Exercise management in type 1 diabetes:a consensus statement

Type 1 diabetes is a challenging condition to manage for various physiological and behavioural reasons. Regular exercise is important, but management of different forms of physical activity is particularly difficult for both the individual with type 1 diabetes and the health-care provider. People with type 1 diabetes tend to be at least as inactive as the general population, with a large percentage of individuals not maintaining a healthy body mass nor achieving the minimum amount of moderate to vigorous aerobic activity per week. Regular exercise can improve health and wellbeing, and can help individuals to achieve their target lipid profile, body composition, and fitness and glycaemic goals. However, several additional barriers to exercise can exist for a person with diabetes, including fear of hypoglycaemia, loss of glycaemic control, and inadequate knowledge around exercise management. This Review provides an up-to-date consensus on exercise management for individuals with type 1 diabetes who exercise regularly, including glucose targets for safe and effective exercise, and nutritional and insulin dose adjustments to protect against exercise-related glucose excursions

Glucose-lowering therapies in type 2 diabetes: Opportunities and challenges for peptides

This overview considers the opportunities and challenges that face the use of gluco-regulatory peptides to treat type 2 diabetes. New insulin analogues and formulations are being developed with pharmacokinetic properties to speed-up or prolong transfer from a subcutaneous injection site to the target tissues, or to selectively favour effects on the liver. Alternative routes of insulin administration continue to attract attention, and advances in the integration of glucose monitoring with insulin pump devices are improving miniaturised ‘closed loop’ artificial pancreas systems. Proof of concept has been established for non-cellular glucose-responsive insulin delivery (‘smart insulins’) to release insulin from implants or circulating depots in proportion to circulating glucose. The many peptides involved in blood glucose control offer diverse therapeutic opportunities. Exploitation of multiple selected receptor targets using constructs of hybrid and chimeric peptides, especially those based on glucagon and gastrointestinal hormones, has gained much credence from initial preclinical studies. Peptide templates identified from comparative endocrine studies have also provided valuable insights in this respect and indicated novel approaches to address associated conditions such as obesity and infections at the same time. Nevertheless, there are many challenges to the use of therapeutic peptides that impose on every step in the complex pathway from design and testing through to making a fully characterised therapeutic product, and optimising administration, tissue targeting and degradation. Stability of peptides and immunological uncertainties of novel structures require particular consideration as well as the need to avoid over-reduction of blood glucose into hypoglycaemia

Recomendaciones del Grupo GARIN para el manejo de pacientes no críticos con diabetes o hiperglucemia de estrés y nutrición artificial

Background & aims: By means of this update, the GARIN working group aims to define its position regarding the treatment of patients with diabetes or stress hyperglycaemia and artificial nutrition. In this area there are many aspects of uncertainty, especially in non-critically ill patients. Methods: Bibliographical review, and specific questions in advance were discussed and answered at a meeting in the form of conclusions. Results: We propose a definition of stress hyperglycaemia. The indications and access routes for artificial nutrition are no different in patients with diabetes/stress hyperglycaemia than in non-diabetics. The objective must be to keep pre-prandial blood glucose levels between 100 and 140 mg/dl and post-prandial levels between 140 and 180 mg/dl. Hyperglycemia can be prevented through systematic monitoring of capillary glycaemias and adequately calculate energy-protein needs. We recommend using enteral formulas designed for patients with diabetes (high monounsaturated fat) to facilitate metabolic control. The best drug treatment for treating hyperglycaemia/diabetes in hospitalised patients is insulin and we make recommendations for adapt the theoretical insulin action to the nutrition infusion regimen. We also addressed recommendations for future investigation. Conclusions: This recommendations about artificial nutrition in patients with diabetes or stress hyperglycaemia can add value to clinical work.Introducción y objetivos: En el tratamiento de los pacientes con diabetes o hiperglucemia de estrés y la nutrición artificial existen muchas áreas de incertidumbre, sobre todo en pacientes no críticos. El grupo de trabajo GARIN tiene como objetivo definir su posición en este campo. Material y métodos: Revisión bibliográfica previa y reunión presencial en la que se discutieron y contestaron preguntas específicas sobre el tema. Resultados: Proponemos una definición de hiperglucemia de estrés. Las indicaciones y las rutas de acceso a la nutrición artificial no difieren en los pacientes con hiperglucemia de estrés o diabetes respecto a los no diabéticos. El objetivo debe ser mantener los niveles de glucemia preprandial entre 100 y 140 mg/dl y postprandial entre 140 y 180 mg/dl. La hiperglucemia puede prevenirse a través de una monitorización sistemática de las glucemias capilares y un cálculo adecuado de las necesidades energético-proteicas. Recomendamos el uso de fórmulas enterales diseñadas para pacientes con diabetes (alto contenido en grasas monoinsaturadas) para facilitar el control metabólico. El mejor tratamiento farmacológico para tratar la hiperglucemia/diabetes en pacientes hospitalizados es la insulina, aconsejando adaptar la acción teórica de la insulina al régimen de infusión de la nutrición. También realizamos recomendaciones para investigaciones futuras. Conclusiones: Estas recomendaciones aportan respuestas concretas sobre cuestiones comunes en la asistencia a pacientes con diabetes o hiperglucemia de estrés y nutrición artificial

