- About this Journal ·
- Abstracting and Indexing ·
- Aims and Scope ·
- Annual Issues ·
- Article Processing Charges ·
- Articles in Press ·
- Author Guidelines ·
- Bibliographic Information ·
- Citations to this Journal ·
- Contact Information ·
- Editorial Board ·
- Editorial Workflow ·
- Free eTOC Alerts ·
- Publication Ethics ·
- Reviewers Acknowledgment ·
- Submit a Manuscript ·
- Subscription Information ·
- Table of Contents
Experimental Diabetes Research
Volume 2011 (2011), Article ID 481427, 10 pages
Exercise Increases Insulin Content and Basal Secretion in Pancreatic Islets in Type 1 Diabetic Mice
1Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160, USA
2Department of Anatomy and Cell Biology, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160, USA
Received 19 April 2011; Accepted 17 May 2011
Academic Editor: N. Cameron
Copyright © 2011 Han-Hung Huang et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Exercise appears to improve glycemic control for people with type 1 diabetes (T1D). However, the mechanism responsible for this improvement is unknown. We hypothesized that exercise has a direct effect on the insulin-producing islets. Eight-week-old mice were divided into four groups: sedentary diabetic, exercised diabetic, sedentary control, and exercised control. The exercised groups participated in voluntary wheel running for 6 weeks. When compared to the control groups, the islet density, islet diameter, and β-cell proportion per islet were significantly lower in both sedentary and exercised diabetic groups and these alterations were not improved with exercise. The total insulin content and insulin secretion were significantly lower in sedentary diabetics compared to controls. Exercise significantly improved insulin content and insulin secretion in islets in basal conditions. Thus, some improvements in exercise-induced glycemic control in T1D mice may be due to enhancement of insulin content and secretion in islets.
Across the globe, the incidence of type 1 diabetes (T1D) is increasing at an alarming rate with the age of onset decreasing within a 20-year period . T1D is an autoimmune disease that leads to impaired glucose homeostasis, because the insulin-producing cells (β-cells) located in the pancreatic islets of Langerhans are attacked by the immune system . The clinical benefits attributed to exercise for individuals with type 2 diabetes have been well documented [3–7]. In T1D, far fewer reports have focused on the role of exercise, and yet there are strong indications for decreased risk of diabetes-associated complications including improved arterial function [8–11], cardiac performance [12–17], and lipid metabolism  resulting in lower total cholesterol, LDL-c, and triglycerides [19, 20].
Only recently have studies focused on the relationship between exercise and blood glucose regulation in T1D. In general, these reports have shown reduced insulin dosage with increased physical activity  along with better glycemic control . In fact, moderate to vigorous activity has been associated with greater overall fitness, a higher fat free mass, and lower glycosylated hemoglobin (HbA1c) levels in people with T1D [19, 20]. In a randomized study of 196 adults with T1D, those that exercised moderately once to three times per week significantly reduced the HbA1c levels and insulin requirements . Even more convincing is a large cross-sectional study of over 19,000 children with T1D, finding that the amount of physical activity was one of the strongest factors predicting lower HbA1c values .
In spite of these impressive results, little is known about the mechanism of action to explain the lowered blood glucose levels with exercise. There are two general sites where exercise could directly affect blood glucose regulation: (1) insulin secretion of the islets and (2) insulin-stimulated glucose uptake in the skeletal muscle [18, 25, 26]. Only two papers have directly tested the first possibility: changes in insulin levels with exercise in T1D. Unfortunately, the only assay used was an immunohistochemical measurement of the number of hormone-positive cells in the islets of exercised diabetic rats [27, 28]. Clearly, more must be done to begin to unravel the cellular changes occurring in islets with exercise training. We utilized a T1D animal model to examine islet morphology, density, size, cell composition, insulin secretion, and insulin content after 6 weeks of voluntary exercise. By testing the hypothesis in an extremely severe form of T1D without insulin treatment, we ensured that any changes we identified in the islets were due directly to the effects of exercise and not secondarily to a reduction of blood glucose levels.
