Bartłomiej Matejko

Sleep characteristics in type 1 diabetes and associations with glycemic control: systematic review and meta-analysis

OBJECTIVES The association between inadequate sleep and type 2 diabetes has garnered much attention, but little is known about sleep and type 1 diabetes (T1D). Our objectives were to conduct a systematic review and meta-analysis comparing sleep in persons with and without T1D, and to explore relationships between sleep and glycemic control in T1D. METHODS Studies were identified from Medline and Scopus. Studies reporting measures of sleep in T1D patients and controls, and/or associations between sleep and glycemic control, were selected. RESULTS A total of 22 studies were eligible for the meta-analysis. Children with T1D had shorter sleep duration (mean difference [MD] = -26.4 minutes; 95% confidence interval [CI] = -35.4, -17.7) than controls. Adults with T1D reported poorer sleep quality (MD in standardized sleep quality score = 0.51; 95% CI = 0.33, 0.70), with higher scores reflecting worse sleep quality) than controls, but there was no difference in self-reported sleep duration. Adults with TID who reported sleeping >6 hours had lower hemoglobin A1c (HbA1c) levels than those sleeping ≤6 hours (MD = -0.24%; 95% CI = -0.47, -0.02), and participants reporting good sleep quality had lower HbA1c than those with poor sleep quality (MD = -0.19%; 95% CI = -0.30, -0.08). The estimated prevalence of obstructive sleep apnea (OSA) in adults with TID was 51.9% (95% CI = 31.2, 72.6). Patients with moderate-to-severe OSA had a trend toward higher HbA1c (MD = 0.39%, 95% CI = -0.08, 0.87). CONCLUSION T1D was associated with poorer sleep and high prevalence of OSA. Poor sleep quality, shorter sleep duration, and OSA were associated with suboptimal glycemic control in T1D patients.

Insulin Pump Therapy is Equally Effective and Safe in Elderly and Young Type 1 Diabetes Patients

OBJECTIVES It is generally accepted that in adult type 1 diabetes patients (T1D) continuous subcutaneous insulin infusion (CSII) via a personal pump is more effective than the multiple daily injections (MDI) model. However, it is not clear whether all age groups of adult T1D patients may equally benefit from CSII therapy. We aimed to compare the glycemic control and use of selected pump tools in T1D subjects using CSII over the age of 50 (50+ T1D) with patients younger than 50 years of age. METHODS The last available insulin pump/blood glucose meter downloads and last available HbA1c levels of 124 adult T1D subjects using CSII were reviewed. We divided our cohort into two subgroups: 50+ T1D patients (n = 13) and younger patients (n = 111). RESULTS There were no differences in glycemic control achieved with CSII treatment in 50+ T1D patients vs. younger subjects. HbA1c levels were 7.01 ± 0.67% and 7.34 ± 1.24% (p = 0.46), and the mean glycemia based on glucometer downloads was 141.8 ± 17.7 mg/dl and 150.8 ± 35.7 mg/dl (p = 0.69), respectively. Also, there were no differences with respect to the use of important personal pump options and tools. CONCLUSION In conclusion, insulin pump therapy appears to be effective and safe in T1D patients regardless of age.

The Influence of Dietary Carbohydrate Content on Glycaemia in Patients with Glucokinase Maturity-Onset Diabetes of the Young

Mutations in the glucokinase (GCK) gene result in maturity-onset diabetes of the young (MODY). Pharmacotherapy is not effective in GCK MODY. Thus, nutritional intervention seems to be the only therapeutic option. This study evaluated the effect of the quantity of dietary carbohydrate on glucose levels in 10 GCK mutation carriers: seven with MODY and three with prediabetes. All patients were exposed to high-carbohydrate diets for 2 days and then switched to low-carbohydrate diets (60% versus 25% of the daily calorie intake) for another 2 days, after a 1-day washout. Glucose levels were assessed by continuous blood glucose monitoring. In patients with GCK MODY on high-carbohydrate diets, glucose levels were significantly higher, and more hyperglycaemic episodes occurred, compared with patients on low-carbohydrate diets. This short-term observational study suggested that diets with a modestly limited carbohydrate content may improve glycaemic control in patients with GCK MODY.

Personal Insulin Pump With Predictive Low Glucose Management Technology at High Altitude.