HbA1c, weight, quality of life and hypoglycaemia awareness after a structured education programme teaching carbohydrate counting and insulin dose adjustment

Objective - The primary aim was to assess the effects of Aintree Hospital’s ‘4-Step’ programme which teaches carbohydrate counting and insulin dose adjustment to patients with Type 1 diabetes, on HbA1c, Weight, Quality of life and Hypoglycaemia awareness. A secondary aim was to compare the effects of group education and one to one clinics in HbA1c, Weight, Quality of life and Hypoglycaemia awareness. Methods -All parameters were measured at baseline and four months later. HbA1c is measured by blood test, Quality of Life using the Problem Areas in Diabetes questionnaire and Hypoglycaemia Awareness using the ‘Symptom Awareness of Hypoglycaemia’ questionnaire. A convenience sampling technique was used whereby patient data was collected over a 6 month period from all patients who fit the criteria. Those excluded were patients with patients receiving nutritional support and those undertaking weight management programmes, those undergoing chemo/radiotherapy and those on renal dialysis. Fifty two sets of patient data were collected in total. All patients underwent either group or one-to-one clinic sessions. The programme was of four weeks duration and patients were followed up for repeat measurements three months after the programme. Where populations fit a normal ’Gaussian’ distribution parametric paired t-tests were chosen for statistical analysis. Where the population was found to be skewed, non- parametric Wilcoxon tests were used. Results - Following the programme overall HbA1c levels improved by 0.29% (p=0.008) with greater improvements occurring in those undertaking joint clinics (p=0.037) than groups (p=0.111). There was an overall weight loss of 0.5kg which did not reach statistical significance (p=0.100). However weight loss was greater in those attending group education (p=0.04) compared to those attending clinics (p=0.438). Quality of life scores improved by 11% overall (p=0.000) with group education being slightly more effective in achieving improvements (p=0.000) than group education (p=0.001). There was no change in symptoms of Hypoglycaemia awareness in the population as a whole (p=0.052) although as with HbA1c, those undergoing individual education had great improvements (p=0.046) compared to those in groups (p=0.409). Conclusions - The study has served to demonstrate the effectiveness of Aintree’s ‘4-Step’ programme in achieving key improvements in clinical and non-clinical aspects of patients’ diabetes care. While the improvement in HbA1c is beneficial, it is unclear whether this is sustained over time. Longer term follow-up and refresher education at intervals may increase the likelihood of sustained clinical benefits. Whilst weight loss was shown to be minimal, the study importantly demonstrates that the ‘4-Step’ programme does not lead to weight gain, an important finding when offering a programme enabling greater food freedom. Quality of Life improvements were highly significant with impressive improvements. However, future studies would benefit from including a more detailed analysis of the Quality of Life questionnaire. Whilst highlighting aspects which are most favourably influenced by the programme, this would also enable targeting of those aspects which demonstrate lower levels of satisfaction for future service provision. Hypoglycaemia Awareness did not improve, possibly due to the short study duration. Future evaluations may be better placed to measure frequency of hypoglycaemia for a more accurate assessment of the impact of the ‘4-Step’ programme on hypoglycaemic events

