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Transcript of Exercise and Type 2 Diabetes - Healing, Teaching & · PDF file1 Exercise and Type 2 Diabetes...
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Exercise and Type 2 Diabetes
Larry S. Verity, PhD, FACSM
School of Exercise & Nutritional Sciences
College of Health and Human Services
San Diego State University
Portland 2011 - T2DM
Characteristics of Type 1 & Type 2 Diabetes Mellitus
2
Portland 2011 - T2DM
Rate of New Cases of Type 1 & Type 2 Diabetes among Youth < 20 yrs
Portland 2011 - T2DM
Estimated Growth in Type 2 Diabetes: US Population From 2000-2050
0
20
40
60
80
100
120
2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050
Year
Percen
t in
crease
Type 2 DM General population Working age population (20-59)
Bagust A, et al. Diabetes, 50 [Suppl 2], A205, 2001
3
Portland 2011 - T2DM
Age-adjusted % of U.S. Adults Who Were
Obese or Who Had Diagnosed Diabetes Obesity (BMI ≥30 kg/m2)
Diabetes
1994
1994
2000
2000
No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0%
No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% >9.0%
CDC‟s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
2009
2009
Portland 2011 - T2DM
Diabetes Prevalence: Age and Ethnicity
0
5
10
15
20
25
Per
cen
tag
e (%
)
White - NH Black - NH Hispanic Native Am/Al
20-39 40-49 50-59 60-74 75+
4
Portland 2011 - T2DM
Type 2 diabetes
Years from diagnosis
0 5 -10 -5 10 15
Pre-diabetes
Onset Diagnosis
Insulin secretion
Insulin resistance
Postprandial glucose
Macrovascular complications (65% die of CVD)
Ramlo-Halsted BA, Edelman SV. Prim Care. 1999;26:771-789; Nathan DM. N Engl J Med. 2002;347:1342-1349
Fasting glucose Microvascular complications
Natural History of Type 2 Diabetes
Portland 2011 - T2DM
100
75
50
25
0 -10 -6 -2 2 0 6 10 14 -12
Years From Diagnosis
b-Cell
Function
(% b)
Stages of Type 2 Diabetes
Type 2 Diabetes Phase I
MonoTherapy
Type 2 Diabetes Phase II
Combination Oral
Therapy
Phase III
Insulin
Based on data of UKPDS 16: Diabetes. 1995.
5
Cardiometabolic Risk - Graphic
Abnormal Lipid Metabolism
LDL ApoB HDL Trigly.
Cardiometabolic
Risk Global Diabetes / CVD Risk
Overweight / Obesity
Inflammation Hypercoagulation
Hypertension
Unhealthy Eating
Age, Race, Gender,
Family History
Glucose BP Lipids
Age Genetics
Insulin Resistance ?
Smoking
Physical Inactivity
Insulin Resistance
Syndrome
Portland 2011 - T2DM
Proportion of Patients with Cardiovascular Disease Increases with Duration
of Diabetes
Years after DM Diagnosis
≤ 2 3-5 6-9 10-14 15+
15%
21% 24%
29%
48%
Harris, S et al.; Type 2 Diabetes and Associated Complications in Primary Care in Canada: The Impact of Duration of Disease on Morbidity Load. CDA 2003.
6
Portland 2011 - T2DM
Management Team
Exercise Professional
Registered Dietician
Diabetes Educator
Contemporary Diabetes Care Team Approach
Physician(s) Diabetologist
Portland 2011 - T2DM
Management of Diabetes Mellitus: Therapeutic Steps in Management
• Medical management
• Use of medications to
manage glucose
• oral agents and/or
• insulin
• Frequent monitoring
of blood glucose
• Proper diet and
exercise
7
Portland 2011 - T2DM
Mechanisms of Action of Pharmacologic Agents for Diabetes
Portland 2011 - T2DM
Insulin Secretion
β-Cell Neogenesis
β-Cell Apoptosis
Glucagon Secretion
Glucose Production
Heart
GI Tract Liver
Muscle Drucker DJ, Cell Metab. 2006;3:153-165.
Brain
Appetite
Cardioprotection
Cardiac Output GLP-1
Stomach
Gastric Emptying
Neuroprotection
Glucose Uptake
_
+
Summary of Pharmacologic Incretin Actions on Different Target Tissues
8
Portland 2011 - T2DM
• insulin sensitivity
• of diabetes medications
• glucose control for type 2
• Predictor of successful weight management
• Aids in managing other Cardiometabolic risks • Hypertension
• Dyslipidemia
• Obesity, Body weight/fat and morphology
• Psychoemotional benefits • Anxiety, Depression, Self-esteem
Exercise + Lifestyle Benefits
Portland 2011 - T2DM
Diabetes Prevention Program [DPP]:
Preventive Strategies? Clinical trials examined prevention
of type 2 diabetes
LIFESTYLE was very effective Physical activity > 150 mins/wk
MNT for diabetes
Strategies for success
Is the DPP an effective „model‟ for secondary prevention?