2. Materials and Methods
The animal protocols were approved by the Institutional Animal Care and Use Committee. Fifty-three 8-week-old male A/J mice were divided into four groups: (1) sedentary (nonexercised) diabetic (), (2) exercised diabetic (), (3) sedentary control (), and exercised control (). Both diabetic groups were injected with streptozotocin, toxic to islet β-cells, (freshly dissolved in 10 mM sodium citrate, pH 4.5, with 0.9% NaCl, (Sigma, St. Louis, Mo, USA)) on consecutive days (1st injection of 85 mg/kg body weight and 2nd injection of 65 mg/kg body weight) to induce diabetes. Control animals were injected with 0.4 mL of sodium citrate buffer, pH 4.5. Mice were fasted 3 hours before and 3 hours after each injection. Blood glucose levels were monitored weekly (glucose diagnostic reagents; Sigma) after fasting for 2 hours. Mice in the two diabetic groups were identified as having diabetes when blood glucose levels reached greater than 190 mg/dL.
After the induction of diabetes, the mice from the exercise groups were individually housed in cages containing exercise wheels (Mini Mitter Co. Inc., a Respironics Company, Bend, Ore, USA) for 6 weeks starting 3 days after the 2nd injection of streptozotocin. Each wheel revolution was continuously recorded and summarized in thirty-minute intervals with the Vital View Data Acquisition System (Mini Mitter Co. Inc.) throughout the duration of the study. At the termination of the study, mice were overanesthetized with avertin after a 2-hour fast and the pancreata either processed for immune-staining or for isolated islet retrieval.
2.3. Pancreatic Sections
The pancreata were rapidly harvested and fixed in 10% normal buffered formalin. The tissues were subsequently dehydrated in graded concentrations of ethanol, cleared in xylene, and subsequently embedded in paraffin wax at 55°C. The tissues were sectioned at 8 μm thickness, mounted on Superfrost/Plus microscope slides (Fisher Scientific, Pittsburg, Pa, USA, no. 12-550-15) and dried at 40°C overnight and stored at 4°C until processing. The paraffin-embedded sections were deparaffinized/rehydrated in xylene followed by ethanol and PBS serial rehydration. Antigen retrieval was completed in 0.01 M citrate buffer, pH 6.2, with 0.002 M EDTA for 30 min using a steamer. Cells were permeabilized in 1.0% Triton X-100 in 0.1 M PBS, pH 7.4 for 30 min. Hematoxylin and eosin (H&E) staining was performed on some sections to illustrate the general islet morphology under light microscopy.
2.4. Immunofluorescence Staining
Sections were blocked in 10% normal donkey serum, 1.0% bovine serum albumin (BSA), and 0.03% Triton X-100 diluted in 0.1 M PBS, pH 7.4 for 30 min. Incubation with the primary antibody mix was performed at 4°C overnight in a wet chamber followed by incubation with the mix of fluorophore-conjugated secondary antibody at room temperature for 2 hr in a wet chamber protected from light. Both primary and secondary antibodies were diluted in 1% NDS, 1% BSA, and 0.03% Triton X-100. Slides were mounted with antifading the agent Gel/Mount (Biomeda, Foster City, Calif, USA, no. M01). The following primary antibodies were used: anti-insulin (1 : 100, Abcam, Cambridge, Mass,USA, no. ab7842), antiglucagon (1 : 200, Abcam, no. ab10988), and antisomatostatin (1 : 200, Abcam, no. ab53165). Corresponding secondary antibodies were conjugated with Cy2 (1 : 200, Jackson ImmunoResearch Laboratories Inc., West Grove, Pa,USA, no. 706-225-148), Alexa 555 (1 : 400, Molecular Probes, Eugene Ore,USA, no. A31570), and Alexa 647 (1 : 400, Molecular Probes, no. A31573). Images were collected using a Nikon C1si confocal microscope.
2.5. Islet Density, Size, and Cell Composition
Islet density was defined as the numbers of islets per microscopic field. Four random fields were selected per section. Twenty-four nonserial sections of pancreatic tissues from 3 animals per group were evaluated. Islet size was estimated by measuring the diameter of the islet under the software Nikon EZ-C1 3.0 FreeViewer. For cell composition analysis, the relative proportion of α-, β-, or δ-cells in each islet was evaluated by counting the number of individual types of cell and dividing by the total sum of endocrine (α, β, and δ) cells per islet. For each group, 88 to 106 islets from nonserial sections of pancreatic tissues from 3 animals were analyzed for both cell size and cell composition. All the evaluations were done by three blinded examiners with a high interrater reliability (intraclass correlation coefficient; ICC > 0.8).