The INCA System: A Further Step Towards a Telemedical Artificial Pancreas

Biomedical engineering research efforts have accomplished another level of a ldquotechnological solutionrdquo for diabetes: an artificial pancreas to be used by patients and supervised by healthcare professionals at any time and place. Reliability of continuous glucose monitoring, availability of real-time programmable insulin pumps, and validation of safe and efficient control algorithms are critical components for achieving that goal. Nevertheless, the development and integration of these new technologies within a telemedicine system can be the basis of a future artificial pancreas. This paper introduces the concept, design, and evaluation of the ldquointelligent control assistant for diabetes, INCArdquo system. INCA is a personal digital assistant (PDA)-based personal smart assistant to provide patients with closed-loop control strategies (personal and remote loop), based on a real-time continuous glucose sensor (Guardian RT, Medtronic), an insulin pump (D-TRON, Disetronic Medical Systems), and a mobile general packet radio service (GPRS)-based telemedicine communication system. Patient therapeutic decision making is supervised by doctors through a multiaccess telemedicine central server that provides to diabetics and doctors a Web-based access to continuous glucose monitoring and insulin infusion data. The INCA system has been technically and clinically evaluated in two randomized and crossover clinical trials showing an improvement on glycaemic control of diabetic patients

Improved Nocturnal Glycaemia and Reduced Insulin Use Following Clinical Exercise Trial Participation in Individuals With Type 1 Diabetes

Aim: To explore the influence of clinical exercise trial participation on glycaemia and insulin therapy use in adults with type 1 diabetes (T1D). Research Design and Methods: This study involved a secondary analysis of data collected from 16 individuals with T1D who completed a randomized clinical trial consisting of 23-h in-patient phases with a 45-min evening bout of moderate intensity continuous exercise. Participants were switched from their usual basal-bolus therapy to ultra-long acting insulin degludec and rapid-acting insulin aspart as well as provided with unblinded interstitial flash-glucose monitoring systems. To assess the impact of clinical trial participation, weekly data obtained at the screening visit (pre-study involvement) were compared against those collated on the last experimental visit (post-study involvement). Interstitial glucose [iG] data were split into distinct glycaemic ranges and stratified into day (06:00–23:59) and night (00:00–05:59) time periods. A p-value of ≤ 0.05 was accepted for significance. Results: Following study completion, there were significant decreases in both the mean nocturnal iG concentration (Δ-0.9 ± 4.5 mmol.L−1, p < 0.001) and the time spent in severe hyperglycaemia (Δ-7.2 ± 9.8%, p = 0.028) during the night-time period. The total daily (Δ-7.3 ± 8.4 IU, p = 0.003) and basal only (Δ-2.3 ± 3.8 IU, p = 0.033) insulin dose requirements were reduced over the course of study involvement. Conclusions: Participation in clinical research may foster improved nocturnal glycaemia and reduced insulin therapy use in people with T1D. Recognition of these outcomes may help encourage volunteers to partake in clinical research opportunities for improved diabetes-related health outcomes. Clinical Trial Registration: DRKS.de; DRKS00013509

Interventions To Improve Patients' Compliance With Therapies Aimed At Lowering Glycated Hemoglobin (hba1c) In Type 1 Diabetes: Systematic Review And Meta-analyses Of Randomized Controlled Clinical Trials Of Psychological, Telecare, And Educational Interventions

