and shortly after exercise, compared with the rest study, and again from 7-11 h after exercise. Counterregulatory hormone levels were similar between exercise and rest studies except for peaks in the immediate postexercise period (epinephrine, norepinephrine, GH, and cortisol peaks: 375.6 +/- 146.9 pmol/liter, 5.59 +/- 0.73 nmol/liter, 71.9 +/- 14.8 mIU/liter, and 558 +/- 69 nmol/liter, respectively). CONCLUSIONS The biphasic increase in glucose requirements to maintain euglycemia after exercise suggests a unique pattern of early and delayed risk for nocturnal hypoglycemia after afternoon exercise.
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Affiliation(s)
- Sarah K McMahon
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, P.O. Box D184, Perth, Western Australia 6840, Australia
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Colberg SR. The impact of exercise on insulin action in type 2 diabetes mellitus: Relationship to prevention and control. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/s1557-0843(06)80018-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Sandoval DA, Guy DLA, Richardson MA, Ertl AC, Davis SN. Acute, same-day effects of antecedent exercise on counterregulatory responses to subsequent hypoglycemia in type 1 diabetes mellitus. Am J Physiol Endocrinol Metab 2006; 290:E1331-8. [PMID: 16449302 DOI: 10.1152/ajpendo.00283.2005] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Exercise-induced hypoglycemia can occur within hours after exercise in type 1 diabetes mellitus (T1DM) patients. This study tested the hypothesis that an acute exercise bout causes (within hours) blunted autonomic and metabolic responses to subsequent hypoglycemia in patients with T1DM. Twelve T1DM patients (3 W/9 M) were studied during a single-step, 2-h hyperinsulinemic (572 +/- 4 pmol/l) hypoglycemic (2.8 +/- 0.1 mmol/l) clamp 2 h after either a hyperinsulinemic euglycemic (AM EUG) or hypoglycemic clamp (AM HYPO) or after sitting in a chair with basal insulin infusion (AM CON) or 90 min of moderate-intensity exercise (50% Vo(2 max), AM EX). Both AM HYPO and AM EX significantly blunted epinephrine responses and muscle sympathetic nerve activity responses to subsequent hypoglycemia compared with both control groups. Endogenous glucose production was significantly lower and the exogenous glucose infusion rate needed to maintain the hypoglycemic level was significantly greater during subsequent hypoglycemia in AM EX vs. CON. Rate of glucose disposal (Rd) was significantly reduced following AM HYPO. In summary, within 2.5 h, both moderate-intensity AM EX and AM HYPO blunted key autonomic counterregulatory responses. Despite this, glucose Rd was reduced during afternoon hypoglycemia following morning hypoglycemia, indicating posthypoglycemic insulin resistance. After morning exercise, endogenous glucose production was blunted, but glucose Rd was maintained during afternoon hypoglycemia, thereby indicating reduced metabolic defenses against hypoglycemia. These data suggest that exercise-induced counterregulatory failure can occur very rapidly, increasing the risk for hypoglycemia in T1DM within hours.
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Affiliation(s)
- Darleen A Sandoval
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
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Abstract
Iatrogenic hypoglycemia is a problem for people with diabetes. It causes recurrent morbidity, and sometimes death, as well as a vicious cycle of recurrent hypoglycemia, precluding maintenance of euglycemia over a lifetime of diabetes. Improved therapeutic approaches that will minimize both hypo- and hyperglycemia will be based on insight into the pathophysiology of glucoregulation, specifically glucose counterregulation, in insulin-deficient (type 1 and advanced type 2) diabetes. In such patients, hypoglycemia is the result of the interplay of relative or absolute therapeutic insulin excess and compromised physiological (the syndrome of defective glucose counterregulation) and behavioral (the syndrome of hypoglycemia unawareness) defenses against falling plasma glucose concentrations. The concept of hypoglycemia-associated autonomic failure (HAAF) in diabetes posits that recent antecedent iatrogenic hypoglycemia causes both defective glucose counterregulation (by reducing epinephrine responses to a given level of subsequent hypoglycemia in the setting of absent decrements in insulin and absent increments in glucagon) and hypoglycemia unawareness (by reducing sympathoadrenal and the resulting neurogenic symptom responses to a given level of subsequent hypoglycemia) and thus a vicious cycle of recurrent hypoglycemia. The clinical impact of HAAF is well established in type 1 diabetes; it also affects those with advanced type 2 diabetes. It is now known to be largely reversible, by as little as 2-3 weeks of scrupulous avoidance of hypoglycemia, in most affected patients. However, the mechanisms of HAAF and its component