2.6. Insulin Content In Situ
To determine the insulin content in the pancreatic islets in situ, insulin immunohistochemistry (IHC) was performed on paraffin-embedded pancreatic tissue (Histostain-Plus, Invitrogen) using anti-insulin antibody (1 : 100, Santa Cruz Biotechnology, Inc., no. sc-9168). After staining, slides were dehydrated in xylene and placed on coverslips in Permount mounting medium (Fisher Scientific, no. S15-100). The specificity of insulin immunoreactivity was confirmed by omitting the primary antibodies from some sections. Images were analyzed with Ps Adobe Photoshop CZ4 extended software by determining the average pixel value of staining per islet and per single cell, using our published procedure . Background staining was subtracted from each value. Eighteen to 25 islets were randomly selected from nonserial sections of pancreatic tissues from 3 to 5 animals per group.
2.7. Islet Isolation
Islet isolation methods followed our published procedures described in detail [30–32]. Briefly, mice were anesthetized with an intraperitoneal injection of avertin (20 mg/kg). After the peritoneal cavity was exposed, the pancreatic main duct to the intestine was clamped and the pancreas cannulated in situ via the common bile duct. The pancreas was distended with collagenase and removed. Islets were gently tumbled, washed, and passed through a sterile 30-mesh stainless steel screen and centrifuged. The pellet was mixed with histopaque, centrifuged, and the islets floating on the gradient were collected and sedimented. Islets were passed through a sterile 40 μm mesh cell strainer with Hank's buffered salt solution (HBSS). After this cleaning process, islets were placed into CMRL 1066 medium containing 2 mM glutamine, 10% fetal bovine serum (FBS), and 1% antibiotic/ antimycotic solution and put into a 37°C culture chamber containing 5% CO2.
2.8. Insulin Secretion and Content
Glucose-induced insulin static secretion assays followed our published procedures . Isolated islets were placed in 24-well plate with more than 10 islets per well and assigned to two groups: low glucose (3 mM) and high glucose (16.6 mM). All wells were preincubated for 2.5 hours in RPMI 1640 containing 10% fetal bovine serum and 3 mM glucose in a 37°C containing 5% CO2. After preincubation, media was removed from each well and discarded. Low (3 mM as basal condition) or high (16.6 mM) glucose solutions were added, according to the design. After 30 minutes static incubation in the 37°C and 5% CO2, the islets were sedimented and the conditioned medium was collected and frozen at −80°C. At the end of the static incubation, the islets were harvested and frozen at −80°C. The total protein in the islets was extracted by sonication in acid ethanol (0.18 M HCl in 95% ethanol). The released insulin and the total intracellular insulin amounts were determined by the ELISA (ALPCO, Salem, NH, USA) as we have published previously . Insulin secretion and content was normalized to islet numbers using previously published standard procedures [33–36] and by volume (islet equivalents) [30–32]. The experiment was replicated 4-5 times per group.
Results were expressed as averages of each group or cell population ± SEM and were compared using ANOVA with Fisher least significant difference, repeated measures ANOVA, or student’s -test, depending on the experimental design. Significant differences were defined as .
The exercised diabetic and exercised control mice were given unlimited access to voluntary running wheels for 6 weeks. The average running distance was km/day for the exercised diabetic group and km/day for the exercised control group (). In the dependent variables (body weight, fasting glucose levels, islet morphology, insulin content, and insulin secretion), there was no difference in the parameters between the two nondiabetic groups (sedentary control and exercised control). Since the focus of the study was the effects of exercise on islets and no differences were noted between the two control nondiabetic groups, we compared the data from the two diabetic groups (sedentary nonexercised, diabetic mice, and exercised diabetic mice) to the sedentary, nonexercised controls.
Over the 6-week study, the sedentary control group exhibited a 13% increase in body weight. Both diabetic groups exhibited significant reductions in body weight compared to controls (). The sedentary and exercised diabetic groups displayed a 14% and 11% reduction in body weight over the 6-week experiment, respectively (Figure 1(a)).
Fasting glucose levels were significantly higher in both diabetic groups (exercised and sedentary) compared to the controls (). Among the diabetic groups, blood glucose levels trended upward over the course of the study to levels above 300 mg/dL. When compared to the sedentary diabetic group, the exercised diabetic group showed significantly lower glucose levels at weeks 1 and 2 () (Figure 1(b)). However, the difference was not statistically significant at later time points.