Background: Brazilian records on glycemic control in patients with type 1 diabetes show treatment efficacy. Poor patient adherence to therapeutic proposals influences these results and can be associated with social, psychological, and economic aspects, besides others factors. The aim of this study was to evaluate the efficacy of psychological, telecare, and educational interventions to improve treatment compliance among patients with type 1 diabetes. Compliance was assessed indirectly using reduction of glycated hemoglobin (HbA1c) as the principal outcome measure. Methods: Systematic review and meta-analyses of randomized controlled clinical trials (RCTs) were performed using Medline, Embase, Cochrane and Scopus databases up to April 2015. The following medical subject headings were used: Diabetes Mellitus, Type 1, Patient Compliance or Adherence, Hemoglobin A, glycated, and Randomized Controlled Trial. The principal outcome was change in HbA1c between baseline and follow-up. Where appropriate, trials were combined in meta-analysis using fixed effects models. Results: From 191 articles initially identified, 57 were full text reviewed, and 19 articles met the inclusion criteria providing data from 1782 patients (49.4 % males, age 18 years). The RCTs (2 to 24 months in duration) were divided into four groups according to type of intervention: psychology (seven studies; 818 patients), telecare (six studies; 494 patients); education (five studies; 349 patients), and psychoeducation (one study; 153 patients). All studies reported some type of adherence measurement of the interventions. Decrease in HbA1c was observed after psychology (MD -0.310; 95 % CI, -0.599 to -0.0210, P = 0.035) but not after telecare (MD -0.124 %; 95 % CI, -0.268, 0.020; P = 0.090) or educational (MD -0.001; 95 % CI, -0.202, 0.200; P = 0.990) interventions. Conclusion: Psychological approaches to improve adherence to diabetes care treatment modestly reduced HbA1c in patients with type 1 diabetes; telecare and education interventions did not change glycemic control. However, the limited number of studies included as well as their methodological quality should be taken into account. © 2016 Viana et al.1

Interventions To Improve Patients' Compliance With Therapies Aimed At Lowering Glycated Hemoglobin (hba1c) In Type 1 Diabetes: Systematic Review And Meta-analyses Of Randomized Controlled Clinical Trials Of Psychological, Telecare, And Educational Interventions

Brazilian records on glycemic control in patients with type 1 diabetes show treatment efficacy. Poor patient adherence to therapeutic proposals influences these results and can be associated with social, psychological, and economic aspects, besides others factors. The aim of this study was to evaluate the efficacy of psychological, telecare, and educational interventions to improve treatment compliance among patients with type 1 diabetes. Compliance was assessed indirectly using reduction of glycated hemoglobin (HbA1c) as the principal outcome measure. Methods: Systematic review and meta-analyses of randomized controlled clinical trials (RCTs) were performed using Medline, Embase, Cochrane and Scopus databases up to April 2015. The following medical subject headings were used: Diabetes Mellitus, Type 1, Patient Compliance or Adherence, Hemoglobin A, glycated, and Randomized Controlled Trial. The principal outcome was change in HbA1c between baseline and follow-up. Where appropriate, trials were combined in meta-analysis using fixed effects models. Results: From 191 articles initially identified, 57 were full text reviewed, and 19 articles met the inclusion criteria providing data from 1782 patients (49.4 % males, age 18 years). The RCTs (2 to 24 months in duration) were divided into four groups according to type of intervention: psychology (seven studies; 818 patients), telecare (six studies; 494 patients); education (five studies; 349 patients), and psychoeducation (one study; 153 patients). All studies reported some type of adherence measurement of the interventions. Decrease in HbA1c was observed after psychology (MD -0.310; 95 % CI, -0.599 to -0.0210, P = 0.035) but not after telecare (MD -0.124 %; 95 % CI, -0.268, 0.020; P = 0.090) or educational (MD -0.001; 95 % CI, -0.202, 0.200; P = 0.990) interventions. Conclusion: Psychological approaches to improve adherence to diabetes care treatment modestly reduced HbA1c in patients with type 1 diabetes; telecare and education interventions did not change glycemic control. However, the limited number of studies included as well as their methodological quality should be taken into account. © 2016 Viana et al.17

