Metformin and Micronutrient Status in Type 2 Diabetes: Does Polypharmacy Involving Acid-Suppressing Medications Affect Vitamin B12 Levels?

Metformin is the first-choice drug in uncomplicated type 2 diabetes (T2DM) and is effective in improving glycaemic control. It is the most widely prescribed oral antidiabetic medicine and has a good safety profile. However, there is an abundance of evidence that metformin use is associated with decreased Vitamin B12 status, though the clinical implications of this in terms of increased risk of diabetic peripheral neuropathy are debated. There is growing evidence that other B vitamins, vitamin D and magnesium may also be impacted by metformin use in addition to alterations to the composition of the microbiome, depending on the dose and duration of therapy. Patients using metformin for prolonged periods may, therefore, need initial screening with intermittent follow-up, particularly since vitamin B12 deficiency has similar symptoms to diabetic neuropathy which itself affects 40-50% of patients with T2DM at some stage. Among patients with T2DM, 40% are reported to experience symptomatic gastroesophageal reflux disease (GORD), of whom 70% use oral antidiabetic medications. The most common medications used to treat GORD are proton pump inhibitors (PPIs) and antagonists of histamine selective H2 receptors (H2RAs), both of which independently affect vitamin B12 and magnesium status. Research indicates that co-prescribing metformin with either PPIs or H2RAs can have further deleterious effects on vitamin B12 status. Vitamin B12 deficiency related to metformin and polypharmacy is likely to contribute to the symptoms of diabetic neuropathy which may frequently be under-recognised. This review explores current knowledge surrounding these issues and suggests treatment strategies such as supplementation.

Quantification of Movement Characteristics in Women's English Premier Elite Domestic Rugby Union.

This study aims were to determine the positional physical requirements of English domestic women's rugby union match-play. Global positioning system data (Catapult Minimax S4) were collected at 10 Hz of 129 competitive player games from the Tyrrells Premier15 league. Players were classified according to broad (Forwards, Backs) and specific positions (front-, second-, back-row, scrum-half, inside-, and outside-backs). Total distances, maximum speed, and player loads were calculated. Mean total distance was 4982 m and was similar between the Forwards and Backs, with second-row players covering the most (5297 m) and outside-backs the least (4701 m). Inside- and outside-backs covered a significantly greater distance at high speed running (134 m; 178 m) and sprinting (74 m; 92 m) speeds, respectively, whereas the second- and back-row covered greater distances jogging (1966 m; 1976 m) and the front-row spent the greatest overall distance walking (2613 m). Outside-backs reached greater maximum speed than all other positions (24.9 km.h-1). The mean player load was highest in the back-row (562 AU) and second-row (555 AU) and these were higher than the outside-backs (476 AU). These findings indicate that the demands placed on female rugby players are position specific and differ from male players. Additionally, the data are the first obtained from the 10 Hz GPS and from within English domestic women's rugby, thus adding to the overall limited data available on women's rugby union.

Effect of the PreBind Engagement Process on Scrum Timing and Stability in the 2013-16 Six Nations.

This study examined whether changes in scrum engagement laws from the "crouch-touch-set" in 2013 to the "PreBind" engagement from 2014 onward have led to changes in scrum characteristics, specifically timing, in international rugby union. Duration and outcomes were identified for all scrums occurring in the 2013-16 Six Nations (N = 60 games) using video analysis. Scrum duration increased after the introduction of the PreBind engagement from 59 s in 2013 to 69 s in 2016 (P = .024, effect size = 0.93). A significant increase in mean contact duration per scrum occurred when prebinding was adopted (P < .05), moving from 7.5 s under the crouch-touch-set process to 8.5, 10.0, and 10.8 s with PreBind in 2014, 2015, and 2016 (effect size = 0.71, 2.05, and 3.0, respectively). The number of scrum resets and collapsed scrums, along with early engagement and pulling down infringements, was lower under the PreBind process. Overall, the PreBind engagement resulted in longer scrums with significant increases observed in overall and contact durations, with improved stability-related characteristics. The longer contact time is a consequence of increased stability with a shift from high-energy impact to a sustained push phase with a lower force that is a benefit to player welfare.

Differentiating technical skill and motor abilities in selected and non-selected 3-5 year old team-sports players.

This study examined the difference in 22 3-5year old boys selected to an advanced or non-advanced group on an English community-based professional club training program. Time to complete 15m linear sprint and 15m zig-zag agility tests, with and without a ball, were used to assess the children's technical skill and motor ability. Age and body mass of both groups were the same, whereas height was greater and BMI was lower in the selected group (p<0.01). Linear sprint times without and with the ball were 3.98±0.35 and 4.44±0.36s, respectively for the selected and corresponding times were 4.64±1.04 and 11.2±5.37s for the non-selected (p<0.01, ES 0.8, 1.8). Similar results were found when a change of movement was included, both with and without the ball. A model of selection indicated that performance in an agility test with the ball and height had the greatest discriminatory power and explained 95.5% of between group variance. Selected players performed significantly better in tests when ball control was required. These findings suggest that technical proficiency and physical differences may influence team selection in three to five year old children.

Tier-specific evolution of match performance characteristics in the English Premier League: it's getting tougher at the top.

This study investigated the evolution of physical and technical performances in the English Premier League (EPL), with special reference to league ranking. Match performance observations (n = 14,700) were collected using a multiple-camera computerised tracking system across seven consecutive EPL seasons (2006-07 to 2012-13). Final league rankings were classified into Tiers: (A) 1st-4th ranking (n = 2519), (B) 5th-8th ranking (n = 2965), (C) 9th-14th ranking (n = 4448) and (D) 15th-20th ranking (n = 4768). Teams in Tier B demonstrated moderate increases in high-intensity running distance while in ball possession from the 2006-07 to 2012-13 season (P < 0.001; effect size [ES]: 0.68), with Tiers A, C and D producing less pronounced increases across the same period (P < 0.005; ES: 0.26, 0.41 and 0.33, respectively). Large increases in sprint distance were observed from the 2006-07 to 2012-13 season for Tier B (P < 0.001; ES: 1.21), while only moderate increases were evident for Tiers A, C and D (P < 0.001; ES: 0.75, 0.97 and 0.84, respectively). Tier B demonstrated large increases in the number of passes performed and received in 2012-13 compared to 2006-07 (P < 0.001; ES: 1.32-1.53) with small-to-moderate increases in Tier A (P < 0.001; ES: 0.30-0.38), Tier C (P < 0.001; ES: 0.46-0.54) and Tier D (P < 0.001; ES: 0.69-0.87). The demarcation line between 4th (bottom of Tier A) and 5th ranking (top of Tier B) in the 2006-07 season was 8 points, but this decreased to just a single point in the 2012-13 season. The data demonstrate that physical and technical performances have evolved more in Tier B than any other Tier in the EPL and could indicate a narrowing of the performance gap between the top two Tiers.

Factors influencing physical and technical variability in the English Premier League.