3.1. Islet Morphology
Cellular atrophy and extensive vacuoles were present in 80% of the islets from sedentary diabetic mice (Figure 2). No overt vacuoles were noted in the tissue samples from the control, nondiabetic animals. The same characteristics (cellular atrophy and vacuoles) were identified in 73% of the islets from the exercised diabetic group. Thus, among diabetic animals, voluntary exercise had no significant effect on the proportion of islets with vacuoles.
3.2. Islet Density and Size
Diabetes negatively affected the number of islets per area, as the islet density was significantly lower in the two diabetic groups compared to the control (). Typical islet density from a control animal is shown in the pancreatic section triple stained for insulin, glucagon, and somatostatin (Figure 3(a)). Figure 3(b) summarizes the islet density for sedentary control, diabetic, and exercise-trained diabetic animals. The sedentary diabetic and exercised diabetic mice had significantly lower islet densities than controls (33% and 30%, resp.). There was no statistically significant difference between two diabetic groups.
Diabetes caused a significant decrease in the diameter of the individual islets in both the exercised and sedentary groups (Figure 3(c)). The sedentary diabetic group had a 23% smaller islet size (diameter) compared to control animals, while the exercised diabetic group had 28% smaller islets compared to the nondiabetic controls ().
3.3. Islet Cell Composition
Pancreatic islets in mammals are composed of several types of endocrine cells, primarily insulin-producing β-cells, glucagon-producing α-cells, and somatostatin-producing δ-cells. Immunofluorescent staining was used to determine the cell composition of individual islets (Figure 4(a)). In islets from the control group, β-cells comprised the major (80%) cell type. However, in the islets from the diabetic animals, the alpha cells were the majority (56%) cell type (Figure 4(a)). The percentage of insulin-positive, glucagon-positive, and somatostatin-positive cells from each group of animals is shown in Figure 4(b). The percentage of insulin-positive cells was significantly () lower in islets from sedentary diabetic rats (20.0 ± 1.4%) as compared to the controls (%). The percentage of glucagon-positive cells was significantly higher () in islets from sedentary diabetic rats (%) as compared to the controls (%). Finally, the percentage of somatostatin-positive cells was also significantly higher () in islets from sedentary diabetic rats (%) as compared to the controls (10.4 ± 0.8%). The cell composition was nearly identical between the sedentary and exercise-trained diabetic animals (NS, Figure 4(b)).
3.4. Insulin Content
Diabetes significantly reduced the total insulin content of isolated islets from the three groups of animals. Insulin content was normalized to islet using previously published procedures [34, 36]. The average insulin content in the control group was 62.0 ± 4.9 ng/islet. For the sedentary diabetic rats, the insulin content was 0.4 ± 0.1 ng/islet. Exercise increased the insulin content by more than 3 times over the sedentary diabetic animals (1.5 ± 0.4 ng/islet). Figure 5(a) compares only the two diabetic groups as the control value was too large to effectively fit on the scale.
In addition to the in vitro measurements, we analyzed insulin content in situ using published procedures [28, 29]. First, insulin immune reactivity per islet was calculated using published techniques . In the islets from control animals, there was strong insulin staining in all β-cells (Figure 5(b)). However, in the sedentary diabetic groups, there was a weak insulin immunoreactivity and it was found in only a few β-cells within the islets. Interestingly, in the exercised diabetic group, there was an increase in the insulin labeling intensity (Figure 5(c)). As shown in Figure 5(c), the intensity of insulin-positive staining per islet in the exercised diabetic group was significantly higher compared to the sedentary diabetic group (). Exercise improved the total insulin content per islet from 48% to 72% when normalized to the control levels. Further analysis of the insulin intensity per β-cell also showed significantly higher insulin intensity in the exercised diabetic group compared to the sedentary diabetic group. Exercise improved the individual cell insulin label intensity from 92% to 114% when normalized to the controls (Figure 5(d); ).
3.5. Insulin Secretion
The glucose stimulated insulin secretion was measured in low (3 mM) or high (16.6 mM) glucose conditions for 30 minutes. Under low glucose, the insulin secretion in the two diabetic groups was significantly lower than the control group (Figure 6(a), ). Interestingly, the insulin secretion in the exercised diabetic group was significantly () higher when compared to the sedentary diabetic group (Figure 6(a)). Under high glucose, the insulin secretion in the diabetic groups was again significantly lower than in the control (). However, there was no significant difference between the exercised diabetic group and sedentary diabetic group. These results were the same whether insulin secretion was normalized by islet or by volume (islet equivalent).