Use of insulin degludec in pregnancy: two case reports and a literature review

Abstract As of now, insulin Degludec has no indication for use in pregnancy, because of the lack of studies that prove its safety for foetus. However it isn't infrequent that some women conceive while treating with insulin Degludec. So, before deciding to change the type of insulin therapy during pregnancy, an evaluation of the risk associated to a possible temporary worsening of glycaemic control, due to that insulin replacement, is needed. Referring to case series reported in the scientific literature could provide a support when a clinical decision need to be taken. We report two cases of women affected by type 1 diabetes who had unplanned pregnancies during treatment with insulin Degludec. In order to avoid the risk of a possible worsening of glycaemic control due to insulin switch, we decided to continue the treatment with Degludec during their pregnancies, after obtaining the patients' written informed consent. Daily insulin requirement gradually increased for both women pregnancy progressed, and glycated haemoglobin (HbA1c) values improved from the first observation to delivery: 55 mmol/mol (7.2%) at 9 weeks to 47 mmol/mol (6.5%) at 36 weeks, in Patient 1 (P1); 44 mmol/mol (6.2%) at 8 weeks to 33 mmol/mol (5.2%) at 36 weeks, in Patient 2 (P2). P1 delivered at week 37 with a caesarean section due to failed induction. The newborn, a girl of 3398 g at birth, developed neonatal hypoglycaemia and respiratory distress (Apgar 6-6). Six days after birth she underwent colectomy because of necrotizing enterocolitis and was finally diagnosed with atypical cystic fibrosis. P2 gave birth to a healthy girl (weight 2745g at birth, Apgar 7-9) at 37 weeks, undergoing a caesarean section for maternal cervical dystocia, without neonatal complications. Our experience provides additional evidence on the safety of insulin Degludec in pregnancy without any maternal or neonatal outcome suggesting its toxicity

Interventions To Improve Patients' Compliance With Therapies Aimed At Lowering Glycated Hemoglobin (hba1c) In Type 1 Diabetes: Systematic Review And Meta-analyses Of Randomized Controlled Clinical Trials Of Psychological, Telecare, And Educational Interventions

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)Brazilian records on glycemic control in patients with type 1 diabetes show treatment efficacy. Poor patient adherence to therapeutic proposals influences these results and can be associated with social, psychological, and economic aspects, besides others factors. The aim of this study was to evaluate the efficacy of psychological, telecare, and educational interventions to improve treatment compliance among patients with type 1 diabetes. Compliance was assessed indirectly using reduction of glycated hemoglobin (HbA1c) as the principal outcome measure. Methods: Systematic review and meta-analyses of randomized controlled clinical trials (RCTs) were performed using Medline, Embase, Cochrane and Scopus databases up to April 2015. The following medical subject headings were used: Diabetes Mellitus, Type 1, Patient Compliance or Adherence, Hemoglobin A, glycated, and Randomized Controlled Trial. The principal outcome was change in HbA1c between Baseline and follow-up. Where appropriate, trials were combined in meta-analysis using fixed effects models. Results: From 191 articles initially identified, 57 were full text reviewed, and 19 articles met the inclusion criteria providing data from 1782 patients (49.4 % males, age 18 years). The RCTs (2 to 24 months in duration) were divided into four groups according to type of intervention: psychology (seven studies; 818 patients), telecare (six studies; 494 patients); education (five studies; 349 patients), and psychoeducation (one study; 153 patients). All studies reported some type of adherence measurement of the interventions. Decrease in HbA1c was observed after psychology (MD -0.310; 95 % CI, -0.599 to -0.0210, P = 0.035) but not after telecare (MD -0.124 %; 95 % CI, -0.268, 0.020; P = 0.090) or educational (MD -0.001; 95 % CI, -0.202, 0.200; P = 0.990) interventions. Conclusion: Psychological approaches to improve adherence to diabetes care treatment modestly reduced HbA1c in patients with type 1 diabetes; telecare and education interventions did not change glycemic control. However, the limited number of studies included as well as their methodological quality should be taken into account.17Conselho Nacional de Desenvolvimento Cientifico e Tecnologico (CNPq)Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior (CAPES)Fundo de Incentivo a Pesquisa (FIPE) of Hospital de Clinicas de Porto Alegre (HCPA)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES