ATTD Yearbook – Exploring exercise as a diabetes treatment and closed-loop technologies for managing diabetes
DRWF Research manager DR Eleanor Kennedy’s blog reports from day 3 of the 14th International Conference on Diabetes Technologies & Treatments (ATTD 2021) held this year as a fully virtual meeting.
Presentation of the ATTD Yearbook!
One of the most important sessions at this meeting every year is the presentation of the ATTD Yearbook, an annual publication which covers the most important articles in diabetes technology that have been published during the year. This ‘must read’ resource is a compilation of key papers selected by associate editors from around the world on the following diabetes topics:
COVID-19 and virtual diabetes clinics
Continuous and intermittent glucose monitoring
Insulin pumps and pens (insulin delivery hardware)
New insulins, biosimilars and insulin therapy
Decision support systems and closed-loop
Using digital health technology to prevent and treat diabetes
Technology and pregnancy
Exercise and nutrition as therapy in diabetes
Primary care and diabetes technologies and treatments
Practical implementation of diabetes technology
Diabetes technology and the human factor
Immune intervention for type 1 diabetes
New medications for the treatment of diabetes
NFALD, NASH and diabetes
Exercise as a therapy in Diabetes
Associate editors from each of the above chapters stepped up to prevent their highlights and, obviously, it’s impossible to cover them all here. So I selected just one – Mike Riddell from the University of Toronto and Dessi Zaharieva from Stanford University on exercise and as therapy in diabetes – to whet your appetite.
They noted an emphasis on wearables to track both exercise and glycaemic management, focusing on the impact of different micro- and macronutrients. The three they picked out for the meeting represent the field as a whole.
HIIT training proves effective at reducing insulin dosage
First, a study on COVID-19, glycaemic control and sedentary time looked at high intensity interval training (HIIT) and its impact on glycaemic control and fitness in type 1 diabetes. This involved a structured programme that patients can set up at home without equipment or supervision. They had heart rate monitors in the form of chest bands and a calendar app to schedule at least three activity days per week for six weeks. The activities included mountain climbers, side-to-side jumps and so on. “What I liked about this intervention is that these are easy activities to do – all you need is a glucose monitor and the instructions,” Mike said. “What was interesting is that the total insulin dose needed by participants went down by 13% and went down over the six weeks of the intervention, while their VO2max increased by 7%. And, with 95% adherence, it looks as if everyone seems to love the variety of these kinds of exercises.”
Closed-loop system more effective than open-loop for Time in Range
Second, the Diabeloop closed-loop system was compared to open loop in people with type 1 diabetes, when exposing participants to two variables that might cause glycaemic excursions – a gastronomic dinner and sustained physical exercise. This showed Time in Range improved – particularly with regards to hypoglycaemia – in the closed-loop group. Dessi said “This data is really valuable for the type 1 diabetes research, because it focuses on challenging real-world situations.”
The final paper involved a group of 3,330 people in Spain with newly diagnosed type 2 diabetes. They were put on one of two types of Mediterranean diet – one with added extra virgin olive oil and added mixed nuts – or on a conventional low-fat diet. After three years of follow-up, fewer patients with diabetes in the olive oil group needed their diabetes medication. “So, the take home message for us, I guess, is that if we go on a Mediterranean diet for type 2 diabetes, the trick is to add a little bit of extra olive oil,” Mike concluded.
Broadening use of closed-loop
Naturally, closed-loop systems were a focus of attention at ATTD21. Charlotte Boughton, from closed-loop pioneer Professor Roman Hovorka’s laboratory at the University of Cambridge introduced a session on clinical studies and spoke about broadening the use of closed-loop. For there has been increased use of diabetes technology – especially continuous glucose monitoring (CGM) in the USA and across Europe in recent years and evidence that its use is associated with better glycaemic control. But there are disparities within the population, with ethnic minorities and those with lower household income tending to have both lower take up of technology and poorer glycaemic control.
Numerous studies show benefit in glycaemic control of closed-loop over pump/CGM as well as improved quality of life and decreased diabetes burden for people with diabetes and their families. “The advantage of closed-loop is because there is a big variability in insulin requirements over the day and it’s easier to have an automated system deal with this,” said Charlotte.
To broaden access, she suggests healthcare professionals think about those groups that wouldn’t normally be put on closed loop: those on multiple daily injections of insulin (MDI), with suboptimal glycaemic control, long duration of diabetes, comorbidities and complications, and adolescents and young adults. This last group is notorious for having ‘peak’ average HbA1c levels, so it could be worthwhile targeting this.
A study from the Australian JDRF closed-loop research group last year compared MDI or pump/fingerprick with closed-loop showed better Time in Range and glucose with closed-loop independent of whether the participant had been on MDI or an insulin pump previously, which supports going straight to closed-loop rather than incremental change (i.e. MDI, then pump, then closed-loop). Other trials show benefit of closed-loop in those with suboptimal glucose control, in 14 to 29-year-olds and in older adults with previously undetected hypoglycaemia.
Could closed-loop be a tool to overcome inequalities in diabetes outcomes? It would seem that healthcare professional bias is an issue that needs addressing, according to a study from Julia Lawton at the University of Edinburgh. Do not make assumptions about who can and cannot benefit!
Automating closed-loop treatments
There is a drive towards making closed-loop as fully automated as possible, while it might be possible by developing multi-hormone systems, according to Ahmad Haidar from McGill University. This might eliminate the need for carb counting, with could reduce inequities by targeting those with lower health literacy. His group has been researching systems using the amylin analogue, pramlintide, which helps with post-prandial glucose control. Thus far they have been working with different ratios of various insulins and pramlintide, with very promising results and feedback – one step further towards the Holy Grail of a fully automated closed-loop tool with no need for a meal bolus or for carb counting.
Utilising closed-loop for adults with problematic hypoglycaemia
And Eric Renard from Montpellier in France talked about using closed-loop in adults with problematic hypoglycaemia, who have previously been excluded from trials. He reported on the NIH-funded International Diabetes Closed-Loop Trial Protocol 2. It showed that the Control-IQ closed loop significantly reduces time spent in the hypoglycaemic range below 70mg/dl and increases Time in Range.
Finally, Klemen Dovc from Ljubljana discussed the role of faster-acting insulin analogues in closed-loop technologies. There have only been a few studies but results so far show that the inclusion of these insulins in a system improve post-prandial glycaemic control and will help towards full automation.
Onwards and upwards for closed-loop technology and, judging by this week’s news in the UK that up to 1000 patients with type 1 diabetes will be fitted with an “artificial pancreas” in a landmark trial, the future is looking very rosy indeed!
Further reports to follow – visit DRWF news page
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