When the insulin release was normalized for the total insulin content, exercise increased the percent of total insulin released in basal conditions by 2.5 times (Figure 6(b)). The percent of released insulin in the islets from sedentary diabetic mice was 0.38%, and from exercised diabetic mice it was 0.94% (). With high glucose exposure, exercise induced a change in the insulin secretion from 0.69 to 0.98% of the total insulin content, although this change did not reach statistical significance.
In the 1950s, Joslin first suggested that exercise should be an essential component to regulate blood glucose levels of people with T1D, along with a restricted diet and insulin therapy . Yet, today the mechanisms by which exercise regulates blood glucose in conditions of T1D are unclear. In the 1980s, classic work by Reaven and Chang showed that exercised rats with T1D had lower plasma glucose and triglyceride levels than their sedentary counterparts . They hypothesized that the results were due to improved peripheral insulin sensitivity; however, no direct measure of islet mass or insulin content was reported. The current study is the first to measure exercise-induced increases in insulin content and secretion in isolated islets from diabetic animals.
We hypothesized that exercise could act by protecting islets during the onset of the disease, because in animal models of type 2 diabetes, long-term aerobic exercise resulted in increased islet β-cell proliferation, increased β-cell mass, and a partial sparing of the abnormal islet morphology noted in the sedentary diabetic rats . Exercise blocked the age-associated morphological changes in the pancreas, including multilobulated, fibrotic islets . In addition, aerobic exercise decreased the presence of proinflammatory cytokines in islet cells , but did not change the islet gene expression pattern in type 2 Zucker diabetic fatty rats .
Morphological examination of the islets from our exercised-trained mice failed to demonstrate differences compared to the sedentary diabetic group. Our findings are similar to a previous report investigating the effect of the exercise on the distribution of α-, β-, and δ-cells and pancreatic polypeptide cells in the islets of streptozotocin-induced diabetic rats . Conversely, another study focused on β-cell health and exercise in T1D concluded that exercise partially spared the β-cells from diabetes . A difference between the exercise protocols may explain the discordant results. In our protocol and the previous paper by Howarth et al., which showed no change in β-cell numbers, the exercise protocol was initiated after the induction of diabetes . In the Coskun et al. study, the aerobic exercise protocol was initiated four weeks prior to the induction of diabetes and the exercise continued for another eight weeks to the termination of the experiment . Thus, exercise may be able to protect β-cells if initiated prior to the onset of the disease but has limited or no ability to rescue the β-cells once lost.
Even though voluntary exercise did not improve the proportion of insulin-producing β-cells in the islets of diabetic animals, it did improve the insulin content in isolated islets. This effect was not an artifact of the isolation procedure, as exercise nearly doubled the total insulin content per islet when examined in situ. Our findings are in agreement with a previous publication that showed a beneficial effect on insulin content in diabetic animals after exercise . The previous publication relied solely on insulin immunohistochemistry to draw conclusions. The data presented here confirm that finding, but also demonstrate that exercise was capable of improving the total insulin content and insulin secretion, when measured directly with quantifiable methods.
One important difference must be highlighted between the previous studies and the current work. In the Coskun et al. paper, the serum glucose measurements were statistically lower in the exercising animals than the sedentary diabetic rats . Thus, one cannot rule out the possibility that any improvements in β-cell numbers or function were due to the lowered blood glucose values. In the present study, blood glucose levels were not significantly different between the exercised and sedentary diabetic rats at the termination of the study. This was accomplished by inducing severe diabetes without insulin treatment, and it provided an advantage when interpreting the data, because any changes were directly related to the effects of exercise without a reduction in blood glucose. Since it is known that high glucose is toxic to islet cells [44, 45], maintaining statistically similar blood glucose readings at the termination of the study ensured that glucotoxicity was not a factor.
Our central finding is that exercise has an effect on the pancreatic islets by stimulating insulin production and/or secretion in diabetic animals. The current results clarify the effect of exercise by showing that the only statistically significant difference in insulin secretion was under low glucose conditions, whether calculated as insulin secretion per islet, per volume (IE), or per total insulin content. While this could be important in maintaining normal blood glucose levels, it would indicate that exercise may not help with postprandial glucose excursions.
In conclusion, this is the first time that insulin content and secretion has been directly measured in T1D animals following exercise training. In fact, only two other publications have focused on the direct effects of exercise on islets under diabetic conditions [27, 28]. In our study, six weeks of voluntary exercise did not alter islet density, morphology, size or cellular composition. However, insulin content increased in situ. Importantly, this is the first study to demonstrate that exercise increased insulin content and improved insulin secretion in isolated islets in uncontrolled T1D.
