A new table for prevention of hypoglycaemia during physical activity in type 1 diabetic patients.

OBJECTIVE: The ability to adjust both insulin and nutrition to allow safe participation in physical activity and high performance has recently been recognized as an important management strategy in these patients. In particular, the important role played by the patient in self-monitoring blood glucose during physical activity and then using these data to improve performance and decrease hypoglycaemias is now fully accepted. The primary objective of this study is to compare different therapeutic options in exercising Type 1 diabetic patients (n=67) with or without CHO compensation and/or with or without insulin dosage reduction in order to prevent hypoglycaemias during and after exercise. METHODS: Sixty-seven type 1 diabetic patients were aggregated into four treatment categories according to four strategies to prevent hypoglycaemia episodes, with or without carbohydrate compensation and/or with or without insulin dosage reduction. The protocol included 7 different disciplines and 9 subgroups according to 3 different durations (<20 min., 20-60 min., > 60 min.) and 3 intensity degrees (<60% of Maximal Heart Rate, 60-75% and > 75%). RESULTS: Our study shows that by replacing adequately the carbohydrates during the practice of physical exercise it is possible to prevent almost all hypoglycaemia episodes, independently of the insulin dosage adjustments. Furthermore, the amount of extra-carbohydrates correlates well with the number of hypoglycaemia while the decrease in insulin dosage does not. CONCLUSION: Adequate carbohydrate replacement during and after exercise seems to be the most important measure to prevent hypoglycaemia. However, the insulin dosage adjustment does not play such an important role. A decrease from 20 to 30% seems reasonable only for a long duration exercise (> 60 min.). Finally, a new user-friendly table for prevention of hypoglycaemia is proposed for physical activity of different intensity and duration.

[Functional insulin therapy: patient education and algorithms]. / Insulinotherapie fonctionnelle: Education des patients et algorithmes.

Functional insulin therapy is a teaching approach of intensified insulin therapy. Its aim is to transfer to the patient the decisional process and the management of its insulin treatment, this according to the various acts of everyday life, and particularly meals. The principles of functional insulin therapy, the pedagogic approach, the benefits observed in type 1 diabetic patients (better diabetes control, and particularly decrease in the number of severe hypoglycaemic events) are briefly described - Nevertheless, to apply this functional insulin therapy in practice, requires a specific teaching program preferably ambulatory in real everyday life conditions, and carried out by a staff highly qualified in diabetology.

Interaction of physical activity and diet: implications for insulin-glucose dynamics.

In Western countries 25-35% of the population have insulin resistance syndrome characteristics. The defects most likely to explain the insulin resistance of the insulin resistance syndrome include: 1) the glucose transport system of skeletal muscle (GLUT-4) and its different signalling proteins and enzymes; 2) glucose phosphorylation by hexokinase; 3) glycogen synthase activity and 4) competition between glucose and fatty acid oxidation (glucose-fatty acid cycle). High carbohydrate/low fat diets deteriorate insulin sensitivity on the short term. However, on the long term, high fat/low carbohydrate diets have a lower satiating power, induce low leptin levels and eventually lead to higher energy consumption, obesity and more insulin resistance. Moderately high-carbohydrate (45-55% of the daily calories)/low-fat diets seem to be a good choice with regard to the prevention of diabetes and cardiovascular risk factors as far as the carbohydrates are rich in fibers. Long-term interventions with regular exercise programs show a 1/3 decrease in the appearance of overt diabetes in glucose intolerant subjects. Furthermore, diet and exercise interventions "normalise" the mortality rate of patients with impared glucose tolerance. Therefore, moderately high carbohydrate/low fat diets are most likely to prevent obesity and type 2 diabetes. Triglycerides should be monitored and, in some cases, a part of the carbohydrates could be replaced by fat rich in monounsaturated fatty acids. However, total caloric intake is of utmost importance, as weight gain is the major determinant for the onset of insulin resistance and glucose intolerance. Regular (when possible daily) exercise, decreases cardiovascular risk. With regard to insulin resistance, resistance training seems to offer some advantages over aerobic endurance activities.

[Sports and diabetes]. / Sport et diabète.

Diabetes and sports are not incompatible. Type-1 diabetic persons must learn how to adapt their insulin dosage and carbohydrate intake, in order to avoid hypoglycaemic attacks. In type-2 diabetic persons, an exercise program can contribute to decrease the cardiovascular risk and improve glycaemic control. A thorough check-up, oriented towards specific complications and exclusion of coronary heart disease, is imperative in any diabetic persons involved in an exercise program. Patient associations provide useful informations and offer programs where the patient can learn how to cope with his disease when exercising.

[Social and economic aspects in diabetes mellitus]. / Soziale und ökonomische Aspekte beim Diabetes mellitus.

The possibility of obtaining health and accident insurance as well as participation in a pension scheme does not pose any problems for diabetics in Switzerland. However, for a life insurance contract, the diabetic must often pay a surplus. The socio-medical evaluation for invalidity insurance for diabetics is based upon an eventual decrease in efficiency associated with functional alteration of certain organs. Diabetics treated only by dietary means can exercise any profession. When treated with oral antidiabetic agents or insulin, certain professions are discouraged, particularly when a metabolic crisis might be hazardous to the diabetic or a third party. Treatment of active diabetics most often aims at obtaining normoglycemia. This should enable patients to follow a physically active, even irregular life in their profession, studies and leisure without excessive risk.

[Evaluation of ambulatory teaching for diabetics in a semi-rural region]. / Evaluation d'un enseignement ambulatoire pour diabétiques dans une région semi-rurale.

An outpatient educational system for diabetics has been employed in Delémont since 1984 in the form of a 4-day course consisting of a total of 15 teaching hours. This teaching method has been evaluated in the first 51 patients. The level of information (tested by a series of multiple choice questions which are submitted to the patients at the beginning, at the end of the course and three months later) was found to improve. The score (0-17) rose from 6.6 to 11.9 and then 12.5; n = 35; p less than 0.001. The HbA1c fell significantly in a three month period from 8.8 to 7.8%, n = 12, p less than 0.02. The slight lowering of average fasting serum glucose levels (from 10.4 to 9.7 mmol/l) and of the patients' weights (from 75.4 to 74.6 kgs) was not significant. - The advantage of the educational system that has been studied is its low cost and the fact that it is accepted well by patients.

Lifestyle, metabolic control and social implications of pump therapy in 54 routine type I diabetic patients.

Our aims were to evaluate the clinical and social implications of continuous subcutaneous insulin infusion (CSII) in ordinary type 1 diabetics, followed on a routine basis using a simple (Mill Hill) or a more complex (Microject MC20, Ames) pump. Fifty four type 1 diabetics were studied during 2 randomized periods of 4 months, one of conventional treatment (CT) (2 to 3 injections/day, self blood glucose (BG) monitoring) and the other of CSII. Each period was preceded by a 5 day training course. We studied clinical parameters, metabolic control (daily values of BG strips, urine analysis, insulin reactions, HbA1c), and acceptability of the treatment to the patient and their relatives. We also recorded all their unexpected phone-calls, consultations and admission to hospital. Thirty-four patients the initial cohort, completed the study, 7 dropped-out, 9 interrupted CSII, mainly because of skin problems and 4 refused to revert back to CT. During CSII, patients noted slight disturbance of sleep (30%), sexual activity (68%), and the wearing of clothes (26%). The main concern was with moderate skin problems (71%) whereas the main advantages were dietary liberalization, reduced numbers of insulin reactions and an improved feeling of well being. The type of pump used did not affect the results. Though acceptability was good in every patient trying the pump, it was better in those who asked to keep the pump after the trial (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Changes in autonomic functions in diabetic neuropathy: cardiovascular reflexes and sweating]. / Altération de fonctions végétatives dans la neuropathie diabétique: réflexes cardiovasculaires et sudation.

Failure of autonomic functions in diabetes has been investigated. Cardiovascular reflexes, and thermoregulation during heat exposure, were studied in 11 diabetic patients. Five had clinical signs of sensorimotor neuropathy and 6 served as age- and sex-matched controls. The subjects were studied by the following tests: orthostatic test, Valsalva, beat-to-beat variation during normal and forced respiration, and analysis of urinary catecholamines. Thermoregulation was measured for 80 minutes, at an ambient temperature of 37 degrees C, in a gradient layer direct calorimeter measuring evaporative heat losses with a precision of +/- 1 watt. The cardiovascular tests showed a relationship between the sensorimotor defects and the autonomic dysfunctions. The beat-to-beat variation was found to be the most sensitive test, the Valsalva and orthostatic test being respectively less so. However, the diabetic patients' autonomic disorders were not associated with a significant decrease in evaporative heat losses. The internal temperature (esophageal) at which sweating began (set point) was higher in some of the neuropathic diabetics than in the controls. Once the set point had been reached, however, the increase in evaporative heat losses was greater in diabetics than in controls. These findings can be accounted for by zones of compensatory hypersweating in patients with polyneuropathy. The changes in evaporative heat loss pattern may represent an early alteration in autonomic diabetic neuropathy.

[Neurovegetative function tests: clinical importance and physiological aspects]. / Tests de fonctions neurovégétatives: intérêt clinique et aspects physiologiques.

Evaluation of autonomic defects in polyneuropathies or diseases of the central nervous system is assuming increasing importance. Five simple non-invasive cardiovascular tests are described: an orthostatic test taking account of changes in arterial blood pressure, the orthostatic test of Ewing, the Valsalva maneuver, sustained handgrip, and heart beat to beat variation. The physiological mechanisms involved in each test, the need to bear in mind failure of the effector organs (cardiovascular system) and also the effect of medication are discussed. Finally, the beat to beat variation expressed as the coefficient of variation and as the meansquare successive difference, measured in 32 healthy subjects, are suggested as reference values.