PURPOSE: To investigate match-to-match variability of physical and technical performances in English Premier League players and quantify the influence of positional and contextual factors. METHODS: Match data (N = 451) were collected using a multicamera computerized tracking system across multiple seasons (2005-06 to 2012-13). The coefficient of variation (CV) was calculated from match to match for physical and technical performances in selected positions across different match contexts (location, standard, and result). RESULTS: Wide midfielders demonstrated the greatest CVs for total distance (4.9% ± 5.9%) and central midfielders the smallest (3.6% ± 2.0%); nevertheless, all positions exhibited CVs <5% (P > .05, effect size [ES] 0.1-0.3). Central defenders demonstrated the greatest CVs and wide midfielders the lowest for both high-intensity running (20.2% ± 8.8% and 13.7% ± 7.7%, P < .05, ES 0.4-0.8) and sprint distance (32.3% ± 13.8% and 22.6% ± 11.2%, P < .05, ES 0.5-0.8). Technical indicators such as tackles (83.7% ± 42.3%), possessions won (47.2% ± 27.9%), and interceptions (59.1% ± 37.3%) illustrated substantial variability for attackers compared with all other positions (P < .05, ES 0.4-1.1). Central defenders demonstrated large variability for the number of times tackled per match (144.9% ± 58.3%) and passes attempted and received compared with other positions (39.2% ± 17.5% and 46.9% ± 20.2%, P < .001, ES 0.6-1.8). Contextual factors had limited impact on the variability of physical and technical parameters. CONCLUSIONS: The data demonstrate that technical parameters varied more from match to match than physical parameters. Defensive players (fullbacks and central defenders) displayed higher CVs for offensive technical variables, while attacking players (attackers and wide midfielders) exhibited higher CVs for defensive technical variables. Physical and technical performances are variable per se regardless of context.

Evolution of match performance parameters for various playing positions in the English Premier League.

This study aimed to investigate position-specific evolution of physical and technical performance parameters in the English Premier League (EPL). Match performance observations (n=14700) were collected using a multiple-camera computerized tracking system across seven seasons (2006-07 to 2012-13). Data were analyzed relative to five playing positions: central defenders (n=3792), full backs (n=3420), central midfielders (n=3200), wide midfielders (n=2136) and attackers (n=2152). High-intensity running distance increased in the final season versus the first season in all playing positions (p<.05, ES: 0.9-1.3) with full backs displaying the greatest increase (∼36% higher in 2012-13). Similar trends were observed for sprint distance with full backs demonstrating the most pronounced increase across the seven seasons (36-63%, p<.001, ES: 0.8-1.3). Central players (central defenders and midfielders) illustrated the most pronounced increases in total passes and pass success rate (p<.05, ES: 0.7-0.9) whilst wide players (full backs and wide midfielders) demonstrated only small-moderate increases in total passes and pass success rate (p<.05, ES: 0.6-0.8). The data demonstrates that evolving tactics in the EPL have impacted on the physical demands of wide players and the technical requirements of central players. These findings could be used for talent identification or position-specific physical and technical training.

Increased variability of lap speeds: differentiating medalists and nonmedalists in middle-distance running and swimming events.

PURPOSE: Previous literature has presented pacing data of groups of competition finalists. The aim of this study was to analyze the pacing patterns displayed by medalists and nonmedalists in international competitive 400-m swimming and 1500-m running finals. METHODS: Split times were collected from 48 swimming finalists (four 100-m laps) and 60 running finalists (4 laps) in international competitions from 2004 to 2012. Using a cross-sectional design, lap speeds were normalized to whole-race speed and compared to identify variations of pace between groups of medalists and nonmedalists. Lap-speed variations relative to the gold medalist were compared for the whole field. RESULTS: In 400-m swimming the medalist group demonstrated greater variation in speed than the nonmedalist group, being relatively faster in the final lap (P < .001; moderate effect) and slower in laps 1 (P = .03; moderate effect) and 2 (P > .001; moderate effect). There were also greater variations of pace in the 1500-m running medalist group than in the nonmedalist group, with a relatively faster final lap (P = .03; moderate effect) and slower second lap (P = .01; small effect). Swimming gold medalists were relatively faster than all other finalists in lap 4 (P = .04), and running gold medalists were relatively faster than the 5th- to 12th-placed athletes in the final lap (P = .02). CONCLUSIONS: Athletes who win medals in 1500-m running and 400-m swimming competitions show different pacing patterns than nonmedalists. End-spurt-speed increases are greater with medalists, who demonstrate a slower relative speed in the early part of races but a faster speed during the final part of races than nonmedalists.

Reliability and stability of performances in 400-m swimming and 1500-m running.