This work was supported by a grant from National Institutes of Health (NIH R01NS43314 to DW), Juvenile Diabetes Research Foundation (DW), Emilie Rosebud Diabetes Research Foundation (LSB), and University of Kansas Medical Center Biomedical Research Training Program (HHH and KF). Core facilities and services were supported by National Institute of Child Health and Human Development Grant number HD02528.
- A.-G. Ziegler, M. Pflueger, C. Winkler et al., “Accelerated progression from islet autoimmunity to diabetes is causing the escalating incidence of type 1 diabetes in young children,” Journal of Autoimmunity, vol. 37, no. 1, pp. 3–7, 2011.
- A. L. Notkins, “Immunologic and genetic factors in type 1 diabetes,” Journal of Biological Chemistry, vol. 277, no. 46, pp. 43545–43548, 2002.
- S. Bweir, M. Al-Jarrah, A. Almalty, et al., “Resistance exercise training lowers HbA1c more than aerobic training in adults with type 2 diabetes,” Diabetology & Metabolic Syndrome, vol. 10, p. 27, 2009.
- N. LeBrasseur, K. Walsh, and Z. Arany, “Metabolic benefits of resistance training and fast glycolytic skeletal muscle,” American Journal of Physiology, vol. 300, pp. E3–E10, 2011.
- A. Swanson, K. Watrin, and L. Wilder, “Clinical Inquiries: how can we keep impaired glucose tolerance and impaired fasting glucose from progressing to diabetes?” The Journal of Family Practice, vol. 59, pp. 532–533, 2010.
- L. VanHoose, Y. Sawers, R. Loganathan et al., “Electrocardiographic changes with the onset of diabetes and the impact of aerobic exercise training in the Zucker Diabetic Fatty (ZDF) rat,” Cardiovascular Diabetology, vol. 9, article 56, 2010.
- C. Sanz, J.-F. Gautier, and H. Hanaire, “Physical exercise for the prevention and treatment of type 2 diabetes,” Diabetes and Metabolism, vol. 36, no. 5, pp. 346–351, 2010.
- J. P. H. Seeger, D. H. J. Thijssen, K. Noordam, M. E. C. Cranen, M. T. E. Hopman, and M. W. G. Nijhuis-Van Der Sanden, “Exercise training improves physical fitness and vascular function in children with type 1 diabetes,” Diabetes, Obesity and Metabolism, vol. 13, no. 4, pp. 382–384, 2011.
- W. G. Mayhan, D. M. Arrick, K. P. Patel, and H. Sun, “Exercise training normalizes impaired NOS-dependent responses of cerebral arterioles in type 1 diabetic rats,” American Journal of Physiology, vol. 300, no. 3, pp. H1013–H1020, 2011.
- B. Trigona, Y. Aggoun, A. Maggio et al., “Preclinical Noninvasive Markers of Atherosclerosis in Children and Adolescents with Type 1 Diabetes Are Influenced by Physical Activity,” Journal of Pediatrics, vol. 157, pp. 533–539, 2010.
- D. M. Roche, S. Edmunds, T. Cable, M. Didi, and G. Stratton, “Skin microvascular reactivity in children and adolescents with type 1 diabetes in relation to levels of physical activity and aerobic fitness,” Pediatric Exercise Science, vol. 20, no. 4, pp. 426–438, 2008.
- I. V. Smirnova, N. Kibiryeva, E. Vidoni, R. Bunag, and L. Stehno-Bittel, “Abnormal EKG stress test in rats with type 1 diabetes is deterred with low-intensity exercise programme,” Acta Diabetologica, vol. 43, no. 3, pp. 66–74, 2006.
- C. H. Shao, X. H. T. Wehrens, T. A. Wyatt et al., “Exercise training during diabetes attenuates cardiac ryanodine receptor dysregulation,” Journal of Applied Physiology, vol. 106, no. 4, pp. 1280–1292, 2009.
- C. H. Hung, Y. W. Chen, D. Z. Shao, C. N. Chang, Y. Y. Tsai, and J. T. Cheng, “Exercise pretraining attenuates endotoxin-induced hemodynamic alteration in type I diabetic rats,” Applied Physiology, Nutrition and Metabolism, vol. 33, no. 5, pp. 976–983, 2008.