syndromes are largely unknown. Loss of the glucagon secretory response, a key feature of defective glucose counterregulation, is plausibly explained by insulin deficiency, specifically loss of the decrement in intraislet insulin that normally signals glucagon secretion as glucose levels fall. Reduced neurogenic symptoms, a key feature of hypoglycemia unawareness, are largely the result of reduced sympathetic neural responses to falling glucose levels. The mechanism by which hypoglycemia shifts the glycemic thresholds for sympathoadrenal activation to lower plasma glucose concentrations, the key feature of both components of HAAF, is not known. It does not appear to be the result of the release of a systemic mediator (e.g., cortisol, epinephrine) during antecedent hypoglycemia or of increased blood-to-brain glucose transport (although increased transport of alternative fuels is conceivable). It is likely the result of alterations of brain metabolism. Although there is an array of clues, the specific alteration remains to be identified. While the research focus has been largely on the hypothalamus, hypoglycemia is now known to activate widespread brain regions, including the medial prefrontal cortex. The possibility that HAAF could be the result of posthypoglycemic brain glycogen supercompensation has also been raised. Finally, there appear to be diverse causes of HAAF. In addition to recent antecedent hypoglycemia, these include exercise- and sleep-related HAAF. Clearly, a unifying mechanism of HAAF would need to incorporate these causes as well. Pending the prevention and cure of diabetes, critical fundamental, translational, and outcomes research is needed if we are to eliminate hypoglycemia from the lives of people affected by diabetes.
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Affiliation(s)
- Philip E Cryer
- Division of Endocrinology, Metabolism and Lipid Research and General Clinical Research Center, Campus Box 8127, Washington University School of Medicine, 660 South Euclid Ave., St. Louis, Missouri 63110, USA.
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Adler GK, Geenen R. Hypothalamic–Pituitary–Adrenal and Autonomic Nervous System Functioning in Fibromyalgia. Rheum Dis Clin North Am 2005; 31:187-202, xi. [PMID: 15639063 DOI: 10.1016/j.rdc.2004.10.002] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In general, there seems to be a reduction in some neuroendocrine and autonomic nervous system (ANS) responses to applied stresses in individuals who have fibromyalgia. This article presents an overview and discussion of these findings with respect to the role of the ANS and the neuroendocrine system in the response to stress, with emphasis on the hypothalamic-pituitary-adrenal axis and the possible implication to fibromyalgia.
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Affiliation(s)
- Gail K Adler
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA.
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Jackson L, Williams FLR, Burchell A, Coughtrie MWH, Hume R. Plasma catecholamines and the counterregulatory responses to hypoglycemia in infants: a critical role for epinephrine and cortisol. J Clin Endocrinol Metab 2004; 89:6251-6. [PMID: 15579785 DOI: 10.1210/jc.2004-0550] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
The purpose of this study was to define plasma catecholamine responses as part of the counterregulatory hormonal reaction to hypoglycemia in infants after a regular 3- to 4-h feed was omitted. Hormone levels were assessed once, at the end of the fast or at hypoglycemia. The 121 infants were subdivided into three groups for analysis: normoglycemia (n = 94, 78%); transient hypoglycemia (n = 11, 9%); or severe and persistent hypoglycemia (n = 16, 13%). The severe and persistent hypoglycemic group had significantly higher levels of cortisol and epinephrine than the normoglycemic group. Norepinephrine and glucagon levels did not differ between the groups. Human GH levels were higher in the transiently hypoglycemic group but not in the severe and persistent hypoglycemic group. Prefeed blood lactate levels differed significantly among the groups and were highest in the severe and persistent groups. Multiple regression analysis showed that cortisol levels were significantly higher in infants who had severe and persistent hypoglycemia. The counterregulatory hormonal response in infants to severe and persistent hypoglycemia was limited to elevations in only cortisol and epinephrine levels but did not involve glucagon or human GH. This limited hormonal response may also contribute to the frequent occurrence of hypoglycemia in these infants.
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Affiliation(s)
- Lesley Jackson
- Maternal and Child Health Sciences, University of Dundee, Dundee DD1 9SY, Scotland, United Kingdom
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Affiliation(s)
- Stuart Alan Weinzimer
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut 06520, USA.