PURPOSE: To assess the reliability and stability of 400-m swimming and 1500-m running competitions to establish the number of samples needed to obtain a stable pacing profile. Coaches, athletes, and researchers can use these methods to ensure that sufficient data are collected before training and race strategies are constructed or research conclusions are drawn. METHOD: Lap times were collected from 5 world and European championship finals between 2005 and 2011, resulting in the capture of data from 40 swimmers and 55 runners. A cumulative mean for each lap was calculated, starting with the most recent data, and the number of races needed for this to stabilize to within 1% was reported. Typical error for each lap was calculated for athletes who had competed in more than 1 final. RESULTS: International swimmers demonstrated more reproducible performances than runners in 3 of the 4 laps of the race (P < .01). Variance in runners' lap times significantly decreased by 1.7-2.7% after lap 1, whereas variance in swimmers' lap times tended to increase by 0.1-0.5% after lap 1. To establish a stable profile, at least ten 400-m swimmers and forty-four 1500-m runners must be included. CONCLUSIONS: A stable race profile was observed from the analysis of 5 events for 1500-m running and 3 events for 400-m swimming. Researchers and athletes can be more certain about the pacing information collected from 400-m swimming than 1500-m running races, as the swimming data are less variable, despite both events being of similar duration.

Validity and reliability of a 1500-m lap-time collection method using public videos.

The collection of retrospective lap times from video footage is a potentially useful research tool to analyze the pacing strategies in any number of competitive events. The aim of this study was to validate a novel method of obtaining running split-time data from publically available video footage. Videos of the 1500-m men's final from the 2004 and 2008 Olympics, 2005 and 2009 World Championships, and 2010 European Championships were obtained from the YouTube Web site, and split times were collected from all competitors using frame-by-frame playback. The typical error of video split times ranged between 0.02 s and 0.11 s for the 4 laps when compared with official split times. Video finishing times were also similar to official finishing times (typical error of 0.04 s). The method was shown to be highly reliable with a typical error of 0.02 s when the same video was analyzed on 2 occasions separated by 8 mo. Video data of track races are widely available; however, camera angles are not always perpendicular to the start/finish line, and some slower athletes may cross the line after the camera has panned away. Nevertheless, the typical errors reported here show that when appropriate camera angles are available this method is both valid and reliable.

The effects of fluid restriction on hydration status and subjective feelings in man.

Hydration status and the effects of hypohydration have been the topic of much public and scientific debate in recent years. While many physiological responses to hypohydration have been studied extensively, the subjective responses to hypohydration have largely been ignored. The present investigation was designed to investigate the physiological responses and subjective feelings resulting from 13, 24 and 37 h of fluid restriction (FR) and to compare these with a euhydration (EU) trial of the same duration in fifteen healthy volunteers. The volunteers were nine men and six women of mean age 30 (sd 12) years and body mass 71.5 (sd 13.4) kg. Urine and blood samples were collected and subjective feelings recorded on a 100 mm verbally anchored questionnaire at intervals throughout the investigation. In the EU trial the subjects maintained their normal diet. Body mass decreased by 2.7 (sd 0.6) % at 37 h in the FR trial and did not change significantly in the EU trial. Food intake in the FR trial (n 10) provided an estimated water intake of 487 (sd 335) ml and urinary losses (n 15) amounted to 1.37 (sd 0.39) litres. This is in comparison with an estimated water intake of 3168 (sd 1167) ml and a urinary loss of 2.76 (sd 1.11) litres in the EU trial. Plasma osmolality and angiotensin II concentrations increased from 0-37 h with FR. Plasma volume decreased linearly throughout the FR trial amounting to a 6.2 (sd 5.1) % reduction by 37 h. Thirst increased from 0-13 h of FR then did not increase further (P>0.05). The subjects reported feelings of headache during the FR trial and also that their ability to concentrate and their alertness were reduced.