Exercise in Type 1 (insulin-dependent) diabetic patients treated with continuous subcutaneous insulin infusion

Sonnenberg, G. E.; Kemmer, F. W.; Berger, Michael

doi:10.1007/bf00400572

Cited by 86 publications

(65 citation statements)

References 24 publications

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“…Although acute increases in insulin sensitivity caused by exercise, paralleled by the potential relative hyperinsulinemia resulting from the inability of diabetic patients to endogenously regulate insulin levels, have been hypothesized to play a role (34), this mechanism is likely to have only a modest impact (3). Additionally, both in well-controlled T1DM patients (i.e., exposed to frequent episodes of antecedent hypoglycemia) and in patients with classical diabetic autonomic neuropathy (32), reduced adrenergic adaptation to prolonged physical exercise has been reported (6).…”

Section: Discussionmentioning

confidence: 99%

Effect of differing antecedent hypoglycemia on counterregulatory responses to exercise in type 1 diabetes

Galassetti¹,

Tate²,

Neill³

et al. 2006

American Journal of Physiology-Endocrinology and Metabolism

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Hypoglycemia frequently occurs during or after exercise in intensively treated patients with type 1 diabetes mellitus (T1DM), but the underlying mechanisms are not clear. In both diabetic and nondiabetic subjects, moderate hypoglycemia blunts counterregulatory responses to subsequent exercise, but it is unknown whether milder levels of hypoglycemia can exert similar effects in a dose-dependent fashion. This study was designed to test the hypothesis that prior hypoglycemia of differing depths induces acute counterregulatory failure of proportionally greater magnitude during subsequent exercise in T1DM. Twenty-two T1DM patients (11 males/11 females, HbA1c 8.0 Ϯ 0.3%) were studied during 90 min of euglycemic cycling exercise after two 2-h periods of previous day euglycemia or hypoglycemia of 3.9, 3.3, or 2.8 mmol/l (HYPO-3.9, HYPO-3.3, HYPO-2.8, respectively). Patients' counterregulatory responses (circulating levels of neuroendocrine hormones, intermediary metabolites, substrate flux, tracer-determined glucose kinetics, and cardiovascular measurements) were assessed during exercise. Identical euglycemia and basal insulin levels were successfully maintained during all exercise studies, regardless of blood glucose levels during the previous day. After day 1 euglycemia, patients displayed normal counterregulatory responses to exercise. Conversely, when identical exercise was performed after day 1 hypoglycemia of increasing depth, a progressively greater blunting of glucagon, catecholamine, cortisol, endogenous glucose production, and lipolytic responses to exercise was observed. This was paralleled by a graduated increase in the amount of exogenous glucose needed to maintain euglycemia during exercise. Our results demonstrate that acute counterregulatory failure during prolonged, moderate-intensity exercise may be induced in a dose-dependent fashion by differing depths of antecedent hypoglycemia starting at only 3.9 mmol/l in patients with T1DM. dose response; glucagon; catecholamines; glucose clamp IN PATIENTS WITH TYPE 1 DIABETES MELLITUS (T1DM), hypoglycemia often occurs in association with physical exercise (10,19). This unfortunately limits the beneficial effects of exercise in type 1 diabetes, such as improving insulin sensitivity (4, 26) glycemic control (29, 42), blood pressure (35), and prevention of cardiovascular disease (2). Despite the many recent advances in diabetes management, the continued high prevalence of hypoglycemia, in general, and exercise-associated hypoglycemia, in particular, remain unresolved clinical challenges. Consequently, patients and physicians often choose suboptimal therapeutic regimens, including less effective insulin dosages and reduced physical activity to reduce the number of hypoglycemic episodes (43).Physical exercise elicits a complex pattern of adaptive neuroendocrine and metabolic responses (referred to as counterregulatory responses) aimed at maintaining glucose homeostasis in the face of increasing energy substrate needs. If adequately activated, these responses, includ...

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Section: Discussionmentioning

confidence: 99%

Effect of differing antecedent hypoglycemia on counterregulatory responses to exercise in type 1 diabetes

Galassetti¹,

Tate²,

Neill³

et al. 2006

American Journal of Physiology-Endocrinology and Metabolism

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“…Sonnenberg et al 24 investigated the effect of exercise on glucose levels among 7 male subjects, 15 to 31 years of age, with T1DM treated with insulin pumps. The subjects performed moderate exercise for 60 minutes on a cycle ergometer with 5 different insulin (soluble, regular) protocols.…”