- K. R. Bidasee, H. Zheng, C.-H. Shao, S. K. Parbhu, G. J. Rozanski, and K. P. Patel, “Exercise training initiated after the onset of diabetes preserves myocardial function: effects on expression of β-adrenoceptors,” Journal of Applied Physiology, vol. 105, no. 3, pp. 907–914, 2008.
- E. Heyman, C. Toutain, P. Delamarche et al., “Exercise training and cardiovascular risk factors in Type 1 diabetic adolescent girls,” Pediatric Exercise Science, vol. 19, no. 4, pp. 408–419, 2007.
- Y. M. Searls, I. V. Smirnova, B. R. Fegley, and L. Stehno-Bittel, “Exercise attenuates diabetes-induced ultrastructural changes in rat cardiac tissue,” Medicine and Science in Sports and Exercise, vol. 36, no. 11, pp. 1863–1870, 2004.
- A. Austin, V. Warty, J. Janosky, and S. Arslanian, “The relationship of physical fitness to lipid and lipoprotein(a) levels in adolescents with IDDM,” Diabetes Care, vol. 16, no. 2, pp. 421–425, 1993.
- M. S. Faulkner, “Cardiovascular fitness and quality of life in adolescents with type 1 or type 2 diabetes,” Journal for Specialists in Pediatric Nursing, vol. 15, no. 4, pp. 307–316, 2010.
- S. F. Michaliszyn and M. S. Faulkner, “Physical activity and sedentary behavior in adolescents with type 1 diabetes,” Research in Nursing & Health, vol. 33, no. 5, pp. 441–449, 2010.
- R. D'hooge, T. Hellinckx, C. Van Laethem et al., “Influence of combined aerobic and resistance training on metabolic control, cardiovascular fitness and quality of life in adolescents with type 1 diabetes: a randomized controlled trial,” Clinical Rehabilitation, vol. 25, no. 4, pp. 349–359, 2011.
- S. Zeqiri, A. Ylli, and N. Zeqiri, “The effect of physical activity in glycemia in patients with diabetes mellitus,” Medicinski Arhiv, vol. 61, no. 3, pp. 146–149, 2007.
- M. A. Salem, M. A. Aboelasrar, N. S. Elbarbary, R. A. Elhilaly, and Y. M. Refaat, “Is exercise a therapeutic tool for improvement of cardiovascular risk factors in adolescents with type 1 diabetes mellitus? A randomised controlled trial,” Diabetology and Metabolic Syndrome, vol. 2, no. 1, article 47, 2010.
- A. Herbst, R. Bachran, T. Kapellen, and R. W. Holl, “Effects of regular physical activity on control of glycemia in pediatric patients with type 1 diabetes mellitus,” Archives of Pediatrics and Adolescent Medicine, vol. 160, no. 6, pp. 573–577, 2006.
- K. J. Nadeau, J. G. Regensteiner, T. A. Bauer et al., “Insulin resistance in adolescents with type 1 diabetes and its relationship to cardiovascular function,” Journal of Clinical Endocrinology and Metabolism, vol. 95, no. 2, pp. 513–521, 2010.
- C. J. Mann, E. Ayuso, X. M. Anguela, and F. Bosch, “Skeletal muscle metabolism in the pathology and treatment of type 1 diabetes,” Current Pharmaceutical Design, vol. 16, no. 8, pp. 1002–1020, 2010.
- F. C. Howarth, F. M. A. Marzouqi, A. M. S. Al Saeedi, R. S. Hameed, and E. Adeghate, “The effect of a heavy exercise program on the distribution of pancreatic hormones in the streptozotocin-induced diabetic rat,” Journal of the Pancreas, vol. 10, no. 5, pp. 485–491, 2009.
- O. Coskun, A. Ocakci, T. Bayraktaroglu, and M. Kanter, “Exercise training prevents and protects streptozotocin-induced oxidative stress and β-cell damage in rat pancreas,” Tohoku Journal of Experimental Medicine, vol. 203, no. 3, pp. 145–154, 2004.
- H.-H. Huang, L. Novikova, S. J. Williams, I. V. Smirnova, and L. Stehno-Bittel, “Low insulin content of large islet population is present in situ and in isolated islets,” Islets, vol. 3, no. 1, pp. 6–13, 2011.
