Influence of lifestyle on the course of type 1 diabetes mellitus

Determinants of healthful eating and physical activity among adolescents and young adults with type 1 diabetes in Qatar: A qualitative study

BACKGROUND

In Qatar, as in the rest of the world, the sharp rise in the prevalence of type 1 diabetes (T1D) is a leading cause for concern, in terms associated with morbidity, mortality, and increasing health costs. Besides adhering to medication, the outcome of diabetes management is also dependent on patient adherence to the variable self-care behaviors including healthful eating (HE) and physical activity (PA). Yet, dietary intake and PA in adolescents and young adults (AYAs) with T1D are known to fall short of recommended guidelines. The aim of this study was to develop an in-depth understanding of the behavioral determinants of HE and PA adherence among Arab AYAs within the age range of 17-24 years with T1D attending Hamad General Hospital.

METHODS

Semi-structured, face-to-face individual interviews were conducted with 20 participants. Interviews were based on an integrative health behavior change model, the I-Change model (ICM). All interviews were audio-recorded, transcribed verbatim, and analyzed using the framework method.

RESULTS

More participants reported non-adherence than adherence. Several motivational determinants of adherence to HE and PA were identified. The majority of participants were cognizant of their own behaviors towards HE and PA. Yet, some did not link low adherence to HE and PA with increased risks of health problems resulting from T1D. Facilitators to adherence were identified as being convinced of the advantages of HE and PA, having support and high self-efficacy, a high level of intention, and a good health care system.

CONCLUSION

The suboptimal adherence in AYAs to HE and PA needs more attention. Supportive actions are needed to encourage adherence to a healthy lifestyle to achieve benefits in terms of glycemic control and overall health outcomes, with a special focus on adolescents. Interventions are needed to foster motivation by addressing the relevant determinants in order to promote adherence to these two behaviors in AYAs with T1D.

Exploring New Drug Targets for Type 2 Diabetes: Success, Challenges and Opportunities

There are substantial shortcomings in the drugs currently available for treatment of type 2 diabetes mellitus. The global diabetic crisis has not abated despite the introduction of new types of drugs and targets. Persistent unaddressed patient needs remain a significant factor in the quest for new leads in routine studies. Drug discovery methods in this area have followed developments in the market, contributing to a recent rise in the number of molecules. Nevertheless, troubling developments and fresh challenges are still evident. Recently, metformin, the most widely used first-line drug for diabetes, was found to contain a carcinogenic contaminant known as N-nitroso dimethylamine (NDMA). Therefore, purity and toxicity are also a big challenge for drug discovery and development. Moreover, newer drug classes against SGLT-2 illustrate both progress and difficulties. The same was true previously in the case of glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors. Furthermore, researchers must study the importance of mechanistic characteristics of novel compounds, as well as exposure-related hazardous aspects of current and newly identified protein targets, in order to identify new pharmacological molecules with improved selectivity and specificity.

Therapeutic approaches targeting molecular signaling pathways common to diabetes, lung diseases and cancer

Diabetes mellitus (DM), is the most common metabolic disease and is characterized by sustained hyperglycemia. Accumulating evidences supports a strong association between DM and numerous lung diseases including chronic obstructive pulmonary disease (COPD), fibrosis, and lung cancer (LC). The global incidence of DM-associated lung disorders is rising and several ongoing studies, including clinical trials, aim to elucidate the molecular mechanisms linking DM with lung disorders, in particular LC. Several potential mechanisms, including hyperglycemia, hyperinsulinemia, glycation, inflammation, and hypoxia, are cited as plausible links between DM and LC. In addition, studies also propose a connection between the use of anti-diabetic medications and reduction in the incidence of LC. However, the exact cause for DM associated lung diseases especially LC is not clear and is an area under intense investigation. Herein, we review the biological links reported between DM and lung disorders with an emphasis on LC. Furthermore, we report common signaling pathways (eg: TGF-β, IL-6, HIF-1, PDGF) and miRNAs that are dysregulated in DM and LC and serve as molecular targets for therapy. Finally, we propose a nanomedicine based approach for delivering therapeutics (eg: IL-24 plasmid DNA, HuR siRNA) to disrupt signaling pathways common to DM and LC and thus potentially treat DM-associated LC. Finally, we conclude that the effective modulation of commonly regulated signaling pathways would help design novel therapeutic protocols for treating DM patients diagnosed with LC.