Section: Discussionmentioning

confidence: 99%

Exercise With and Without an Insulin Pump Among Children and Adolescents With Type 1 Diabetes Mellitus

et al. 2005

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ABSTRACT. Background. The use of insulin pumps is becoming a popular technique for insulin delivery among patients with type 1 diabetes mellitus (T1DM), but there is no consensus regarding the guidelines for proper pump use during exercise.Objective. To investigate the physiologic responses and risk of hypoglycemia among children and adolescents with T1DM when exercising with the pump on (PO) (50% of the basal rate) or pump off (PF).Methods. Ten subjects with T1DM (6 female subjects and 4 male subjects), 10 to 19 years of age, performed prolonged exercise (40 -45 minutes) on a cycle ergometer ϳ2 hours after a standard breakfast and an insulin (Lispro) bolus. Complex carbohydrates (20 g) were provided before and after the exercise. Each patient exercised once with PO and once with PF, in a randomized, crossover (single-blind) manner. During exercise and 45 minutes of recovery, subjects were monitored for cardiorespiratory, metabolic, and hormonal responses. Blood glucose concentrations were recorded for 24 hours after exercise, with a continuous glucose monitoring system, to document late hypoglycemic events.Results. During exercise, blood glucose concentrations decreased by 59 ؎ 58 mg/dL (mean ؎ SD: 29 ؎ 24%) with PF and by 74 ؎ 51 mg/dL (35.5 ؎ 18%) with PO (not significant). No significant differences were found in cortisol, growth hormone, or noradrenaline levels between PO and PF. There were no differences in cardiorespiratory parameters, blood lactate concentrations, or free fatty acids concentrations between pump modes. Hypoglycemic events during exercise were asymptomatic and occurred for 2 subjects with PO and 2 with PF. Nine subjects had late hypoglycemia after PO, compared with 6 after PF (not significant).Conclusions. We found no advantage for subjects with either PO or PF during exercise, and we noted that late hypoglycemia was more common than hypoglycemia during exercise. However, PO was associated with a trend of increased risk for late hypoglycemia. We recommend that the pump be removed or turned off during prolonged exercise and that blood glucose concentrations be monitored for several hours after exercise, regardless of the pump mode.

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“…The underlying mechanisms causing the high incidence of exercise-associated hypoglycemia in type 1 diabetes are still incompletely understood. One mechanism points to the role played by acute increases in insulin sensitivity (and also in relatively elevated insulin levels) that occur during exercise (38). The hyperinsulinemia that typically occurs during clinical practice in patients with type 1 diabetes, however, is modest and very unlikely to cause marked hypoglycemia if counterregulatory responses are intact (19).…”

Section: Discussionmentioning

confidence: 99%

Effect of Antecedent Hypoglycemia on Counterregulatory Responses to Subsequent Euglycemic Exercise in Type 1 Diabetes

et al. 2003

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Exercise-related hypoglycemia is common in intensively treated patients with type 1 diabetes. The underlying mechanisms are not clearly defined. In nondiabetic subjects, hypoglycemia blunts counterregulatory responses to subsequent exercise. It is unknown whether this also occurs in type 1 diabetes. Therefore, the goal of this study was to test the hypothesis that prior hypoglycemia could result in acute counterregulatory failure during subsequent exercise in type 1 diabetes. A total of 16 type 1 diabetic patients (8 men and 8 women, HbA 1c 7.8 ؎ 0.3%) were investigated during 90 min of euglycemic cycling exercise, following either two 2-h periods of previous-day hypoglycemia (2.9 mmol/l) or previous-day euglycemia. Patients' counterregulatory responses (circulating levels of counterregulatory hormones, intermediary metabolites, substrate flux via indirect calorimetry, tracer-determined glucose kinetics, and cardiovascular measurements) were comprehensively assessed during exercise. Identical euglycemia and basal insulin levels were successfully maintained during all exercise studies, regardless of blood glucose levels during the previous day. After resting euglycemia, patients displayed normal counterregulatory responses to exercise. Conversely, when identical exercise was repeated after hypoglycemia, the glucagon response to exercise was abolished, and the epinephrine, norepinephrine, cortisol, endogenous glucose production, and lipolytic responses were reduced by 40 -80%. This resulted in a threefold increase in the amount of exogenous glucose needed to maintain euglycemia during exercise. Our results demonstrate that antecedent hypoglycemia, in type 1 diabetes, can produce acute counterregulatory failure during a subsequent episode of prolonged moderate-intensity exercise. The metabolic consequence of the blunted neuroendocrine and autonomic nervous system counterregulatory responses was an acute failure of endogenous glucose production to match the increased glucose requirements during exercise. These data indicate that counterregulatory failure may be a significant in vivo mechanism responsible for exercise-associated hypoglycemia in type 1 diabetes.

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Exercise in Type 1 (insulin-dependent) diabetic patients treated with continuous subcutaneous insulin infusion

Cited by 86 publications

References 24 publications

Effect of differing antecedent hypoglycemia on counterregulatory responses to exercise in type 1 diabetes

Effect of differing antecedent hypoglycemia on counterregulatory responses to exercise in type 1 diabetes

Exercise With and Without an Insulin Pump Among Children and Adolescents With Type 1 Diabetes Mellitus

Effect of Antecedent Hypoglycemia on Counterregulatory Responses to Subsequent Euglycemic Exercise in Type 1 Diabetes

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