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Galassetti P, Tate D, Neill RA, Morrey S, Wasserman DH, Davis SN. Effect of sex on counterregulatory responses to exercise after antecedent hypoglycemia in type 1 diabetes. Am J Physiol Endocrinol Metab 2004; 287:E16-24. [PMID: 14998785 DOI: 10.1152/ajpendo.00480.2002] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A marked sexual dimorphism exists in healthy individuals in the pattern of blunted neuroendocrine and metabolic responses following antecedent stress. It is unknown whether significant sex-related counterregulatory differences occur during prolonged moderate exercise after antecedent hypoglycemia in type 1 diabetes mellitus (T1DM). Fourteen patients with T1DM (7 women and 7 men) were studied during 90 min of euglycemic exercise at 50% maximal O(2) consumption after two 2-h episodes of previous-day euglycemia (5.0 mmol/l) or hypoglycemia of 2.9 mmol/l. Men and women were matched for age, glycemic control, duration of diabetes, and exercise fitness and had no history or evidence of autonomic neuropathy. Exercise was performed during constant "basal" intravenous infusion of regular insulin (1 U/h) and a 20% dextrose infusion, as needed to maintain euglycemia. Plasma glucose and insulin levels were equivalent in men and women during all exercise and glucose clamp studies. Antecedent hypoglycemia produced a relatively greater (P < 0.05) reduction of glucagon, epinephrine, norepinephrine, growth hormone, and metabolic (glucose kinetics) responses in men compared with women during next-day exercise. After antecedent hypoglycemia, endogenous glucose production (EGP) was significantly reduced in men only, paralleling a reduction in the glucagon-to-insulin ratio and catecholamine responses. In conclusion, a marked sexual dimorphism exists in a wide spectrum of blunted counterregulatory responses to exercise in T1DM after prior hypoglycemia. Key neuroendocrine (glucagon, catecholamines) and metabolic (EGP) homeostatic responses were better preserved during exercise in T1DM women after antecedent hypoglycemia. Preserved counterregulatory responses during exercise in T1DM women may confer greater protection against hypoglycemia than in men with T1DM.
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Affiliation(s)
- Pietro Galassetti
- 715 PRB, Division of Diabetes, Endocrinology & Metabolism, Vanderbilt Univ. School of Medicine, Nashville, TN 37232-6303, USA
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Sandoval DA, Guy DLA, Richardson MA, Ertl AC, Davis SN. Effects of low and moderate antecedent exercise on counterregulatory responses to subsequent hypoglycemia in type 1 diabetes. Diabetes 2004; 53:1798-806. [PMID: 15220204 DOI: 10.2337/diabetes.53.7.1798] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Antecedent moderate-intensity exercise has been shown to blunt autonomic, neuroendocrine, and metabolic counterregulatory responses to subsequent hypoglycemia in nondiabetic individuals. The aims of the current study were to determine 1) whether this occurs in type 1 diabetic patients and 2) whether the degree of blunting is dependent on exercise intensity. Twenty-seven type 1 diabetic patients (13 women and 14 men) were studied during a single-step, 2-h hyperinsulinemic (9 pmol x kg(-1) x min(-1))-hypoglycemic (approximately 2.8 mmol/l) clamp 1 day after two 90-min exercise bouts at 30% (n = 11) or at 50% (n = 11) Vo(2max) or after no prior stress (control subjects, n = 25). After prior exercise at both 30 and 50% Vo(2max), epinephrine (1,959 +/- 553 and 1,528 +/- 424 vs. 3,420 +/- 424 pmol/l, respectively; P < 0.05) and pancreatic polypeptide (97 +/- 32 and 98 +/- 8 vs. 223 +/- 32 pmol/l, respectively; P < 0.05) responses to subsequent hypoglycemia were significantly lower compared with those of control subjects. Endogenous glucose production was significantly lower, while glucose utilization and, consequently, the exogenous glucose infusion rate needed to maintain hypoglycemia were significantly greater after both exercise intensities compared with that of control subjects. Muscle sympathetic nerve activity was significantly reduced by prior exercise of both intensities at baseline (16 +/- 4 and 22 +/- 4 vs. 31 +/- 3 bursts/min) and during hypoglycemia (22 +/- 4 and 27 +/- 5 vs. 41 +/- 3 bursts/min) compared with that of control subjects (P < 0.05). Total hypoglycemic symptoms were also significantly lower (P < 0.05) in both exercise groups compared with the control group. In summary, repeated episodes of prolonged exercise of both low and moderate intensities blunted key autonomic (epinephrine and pancreatic polypeptide) and metabolic (endogenous glucose production and peripheral glucose uptake) counterregulatory responses to next-day hypoglycemia in type 1 diabetes.
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Affiliation(s)
- Darleen A Sandoval
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-6303, USA.
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