Examination of the Igls Criteria for Defining Functional Outcomes of β-cell Replacement Therapy: IPITA Symposium Report

CONTEXT

The Igls criteria were developed to provide a consensus definition for outcomes of β-cell replacement therapy in the treatment of diabetes during a January 2017 workshop sponsored by the International Pancreas & Islet Transplant Association (IPITA) and the European Pancreas & Islet Transplant Association. In July 2019, a symposium at the 17th IPITA World Congress was held to examine the Igls criteria after 2 years in clinical practice, including validation against continuous glucose monitoring (CGM)-derived glucose targets, and to propose future refinements that would allow for comparison of outcomes with artificial pancreas system approaches.

EVIDENCE ACQUISITION

Utilization of the criteria in various clinical and research settings was illustrated by population as well as individual outcome data of 4 islet and/or pancreas transplant centers. Validation against CGM metrics was conducted in 55 islet transplant recipients followed-up to 10 years from a fifth center.

EVIDENCE SYNTHESIS

The Igls criteria provided meaningful clinical assessment on an individual patient and treatment group level, allowing for comparison both within and between different β-cell replacement modalities. Important limitations include the need to account for changes in insulin requirements and C-peptide levels relative to baseline. In islet transplant recipients, CGM glucose time in range improved with each category of increasing β-cell graft function.

CONCLUSIONS

Future Igls 2.0 criteria should consider absolute rather than relative levels of insulin use and C-peptide as qualifiers with treatment success based on glucose assessment using CGM metrics on par with assessment of glycated hemoglobin and severe hypoglycemia events.

Glycemic control in children and teenagers with type 1 diabetes around lockdown for COVID-19: A continuous glucose monitoring-based observational study

AIMS/INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic urged authorities to impose rigorous quarantines and brought considerable changes to people's lifestyles. The impact of these changes on glycemic control has remained unclear, especially the long-term effect. We aimed to investigate the impact of COVID-19 lockdown on glycemic control in children and adolescents with type 1 diabetes.

MATERIALS AND METHODS

This observational study enrolled children with type 1 diabetes using continuous glucose monitoring. Continuous glucose monitoring data were extracted from the cloud-based platform before, during and after lockdown. Demographics and lifestyle change-related information were collected from the database or questionnaires. We compared these data before, during and after lockdown.

RESULTS

A total of 43 children with type 1 diabetes were recruited (20 girls; mean age 7.45 years; median diabetes duration 1.05 years). We collected 41,784 h of continuous glucose monitoring data. Although time in range (3.9-10.0 mmol/L) was similar before, during and after lockdown, the median time below range <3.9 mmol/L decreased from 3.70% (interquartile range [IQR] 2.25-9.53%) before lockdown to 2.91% (IQR 1.43-5.95%) during lockdown, but reversed to 4.95% (IQR 2.11-9.42%) after lockdown (P = 0.004). Time below range <3.0 mmol/L was 0.59% (IQR 0.14-2.21%), 0.38% (IQR 0.05-1.35%) and 0.82% (IQR 0.22-1.69%), respectively (P = 0.008). The amelioration of hypoglycemia during lockdown was more prominent among those who had less time spent <3.9 mmol/L at baseline. During lockdown, individuals reduced their physical activity, received longer sleep duration and spent more time on diabetes management. In addition, they attended outpatient clinics less and turned to telemedicine more frequently.

CONCLUSION

Glycemic control did not deteriorate in children and teenagers with type 1 diabetes around the COVID-19 pandemic. Hypoglycemia declined during lockdown, but reversed after lockdown, and the changes related to lifestyle might not provide a long-term effect.

The impact of pharmacological and lifestyle interventions on body weight in people with type 1 diabetes: A systematic review and meta-analysis

AIM

To systematically review the effects of pharmacological and lifestyle interventions on body weight as a secondary outcome in people with type 1 diabetes.

METHODS

The Ovid Medline, Embase and Cochrane Library databases were searched for relevant pharmacological (glucagon-like peptide-1 [GLP-1] receptor agonist, sodium-glucose co-transporter-2 [SGLT-2] inhibitor, dipeptidyl peptidase-4 [DPP-4] inhibitor and metformin) and lifestyle intervention studies (diet and exercise) for adults with type 1 diabetes reporting body weight change and HbA1c published from January 2000 to May 2020. Meta-analyses were performed for 16 randomized controlled trials (RCTs).

RESULTS

Thirty-three RCTs (n = 9344 participants), 26 pharmacological (on average 43.9 years, 83.1 kg, HbA1c 8.1%; 55.8% male) and seven lifestyle-based interventions (on average 37.0 years, 85.0 kg, HbA1c 8.1%; 84.6% male), were analysed. The GLP-1 receptor agonist liraglutide 0.6 mg (mean difference [MD]: -2.22 kg [95% CI: -2.55 to -1.90]), 1.2 mg (MD: -3.74 kg [95% CI: -4.16 to -3.33]) and 1.8 mg (MD: -4.85 kg [95% CI: -5.29 to -4.41]), and the SGLT-2 inhibitors empagliflozin 2.5 mg (MD: -1.47 kg [95% CI: -2.23 to -0.71]), 10 mg (MD: -2.77 kg [95% CI: -3.24 to -2.31]) and 25 mg (MD: -3.06 kg [95% CI: -3.57 to -2.55]) and sotagliflozin 200 mg (MD: -2.40 kg [95% CI: -2.87 to -1.94]) and 400 mg (MD: -3.23 [95% CI: -3.73 to -2.72]) were associated with significant reductions in body weight. No significant effect on body weight was found for DPP-4 inhibitors, other GLP-1-receptor agonists, metformin, or for lifestyle interventions (i.e. exercise and diet).

CONCLUSIONS

In people with type 1 diabetes, several adjuvant pharmacological interventions showed weight reduction as a secondary outcome. Future studies in overweight people with type 1 diabetes are needed to establish whether the lifestyle and pharmacological interventions reviewed here have potential as components of complex interventions aimed at body weight reduction as a primary outcome.

β Cell Hypoxia-Inducible Factor-1α Is Required for the Prevention of Type 1 Diabetes

The development of autoimmune disease type 1 diabetes (T1D) is determined by both genetic background and environmental factors. Environmental triggers include RNA viruses, particularly coxsackievirus (CV), but how they induce T1D is not understood. Here, we demonstrate that deletion of the transcription factor hypoxia-inducible factor-1α (HIF-1α) from β cells increases the susceptibility of non-obese diabetic (NOD) mice to environmentally triggered T1D from coxsackieviruses and the β cell toxin streptozotocin. Similarly, knockdown of HIF-1α in human islets leads to a poorer response to coxsackievirus infection. Studies in coxsackievirus-infected islets demonstrate that lack of HIF-1α leads to impaired viral clearance, increased viral load, inflammation, pancreatitis, and loss of β cell mass. These findings show an important role for β cells and, specifically, lack of β cell HIF-1α in the development of T1D. These data suggest new strategies for the prevention of T1D.

Type 1 diabetes care: Improvement by standardization in a diabetes rehabilitation clinic. An observational report

BACKGROUND

T1D treatment requires informed self-responsible patients, who, however, frequently miss their therapeutic goals, providing considerable potential for improvement.

METHODS

This observational report evaluates T1D patients [N = 109], aged ≥18 years (range 22-82), poorly controlled at home, at and 3 weeks after their admission to our diabetes rehabilitation clinic [DRC], where they were offered standardized, but unmonitored life-style modification.

RESULTS

At admission, patients displayed elevated HbA1c values (66 mmol/mol [57; 81]), a high prevalence of co-morbidities (88%), lipodystrophies due to monolocal insulin injections (42%), a low rate of influenza (16%) and pneumococcal (7%) immunization, and underuse of lipid-lowering drugs (-38%). Standardization of life-style improved glucose (p<0.0001) and lipid metabolism (LDL/HDL ratio p<0.01) permitting reduction of insulin dose and reduction of add-on glucose-lowering drugs (GLDs) other than metformin. Outcome was independent of the mode of insulin treatment strategy and more marked at initially high HbA1c, with DRC-costs/d less than 25% of those encountered at standard hospitals.

CONCLUSION

Type 1 diabetes care requires i) insulin treatment, food intake and life style to be handled in concert, ii) this need cannot be replaced by arbitrary addition of add-on GLDs, and iii) training to this end is 75% cheaper at a DRC than in standard hospitals.

Parental knowledge and metabolic control of children and young adults with type 1 diabetes

INTRODUCTION

The authors aimed to answer the following questions: 1) What level of knowledge of type 1 diabetes do the parents of children and young adults with this disease have? 2) Will this level of knowledge increase after 1 year of observation? 3) Does improving the knowledge of young adults and their parents result in better metabolic control of the patients?

MATERIAL AND METHODS

This study included 227 patients between the ages of 5 and 20 years with type 1 diabetes. The research was conducted from March 2009 to June 2011. The following two time points were examined: the beginning of the study (test 1a) and one year later (test 1b). The knowledge levels of the patients and parents were obtained using a survey and a knowledge test.

RESULTS

Comparison of the results from the two study time points showed that the respondents had a significantly higher level of knowledge after 1 year (p = 0.001). The comparison of glycated hemoglobin levels between the two time points in patients with type 1 diabetes revealed that the levels were significantly higher at test 1b compared to test 1a (p = 0.0005).

CONCLUSIONS

The parents of children and young adults with type 1 diabetes demonstrate a satisfactory level of theoretical knowledge of therapeutic conduct and self-monitoring principles. The test 1b results demonstrated a higher level of theoretical knowledge in all respondents and poorer metabolic control. Poorer metabolic control in some patients suggests that metabolic control in type 1 diabetes depends on factors other than education. Further research is necessary to determine these additional factors.

Aerobic and concentration training and allele 7 in the dopamine receptor D4 (D4DR) gene increase chances of smoking cessation in young Polish women

INTRODUCTION

One reason for the limited effectiveness of the available smoking cessation methods is the fact that the causes of tobacco addiction have not been adequately explained yet. Numerous anti-smoking programs aimed at women involve intense physical activity. The goal of the study was to evaluate the effectiveness of health training for smoking cessation by young women in connection with the dopamine receptor gene (D4DR) in their genetic profile.

MATERIAL AND METHODS

Forty-eight adult female smokers were randomly assigned to: 1) a concentration training group, or 2) an aerobic and concentration training group. Genetic and phenotypic data were obtained from 48 participants. Genotyping was performed for allele 7 in the D4DR gene.

RESULTS

Individuals with allele 7 in the dopamine receptor D4 gene have two times greater chances (OR = 2.13: 95% CI: 0.91-4.96) of quitting smoking than individuals without allele 7. No statistical significance was revealed (p = 0.0805). Individuals undertaking aerobic training in combination with concentration training are three times more likely (OR = 3.06: 95% CI: 1.03-9.05) to quit smoking than individuals who do not perform aerobic training (p = 0.0439).

CONCLUSIONS

The results of the study show that an intensive, 6-week health training program had a significant influence on smoking cessation. Smoking quitters, who are genetically predisposed and decide to take up aerobic training in combination with concentration training, have much greater chances of quitting smoking.

Maternal lipids associated with large-for-gestational-age birth weight in women with type 1 diabetes: results from a prospective single-center study

INTRODUCTION

Despite improvement in diabetes care over the years, the incidence of macrosomia in type 1 diabetic mothers is still very high and even shows an increasing tendency. It is suggested that other factors that maternal hyperglycemia might be associated with excessive fetal growth in diabetic mothers. The aim of this study was to determine whether maternal lipids might contribute to high rates of large-for-gestational-age (LGA) newborns in women with type 1 diabetes (T1DM).

MATERIAL AND METHODS

This prospective, single-center study was performed in a population of women with T1DM admitted to the perinatal center for women with diabetes. Data were collected in the first trimester (< 12^th week), in mid-pregnancy (20^th-24^th weeks), and before delivery (34^th-39^th weeks).

RESULTS

Among 114 women included in the analysis, 30 (26.3%) delivered LGA newborns. The remaining 84 (73.7%) newborns were appropriate for gestational age (AGA). Lower high-density lipoprotein (HDL) HDL concentration in the first trimester was significantly associated with LGA (p = 0.01). Similar associations were observed for the HDL concentrations in mid-pregnancy (p = 0.04) and before delivery (p = 0.03). Higher triglyceride concentrations in the first trimester (p = 0.02) and before delivery (p = 0.008) were associated with LGA. Higher glycated haemoglobin (HbA_1c) levels in mid-pregnancy and before delivery were associated with LGA. The associations between maternal lipids and LGA were independent of maternal body mass index at onset of the study, gestational weight gain and HbA_1c concentrations.

CONCLUSIONS

Decreased HDL and increased triglycerides during pregnancy might contribute to the development of LGA in women with type 1 diabetes.

Association of cardiac autonomic modulation with physical and clinical features of young people with type 1 diabetes

OBJECTIVE

The objective of this study was to verify possible associations between heart rate variability indices and physical activity, body composition, and metabolic and cardiovascular parameters in individuals with type 1 diabetes.

METHOD

A total of 39 young patients with type 1 diabetes were included. Body composition, physical activity, cardiovascular parameters, and metabolic parameters were assessed. For the heart rate variability analysis, heart rate was recorded beat-by-beat using a Polar S810i heart rate monitor for 30 minutes, with the volunteers in the supine position; subsequently, the following indices were considered: standard deviation of all normal RR intervals; root-mean square of differences between adjacent normal RR intervals in a time interval; percentage of adjacent RR intervals with a difference of duration >50 ms; high frequency component in milliseconds squared; high frequency component in normalised units; standard deviation of the instantaneous variability beat-to-beat; and standard deviation of the long-term variability. The association between the heart rate variability indices and independent variables was verified through linear regression in unadjusted and adjusted models (considering gender and age). The statistical significance was set at 5% and the confidence interval at 95%.

RESULTS

High values of at-rest heart rate were associated with reduced parasympathetic activity and global heart rate variability, and higher values of waist-to-hip ratio were related to lower parasympathetic activity, independent of age or gender.

CONCLUSION

For young patients with type 1 diabetes, increases in at-rest heart rate values are associated with reduced parasympathetic activity and global heart rate variability, whereas higher waist-to-hip ratio values are related to lower parasympathetic activity, both independent of age and gender.

Reduction of sitting time has a positive effect on the decrease of insulin resistance in patients with non-alcoholic fatty liver disease

Introduction

Non-alcoholic fatty liver disease (NAFLD) affects a large part of the human population. One of the major environmental factors associated with the risk of NAFLD is the lack of physical activity.

Aim

To compare the level of physical activity and the insulin resistance in NAFLD patients.

Material and methods

Thirty patients with NAFLD underwent a six-month dietary intervention based on the principles of classical dietetics. Data about diet and physical activity was based on 72-hour nutrition diaries and International Physical Activity Questionnaire (IPAQ). Standard blood biochemical analyses were carried out before and after diet at the University Hospital Laboratory.

Results

The study showed that total physical activity and physical activity in leisure time are negatively correlated with insulin resistance (HOMA-IR) (p < 0.05). Insulin (p < 0.05), body weight (p < 0.05), and waist-hip ratio (WHR) (p < 0.05) were also negatively correlated with physical activity in free time. In addition, we noticed a positive correlation between sitting time and the risk of insulin resistance, in the case of HOMA-IR and insulin concentration (p < 0.05).

Conclusions

Dietary intervention and a physical activity plan are important factors in the treatment of non-alcoholic fatty liver disease. Taking regular exercise increases insulin sensitivity and prevents further development of the disease. It seems that diet and physical activity are not the only one risk factors of NAFLD. Our study reveals that the reduction of sitting time has a positive effect on the level of insulin and it reduces insulin resistance in patients with NAFLD.

Efficacy of Insulin Pump Therapy on Diabetes Treatment Satisfaction and Glycemic Control Among Patients with Type 1 Diabetes Mellitus in Saudi Arabia: A Prospective Study

INTRODUCTION

The aim of this study was to explore the impact of insulin pump therapy on diabetes treatment satisfaction and glycemic control among patients with type 1 diabetes mellitus (T1DM) in Saudi Arabia.

METHODS

A 6-month, prospective study was conducted among 47 patients (aged 17-24 years) with T1DM who attended the Insulin Pump Clinic at Prince Sultan Military Medical City, Riyadh, Saudi Arabia, between April 2014 and November 2014. The respondents were purposively and conveniently selected and were interviewed using the Arabic version of the Diabetes Treatment Satisfaction Questionnaire at baseline, 3, and 6 months. Demographics and clinical variables including hemoglobin A1c (HbA1c) were also collected.

RESULTS

The mean (±standard deviation) age of the study cohort was 19.1 ± 1.93 years. Seventeen patients were male (36.2%) and 30 were female (63.8%). Compared to baseline, significant positive differences were found in treatment satisfaction among female patients and patients with long-standing T1DM at 6 months. Frequency of hyperglycemia and hypoglycemia declined significantly in female patients at 6 months and in patients who had a shorter duration of T1DM. Furthermore, significant positive differences were found in HbA1c levels among female patients and among those who had a shorter duration of T1DM compared to baseline. Both female and male patients and those with a shorter duration of T1DM showed a significant decline in insulin necessity at 6 months when compared to baseline.

CONCLUSION

Although multiple daily injections is a feasible preference for insulin supply, insulin pumps should also be considered for patients with T1DM as it appears to increase patients' treatment satisfaction, decrease the frequency of hypoglycemia, hyperglycemia, and reduce HbA1c levels.