- R. R. MacGregor, S. J. Williams, P. Y. Tong, K. Kover, W. V. Moore, and L. Stehno-Bittel, “Small rat islets are superior to large islets in in vitro function and in transplantation outcomes,” American Journal of Physiology, vol. 290, no. 5, pp. E771–E779, 2006.
- S. J. Williams, H. H. Huang, K. Kover et al., “Reduction of diffusion barriers in isolated rat islets improves survival, but not insulin secretion or transplantation outcome,” Organogenesis, vol. 6, no. 2, pp. 115–124, 2010.
- S. J. Williams, Q. Wang, R. R. MacGregor, T. J. Siahaan, L. Stehno-Bittel, and C. Berkland, “Adhesion of pancreatic beta cells to biopolymer films,” Biopolymers, vol. 91, no. 8, pp. 676–685, 2009.
- M. Srinivasan, C. S. Choi, P. Ghoshal et al., “β-cell-specific pyruvate dehydrogenase deficiency impairs glucose-stimulated insulin secretion,” American Journal of Physiology, vol. 299, no. 6, pp. E910–E917, 2010.
- V. C. Calegari, C. C. Zoppi, L. F. Rezende, L. R. Silveira, E. M. Carneiro, and A. C. Boschero, “Endurance training activates AMP-activated protein kinase, increases expression of uncoupling protein 2 and reduces insulin secretion from rat pancreatic islets,” Journal of Endocrinology, vol. 208, no. 3, pp. 257–264, 2011.
- M. Nakata, K. Manaka, S. Yamamoto, M. Mori, and T. Yada, “Nesfatin-1 enhances glucose-induced insulin secretion by promoting Ca2+ influx through L-type channels in mouse islet β-cells,” Endocrine Journal, vol. 58, no. 4, pp. 305–313, 2011.
- C. A. Machado De Oliveira, M. F. Paiva, C. A. Soares Mota et al., “Exercise at anaerobic threshold intensity and insulin secretion by isolated pancreatic islets of rats,” Islets, vol. 2, no. 4, pp. 240–246, 2010.
- V. Shivaswamy, M. McClure, J. Passer et al., “Hyperglycemia induced by tacrolimus and sirolimus is reversible in normal sprague-dawley rats,” Endocrine, vol. 37, no. 3, pp. 489–496, 2010.
- K. Robertson, P. Adolfsson, G. Scheiner, R. Hanas, and M. C. Riddell, “Exercise in children and adolescents with diabetes,” Pediatric Diabetes, vol. 10, no. 12, pp. 154–168, 2009.
- G. M. Reaven and F. Chang, “Effect of exercise-training on the metabolic manifestations of streptozotocin-induced diabetes in the rat,” Diabetologia, vol. 21, no. 4, pp. 415–417, 1981.
- M. A. Király, H. E. Bates, J. T. Y. Yue et al., “Attenuation of type 2 diabetes mellitus in the male Zucker diabetic fatty rat: the effects of stress and non-volitional exercise,” Metabolism, vol. 56, no. 6, pp. 732–744, 2007.
- E. P. Reaven and G. M. Reaven, “Structure and function changes in the endocrine pancreas of aging rats with reference to the modulating effects of exercise and caloric restriction,” Journal of Clinical Investigation, vol. 68, no. 1, pp. 75–84, 1981.
- E. Teixeira de Lemos, F. Reis, S. Baptista et al., “Exercise training decreases proinflammatory profile in Zucker diabetic (type 2) fatty rats,” Nutrition, vol. 25, no. 3, pp. 330–339, 2009.
- M. Colombo, S. Gregersen, M. Kruhoeffer et al., “Prevention of hyperglycemia in Zucker diabetic fatty rats by exercise training: effects on gene expression in insulin-sensitive tissues determined by high-density oligonucleotide microarray analysis,” Metabolism, vol. 54, no. 12, pp. 1571–1581, 2005.
- M. Maris, G. B. Ferreira, W. D'Hertog et al., “High glucose induces dysfunction in insulin secretory cells by different pathways: a proteomic approach,” Journal of Proteome Research, vol. 9, no. 12, pp. 6274–6287, 2010.
- Z. Q. Hou, H. L. Li, L. Gao, L. Pan, J. J. Zhao, and G. W. Li, “Involvement of chronic stresses in rat islet and INS-1 cell glucotoxicity induced by intermittent high glucose,” Molecular and Cellular Endocrinology, vol. 291, no. 1-2, pp. 71–78, 2008.