Long-term recovery from unawareness, deficient counterregulation and lack of cognitive dysfunction during hypoglycaemia, following institution of rational, intensive insulin therapy in IDDM.

As little as 2-3 weeks of scrupulous avoidance of treatment-induced hypoglycemia reverses hypoglycemia unawareness and improves the reduced epinephrine component of defective glucose counterregulation in most affected patients with type 1 diabetes mellitus.

“Perhaps the most compelling support for the clinical impact of HAAF in T1DM is the finding that as little as 2-3 wk of scrupulous avoidance of treatment-induced hypoglycemia reverses hypoglycemia unawareness, and improves the reduced epinephrine component of defective glucose counterregulation in most affected patients (102-105).”

The return of hypoglycemic symptom awareness was associated with a modest increase (∼0.5%) in HbAlc values, but others have reported no loss of glycemic control.

“The return of hypoglycemic symptom awareness was associated with a modest increase (∼0.5%) in HbAlc values (33), but others have reported no loss of glycemic control (32,34).”

Merely directing people with type 1 diabetes to allow their HbA1c to increase is not expected to alter glycaemic thresholds or the associated burden of hypoglycaemia unless the rate of hypoglycaemia drops considerably.

“Our data underscore, however, that merely directing people with type 1 diabetes to allow their HbA1c to increase is not expected to alter glycaemic thresholds or the associated burden of hypoglycaemia unless the rate of hypoglycaemia drops considerably [6, 32, 60].”

Strict avoidance of hypoglycemia for a period of 2 days to 3 months is associated with improvement in recognition of severe hypoglycemia, counterregulatory hormone responses, or both.

“Strict avoidance of hypoglycemia for a period of 2 days to 3 months has been associated with improvement in the recognition of severe hypoglycemia, the counterregulatory hormone responses or both (32)(33)(34)(35)(36)(37)(38)(39).”

A 2- to 3-week period of scrupulous avoidance of hypoglycemia can be expected to restore awareness in patients with a history of hypoglycemia unawareness.

“Given a history of hypoglycemia unawareness, a 2-to 3-wk period of scrupulous avoidance of hypoglycemia is advisable because that can be expected to restore awareness (102-105).”

The reduced sympathoadrenal response to hypoglycemia is not fully normalized after scrupulous avoidance of hypoglycemia or during insulin independence after successful pancreatic islet transplantation.

“For example, the reduced sympathoadrenal response to hypoglycemia is not fully normalized after scrupulous avoidance of hypoglycemia (103-105) or during insulin independence after successful pancreatic islet transplantation (106).”

HAAF is at least partly reversible by scrupulous avoidance of hypoglycemia.

“HAAF is a form of functional sympathoadrenal failure that is most often caused by recent antecedent iatrogenic hypoglycemia (25) and is at least partly reversible by scrupulous avoidance of hypoglycemia (32–34).”

HAAF has been shown to be maintained by recurrent iatrogenic hypoglycemia.

“Indeed, HAAF has been shown to be maintained by recurrent iatrogenic hypoglycemia (33,34).”

Both hypoglycemia unawareness and defective glucose counterregulation are potentially reversible.

“Both hypoglycemia unawareness and defective glucose counterregulation are potentially reversible.”

HAAF has been shown to be maintained by recurrent iatrogenic hypoglycemia.

“Indeed, HAAF has been shown to be maintained by recurrent iatrogenic hypoglycemia (33,34).”

HAAF is a form of functional sympathoadrenal failure that is most often caused by recent antecedent iatrogenic hypoglycemia and is at least partly reversible by scrupulous avoidance of hypoglycemia.

“HAAF is a form of functional sympathoadrenal failure that is most often caused by recent antecedent iatrogenic hypoglycemia (25) and is at least partly reversible by scrupulous avoidance of hypoglycemia (32 -34).”

The return of hypoglycemic symptom awareness was associated with a modest increase (approximately 0.5%) in HbA1c values, but others have reported no loss of glycemic control.

“The return of hypoglycemic symptom awareness was associated with a modest increase ( ; 0.5%) in HbAlc values (33), but others have reported no loss of glycemic control (32,34).”

Mean and peak oxidation rates of Isomaltulose are 50% and 42% lower than the oxidation rates of sucrose, respectively, when ingested at the same rate (1.1 g/min).

“mean and peak oxidation rates of Isomaltulose, has been reported to be 50% and 42% lower than the oxidation rates of sucrose, respectively, when ingested at the same rate (1.1 g·min -1 ) 59 .”

Provision of additional carbohydrates at half-time may afford ergogenic effects in the latter stages of a match.

“it is plausible that provision of additional carbohydrates at half-time may afford ergogenic effects in the latter stages of a match; however, this remains to be confirmed.”

A reduced rate of digestion and absorption of low-glycaemic index carbohydrates prolongs blood glucose concentrations that have typically been found to decline in the second half of intermittent activity.

“it is plausible that a reduced rate of digestion and absorption of low-glycaemic index carbohydrates prolongs blood glucose concentrations that have typically been found to decline in the second half of intermittent activity.”

A half-time rewarm-up that includes a high-intensity component, combined with ingestion of carbohydrates, may prove beneficial for team sports players who experience an exercise-induced rebound glycaemic response.

“Consequently, a half-time rewarm-up that includes a high-intensity component, combined with the ingestion of carbohydrates, may prove beneficial for team sports players who experience an exercise-induced rebound glycaemic response.”

A combination of high-intensity exercise performed during the half-time period and simultaneous carbohydrate ingestion could feasibly maintain blood glucose concentrations thereafter.

“Therefore, it is plausible that a combination of high-intensity exercise performed during the half-time period and simultaneous carbohydrate ingestion could feasibly maintain blood glucose concentrations thereafter.”

Ingestion of 600 ml of a concentrated Maltodextrin drink consumed during a 25 min cycle warm-up that included isolated sprint bouts increased catecholamine concentrations, blunted the insulin response and increased blood glucose concentrations at the onset of exercise.

“Brouns et al. 59 observed that ingestion of 600 ml of a concentrated Maltodextrin drink consumed during a 25 min cycle warm-up that included isolated sprint bouts, increased catecholamine concentrations, blunted the insulin response and actually increased blood glucose concentrations at the onset of exercise.”

Reductions in blood glucose concentrations were observed after 20 min of subsequent continuous exercise, but these differences were non-significant.

“Although reductions in blood glucose concentrations were observed after 20 min of subsequent continuous exercise, these differences were non-significant.”

When blood glucose falls in a nondiabetic adult, the secretion of counterregulatory hormones and the onset of cognitive, physiological, and symptomatic changes occur at reproducible blood glucose thresholds within a defined hierarchy.

“When blood glucose falls in a nondiabetic adult, the secretion of counterregulatory hormones and the onset of cognitive, physiological, and symptomatic changes occur at reproducible blood glucose thresholds (4,7) within a defined hierarchy (5)”