A Randomized Crossover Trial Comparing Glucose Control During Moderate-Intensity, High-Intensity, and Resistance Exercise With Hybrid Closed-Loop Insulin Delivery While Profiling Potential Additional Signals in Adults With Type 1 Diabetes

Abstract

OBJECTIVE To compare glucose control with hybrid closed-loop (HCL) when challenged by high intensity exercise (HIE), moderate intensity exercise (MIE), and resistance exercise (RE) while profiling counterregulatory hormones, lactate, ketones, and kinetic data in adults with type 1 diabetes. RESEARCH DESIGN AND METHODS Open-label multisite randomized crossover trial. Adults with type 1 diabetes undertook 40 min of HIE, MIE, and RE in random order while using HCL (Medtronic MiniMedTM 670G) with a temporary target set 2 h prior to and during exercise and 15 g carbohydrates if pre-exercise glucose was <126 mg/dL to prevent hypoglycemia. Primary outcome was median (interquartile range) continuous glucose monitoring time-in-range (TIR; 70–180 mg/dL) for 14 h post–exercise commencement. Accelerometer data and venous glucose, ketones, lactate, and counterregulatory hormones were measured for 280 min post–exercise commencement. RESULTS Median TIR was 81% (67, 93%), 91% (80, 94%), and 80% (73, 89%) for 0–14 h post–exercise commencement for HIE, MIE, and RE, respectively (n = 30), with no difference between exercise types (MIE vs. HIE; P = 0.11, MIE vs. RE, P = 0.11; and HIE vs. RE, P = 0.90). Time-below-range was 0% for all exercise bouts. For HIE and RE compared with MIE, there were greater increases, respectively, in noradrenaline (P = 0.01 and P = 0.004), cortisol (P < 0.001 and P = 0.001), lactate (P ≤ 0.001 and P ≤ 0.001), and heart rate (P = 0.007 and P = 0.015). During HIE compared with MIE, there were greater increases in growth hormone (P = 0.024). CONCLUSIONS Under controlled conditions, HCL provided satisfactory glucose control with no difference between exercise type. Lactate, counterregulatory hormones, and kinetic data differentiate type and intensity of exercise, and their measurement may help inform insulin needs during exercise. However, their potential utility as modulators of insulin dosing will be limited by the pharmacokinetics of subcutaneous insulin delivery.

Trends of glucose, lactate and ketones during anaerobic and aerobic exercise in subjects with type 1 diabetes: The ACTION‐1 study

“…Participants used a hybrid closed loop system (Medtronic MiniMed 670G) with a temporary target of 150 mg/dl (instead of the target of 120 mg/dl) set 2 h prior to and during exercise and 15 g carbohydrates if pre‐exercise glucose was <126 mg/dl to prevent hypoglycaemia. They did not find any difference in TIR between the exercise tests while a greater increase in lactate and heart rate was seen during HIE compared to MIE and RE, which is similar to our results 37 …”

“…Methods: Twenty-one men with T1D (median [IQR]: age 29 years [28][29][30][31][32][33][34][35][36][37][38], body mass index (BMI) 24.4 kg/m 2 [22.3-24.9], HbA1c 7.2% [6.7-7.8]), completed a cardiopulmonary exercise test (CPET) and a 60-min aerobic exercise (AEX) at 60% VO 2 peak on an ergometer bicycle within a 6-week period. Subjects consumed a standardised breakfast (6 kcal/kg, 20.2 g CHO/100 ml) before exercise without premeal insulin and basal insulin for pump users.…”

“…They did not find any difference in TIR between the exercise tests while a greater increase in lactate and heart rate was seen during HIE compared to MIE and RE, which is similar to our results. 37 In a small study (n = is needed], and the evidence for chronic supplementation is sparse. In addition, the acute intake of ketone supplements might be associated with gastrointestinal symptoms, and further research is warranted on the long-term safety of repeated use of ketone supplements.…”

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Background: Exercise is part of type 1 diabetes (T1D) management due to its cardiovascular and metabolic benefits. However, despite using continuous glucose monitoring, many patients are reluctant to exercise because of fear for hypoglycaemia.

Aims:We assessed trends in glucose, lactate and ketones during anaerobic and aerobic exercise in people with T1D and compared incremental area under the curve (AUC) between both exercises.Methods: Twenty-one men with T1D (median [IQR]: age 29 years [28][29][30][31][32][33][34][35][36][37][38], body mass index (BMI) 24.4 kg/m 2 [22.3-24.9], HbA1c 7.2% [6.7-7.8]), completed a cardiopulmonary exercise test (CPET) and a 60-min aerobic exercise (AEX) at 60% VO 2 peak on an ergometer bicycle within a 6-week period. Subjects consumed a standardised breakfast (6 kcal/kg, 20.2 g CHO/100 ml) before exercise without premeal insulin and basal insulin for pump users.Results: During CPET, glucose levels increased, peaking at 331 mg/dl [257-392] 1-3 h after exercise and reaching a nadir 6 h after exercise at 176 mg/dl .Lactate levels peaked at 6.0 mmol/L [5.0-6.6] (max 13.5 mmol/L).

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Proceedings of 21st ISPAD science school for physicians 2022

“…Closed‐loop glycemic control, characterized by glucose‐responsive automated insulin, is now a part of regular clinical reality for many individuals living with T1D and its performance during and after the physical activity has been extensively evaluated, especially in the controlled environment 35,36 . Closed‐loop has been challenged with different exercise protocols of different durations and intensity, using faster insulin formulation, glucagon, in heterogeneous age groups, with additional devices to detect physical activity, such as activity and heart rate monitoring, and adding glucagon to prevent hypoglycemia 37–41 . These studies have demonstrated reduced frequency and the overall proportion of time spent in hypoglycemia, during and after physical activity, including nocturnal hypoglycemia, and generally improved time in range.…”