The objectives of this research were to determine the impact of 4 different bedtime snack compositions on prevention of nocturnal hypoglycemia and to determine whether optimized titration and delivery of bedtime insulin using multiple daily injections of insulin (MDI) or continuous subcutaneous insulin infusion (CSII) could prevent nocturnal hypoglycemia in the absence of bedtime snacks. We also sought to determine whether 3 months of CSII therapy would improve catecholamine response and symptom awareness to experimentally-induced hypoglycemia. The need for and the most appropriate composition of bedtime snacks were dependent on the glycemic level at bedtime. No bedtime snacks were necessary at bedtime glycemic levels > 10 mmol/L. At bedtime glycemic levels between 7-10 mmol/L , a standard snack and cornstarch-containing snack worked best and at bedtime glycemic levels < 7mmol/L, a standard and protein-rich snack were most effective. Despite optimized titration and delivery of bedtime insulin, including the use of CSII, "the gold standard" of nocturnal insulin replacement, the incidence of nocturnal hypoglycemia over 181 nights was 54 episodes per 100 patientnights. However, there was a substantial reduction, by 36% (p=0.17), in the incidence of nocturnal hypoglycemia with the use of bedtime snacks. Therefore bedtime snacks, tailored to the bedtime glycemic level, are recommended for ail adults undergoing intensive management with MDI or CSII. Although, 3 months of CSII therapy did not improve catecholamine response and symptom awareness to experimentally-induced hypoglycemia, it did not deteriorate the responses either. Therefore, CSII therapy is a viable option in intensive management of adults with type 1 diabetes.

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