These days, compared to days gone by, patients with type 1 diabetes mellitus (T1DM) are becoming more and more physically active, with some choosing to partake in extreme sports such as high-altitude mountain trekking. Although numerous high-altitude mountain expeditions including patients with T1DM have been reported, diabetic device performance at high altitude has not been thoroughly assessed. The devices to which we refer include glucose meters, continuous glucose monitoring (CGM) systems, and insulin pumps, especially newest ones. Here, we present the case of a T1DM patient, and the pump with predictive low glucose management technology user, who climbed Aconcagua—a mountain 6962 meters above sea level. The data provided below are based on both the patient’s report and downloads from the insulin pump. The case study patient is a 42-year-old male, who has been suffering from T1DM for 20 years. His BMI at the time of the study was 24 kg/m, and his last available HbA1c was 7.2%. The patient is a very active individual, who regularly runs marathons and participates in mountain runs. After undergoing treatment with multiple daily insulin injections for many years and being reluctant to insulin pump therapy, he chose to switch to the Medtronic MiniMed 640G (Medtronic MiniMed, Northridge, California, USA) insulin pump with implemented SmartGuard® technology, with protection against hypoglycemia being his primary motivator. The switch was made 3 months prior to his 7-day expedition to Aconcagua. He was informed that the performance of the predictive low glucose management technology at high altitude had not been tested yet; however, he chose to stay on the pump and carry backup insulin in pens with him during the trek. He began his climb at 2950 meters, and at the end of the first day he reached Confuluencia Camp at 3400 meters. His mean blood glucose level during that time stayed around 120 mg/dl. Following acclimatization, he trekked to de Mulas Camp at 4300 meters, where he underwent a medical examination (assessment of mood, heart rate, pulse, oxygen saturation of arterial blood). During the night, after reaching de Mulas Camp, he suffered a headache and experienced fluctuations in blood glucose; however, he did not experience a single episode of hypoglycemia (defined as blood glucose level below 70 mg/ dL). Over the days to follow, he climbed Nido de Condores (5550 meters), Plaza Cólera (5970), and on the 7th day he reached Aconcagua. The final episode of activation of predictive insulin delivery suspension was recorded at an altitude of 5600 meters. The patient recalls that he experienced and addressed a slightly elevated blood sugar level (between 140 and 200 mg/dL) later on; since the “suspend before low” option was set at 70 mg/dL, the SmartGuard had “no chance” to act. According to the patient, the CGM system performed well, and showed no significant discrepancy between data from the CGM system and hand blood glucose meter (Contour® Plus Link 2.4, Ascensia, Basel, Switzerland). During the 7-day expedition the patient experienced just 1 episode of hypoglycemia (blood sugar level of 61 mg/dL); the predictive insulin delivery suspension was activated 11 times. In summary, the insulin pump with predictive low glucose management technology performed well at high altitude; however, further studies are needed before any recommendation for its usage at altitude can be made.

Qualitative Parameters of the Colonic Flora in Patients with HNF1A-MODY Are Different from Those Observed in Type 2 Diabetes Mellitus

Background. Type 2 diabetes mellitus (T2DM) is determined by genetic and environmental factors. There have been many studies on the relationship between the composition of the gastrointestinal bacterial flora, T2DM, and obesity. There are no data, however, on the gut microbiome structure in monogenic forms of the disease including Maturity Onset Diabetes of the Young (MODY). Methods. The aim of the investigation was to compare the qualitative parameters of the colonic flora in patients with HNF1A-MODY and T2DM and healthy individuals. 16S sequencing of bacterial DNA isolated from the collected fecal samples using the MiSeq platform was performed. Results. There were significant between-group differences in the bacterial profile. At the phylum level, the amount of Proteobacteria was higher (p = 0.0006) and the amount of Bacteroidetes was lower (p = 0.0005) in T2DM group in comparison to the control group. In HNF1A-MODY group, the frequency of Bacteroidetes was lower than in the control group (p = 0.0143). At the order level, Turicibacterales was more abundant in HNF1A-MODY group than in T2DM group. Conclusions. It appears that there are differences in the gut microbiome composition between patients with HNF1A-MODY and type 2 diabetes. Further investigation on this matter should be conducted.

Metabolic control in type 1 diabetes patients practicing combat sports: at least two-year follow-up study

BackgroundIt is well recognized that physical activity should be an integral part of the management of diabetes. It remains controversial, however, whether combat sports, often preferred by young individuals type 1 diabetes mellitus (T1DM), may be performed without high risk of metabolic decompensation. The aim of this observational study was to summarize a two-year follow-up period of five young male patients with T1DM practicing combat sports under the care of a physical-activity oriented specialist diabetes outpatient clinic. Of the five patients, three mixed martial arts and two kick-boxing competitors were included in the study. To control glucose in each patient, an individual approach was used that took into consideration the type of training, the sequence of the exercises, and the relative proportion of different forms of exercise.FindingsDuring the follow-up, glycemic control was improved and maintained in all individuals. Neither an episode of hospitalization-requiring diabetic ketoacidosis nor severe hypoglycemia occurred in these patients during the follow-up.ConclusionsIn conclusion, an individual approach for T1DM patients practicing combat sports may result in achieving and maintaining satisfactory glycemic control without increased risk of metabolic decompensation.

Are late-night eating habits and sleep duration associated with glycemic control in adult type 1 diabetes patients treated with insulin pumps?

Little is known about the impact of sleep duration and late‐night snacking on glycemic control in patients with type 1 diabetes using insulin pumps. The aim of the present study was to examine whether late‐night eating habits and short sleep duration are associated with glycemic control in continuous subcutaneous insulin infusion‐treated type 1 diabetic patients.

The impact of a pure protein load on the glucose levels in type 1 diabetes patients treated with insulin pumps.

We aimed to estimate the impact of ingestion of a pure protein load on the glucose levels in T1DM patients treated with insulin pumps. We examined 10 T1DM patients (6 females, mean age—32.3 years, mean HbA1c—6.8%) treated with insulin pumps equipped with a continuous glucose monitoring system (CGMS). In Phase I, baseline insulin infusion was optimized to minimize the differences in fasting glucose levels to less than 30 mg/dL between any two time points between 9 a.m. and 3 p.m. In Phase II, the patients were exposed to single pure protein load. CGMS record was performed and the glucose pattern was defined for 6 hours of each phase. The maximal glucose level increment was similar for the entire duration of the fasting and the protein load test (26.6 versus 27.6 mg/dL, resp., P < 0.78). There was only a borderline difference in change between baseline versus 6th hour glucose (12.5 and 19.0 mg/dL, P = 0.04). Glucose variability, assessed by standard deviation of mean glucose levels, was 36.4 and 37.9 mg/dL, respectively (P = 0.01). The administration of a pure protein load does not seem to have a clinically significant impact on glucose levels in T1DM patients treated with insulin pumps.

Prevalence of Retinopathy in Adult Patients with GCK-MODY and HNF1A-MODY.

We aimed to assess the prevalence of diabetic retinopathy (DR) in adult patients with GCK-MODY and HNF1A-MODY in Poland and to identify biochemical and clinical risk factors associated with its occurrence.We examined 74 GCK mutation carriers, 51 with diabetes and 23 with prediabetes, respectively, and 63 patients with HNF1A-MODY. Retinal photographs, 12 for each patient, were done by a fundus camera. Signs of DR were graded according to the DR disease severity scale. Statistical tests were performed to assess differences between the groups and logistic regression was done for the association with DR.The mean age at examination was 34.5±14.8 and 39.9±15.2 in the GCK-MODY and HNF1A-MODY groups, respectively. Mild nonproliferative DR (NPDR) was found in one patient with the GCK mutation and likely concomitant type 1 diabetes, whereas DR was diagnosed in 15 HNF1A-MODY patients: 9 with proliferative, 3 with moderate NPDR and 2 with mild NPDR. In univariate logistic regression analysis in the HNF1A-MODY group, significant results were found for diabetes duration, fasting glycemia, HbA1c, arterial hypertension, age at the examination, and eGFR. The strongest independent predictors of DR in HNF1A-MODY were markers of glucose control: HbA1c (OR: 2.05, CL%95: 1.2-3.83, p=0.01) and glucose (p=0.006, OR: 1.40, CL%95: 1.12-1.83) analyzed in 2 separated models. Additionally, arterial hypertension independently predicted DR (OR: 9.06, CL%95: 1.19-98.99, p=0.04) in the model with HbA1c as glycaemic control marker.In conclusion, DR of any degree was not present in our GCK-MODY group, while in spite of young age almost every fourth subject with HNF1A-MODY showed signs of this complication.

Comparison of Glomerular Filtration Rate Estimation from Serum Creatinine and Cystatin C in HNF1A-MODY and Other Types of Diabetes

Introduction. We previously showed that in HNF1A-MODY the cystatin C-based glomerular filtration rate (GFR) estimate is higher than the creatinine-based estimate. Currently, we aimed to replicate this finding and verify its clinical significance. Methods. The study included 72 patients with HNF1A-MODY, 72 with GCK-MODY, 53 with type 1 diabetes (T1DM), 70 with type 2 diabetes (T2DM), and 65 controls. Serum creatinine and cystatin C levels were measured. GFR was calculated from creatinine and cystatin C using the CKD-EPI creatinine equation (eGRF-cr) and CKD-EPI cystatin C equation (eGFR-cys), respectively. Results. Cystatin C levels were lower (p < 0.001) in the control (0.70 ± 0.13 mg/L), HNF1A (0.75 ± 0.21), and GCK (0.72 ± 0.16 mg/L) groups in comparison to those with either T1DM (0.87 ± 0.15 mg/L) or T2DM (0.9 ± 0.23 mg/L). Moreover, eGFR-cys was higher than eGRF-cr in HNF1A-MODY, GCK-MODY, and the controls (p = 0.004; p = 0.003; p < 0.0001). This corresponded to 8.9 mL/min/1.73 m2, 9.7 mL/min/1.73 m2, and 16.9 mL/min/1.73 m2 of difference. Additionally, T1DM patients had higher eGFR-cr than eGFR-cys (11.6 mL/min/1.73 m2; p = 0.0004); no difference occurred in T2DM (p = 0.91). Conclusions. We confirmed that eGFR-cys values in HNF1A-MODY patients are higher compared to eGFR-cr. Some other differences were also described in diabetic groups. However, none of them appears to be clinically relevant.