9
Portland 2011 - T2DM
Diabetes Incidence Rates by Ethnicity
0
4
8
12
Caucasian
(n=1768)
African
American
(n=645)
Hispanic
(n=508)
American
Indian
(n=171)
Asian
(n=142)
Case
s/1
00 p
ers
on
-yr
Lifestyle Metformin Placebo
The DPP Research Group, NEJM 346:393-403, 2002
Portland 2011 - T2DM
0
4
8
12
16
24 < 30 30 < 35 > 35
Case
s/10
0 p
ers
on
-yr
Lifestyle Metformin Placebo
(n=1045) (n=995) (n=1194)
Diabetes Incidence Rates by BMI
Body Mass Index (kg/m2) The DPP Research Group, NEJM 346:393-403, 2002
10
Portland 2011 - T2DM
DPP: Weight Loss and Physical Activity
-8
-6
-4
-2
0
0 1 2 3 4Years from Randomization
Weig
ht
Ch
an
ge (
kg
)
0
2
4
6
8
-1 0 1 2 3 4
Years from Randomization
ME
T-h
ou
rs/w
eek
Placebo Metformin Lifestyle
P<.001 P<.001
The DPP Research Group, NEJM 346:393-403, 2002
Portland 2011 - T2DM
Type 2 Diabetes: Exercise Program with NO Complications
Aerobic Frequency
5-7 d/wk
Intensity 40-60% HR Reserve RPE (4-6 on 10)
Time expend > 200 - 300 Kcals/d
Kcals/wk > 1,500 - 2,000 At least 150 mins/wk
Type (aerobic)
Resistance Frequency
> 3 d/wk
Intensity moderate
Repetitions 8-10 per exercise
Sets > 3 sets per exercise
Type major muscle groups: 8-10 exercises
11
Portland 2011 - T2DM ACE Mtng 2011
Association Between Insulin Sensitivity and Physical Exercise: The IRAS Study
Portland 2011 - T2DM ACE Mtng 2011
12
Portland 2011 - T2DM
Effect of Physical Activity on Glucose Control
6
6.5
7
7.5
8
8.5
9
9.5
10
Hb
A1
c (%
)
Exercise Control
HbA1c % is lowered
Clinical implications:
risk for
complications
UKDPS - 0.6% in HbA1c
lowered risk reduction by
32% for complications
and 42% for diabetes-
related death
WMD = -0.66; p<.001
Boule, JAMA, 286:1218-27, 2001
Portland 2011 - T2DM
Physical Activity Alone Results in Minimal Weight Loss
Wing. Med Sci Sports Exerc 1999;31(suppl):S547.
*P<0.05 vs control group
Duration of each study ranged from 4 to 12 months. Subjects were obese, IGT, and T2DM
Stefanick 1998
Stefanick 1998a
Anderssen 1995
Hammer 1989
Verity 1989
Rönnemaa 1988
Wood 1988
Wood 1983
Weight loss (kg)
Control Group
Exercise Group
* *
* *
13
Portland 2011 - T2DM
Physical Activity Usually Does Not Increase Short-Term Diet-Induced Weight Loss
*P<0.05 vs diet-only group.
Wadden 1997
Ross 1996
Marks 1995
Ross 1995
Blonk 1994
Sweeney 1993
Bertram 1990
Weight loss (kg)
Diet Only
Diet + Exercise
*
Wing RR. Med Sci Sports Exerc. 1999;31(suppl):S547-S552.
Each study ranged from 4 to 6 months.
Portland 2011 - T2DM
Fatness, Fitness and Cardiovascular Disease Mortality
Lean <16.7%
Rel
ati
ve
Ris
k o
f C
VD
Mo
rta
lity
Body Fat Category (% Weight as Fat)
Lee et al. Am J Clin Nutr 1999;69:373.
Normal 16.7%-24.9%
Obese >25%
Aerobically fit
Unfit
14
Portland 2011 - T2DM
Physical Activity Helps Preserve Fat-Free Mass During Weight Loss
Diet Only
Lo
ss o
f Fa
t-F
ree
Mas
s (%
To
tal W
eigh
t L
oss
)
Diet Plus Physical Activity
Men
Women
*P<0.05
Ballor and Poehlman, Int J Obes Relat Metab Disord,;18:35, 1994
Portland 2011 - T2DM
Relationship Between Physical Activity and Maintenance of Weight Loss
Not Maintained
Sub
ject
s E
xerc
isin
g (%
) P<0.001
Weight Loss Pattern
Maintained
Am J Clin Nutr. American Society for Clinical Nutrition.
15
Portland 2011 - T2DM ACE Mtng 2011
Morphologic Changes with Activity: Composition & Health Risk Issues
Portland 2011 - T2DM
Diastolic Systolic
Relationship Between Change in Weight and Blood Pressure: Trials of Hypertension Prevention
Stevens, et al. Ann Intern Med 2001;134:1.
Ch
an
ge
in
We
igh
t (k
g)
Ch
an
ge
in
Blo
od
P
ress
ure
(m
m H
g)
1 2 3 4 5
-10
-5
0
5
10
6
4
2
0
-2
-4
-6
-8
Quintile of Weight Change
16
Portland 2011 - T2DM
Diabetes and Hypertension
Adler AI, et al. BMJ 2000;321(7258):412-419.
0%
10%
20%
30%
40%
115 125 135 145 155 165
Systolic BP
Ad
j i
nci
de
nce
/1
00
0 p
t-y
r
MI Microvascular
0%
25%
50%
75%
100%
% hypertensive
Total Men Women
Portland 2011 - T2DM
Difference in Risk Reduction: Tight vs Less Tight BP Control (-10/-5 mm Hg)
% R
isk
Red
uc
tio
n
0
–10
–20
–30
–40
–50
Deaths Related to Diabetes
All-Cause Mortality MI Stroke
–32%
–18% –21%
–44%
UK Prospective Diabetes Study Group. BMJ. 1998;317:703-713.
17
Portland 2011 - T2DM
U.S. Adult Participation in Regular Strengthening Exercises
0
10
20
30
40
50
% P
op
ula
tion
18-24 25-44 45-64 65-74 75+
Age (years)
Men Women
Schoenborn & Barnes, National Center for Health Statistics, 2002
Portland 2011 - T2DM
-20 -10 0 10 20 30 40 50
% Change
Weight (kg)
Waist (cm)
Fat (kg)
FFM (kg)
HbA1c (%)
SBP (mmHg)
DBP (mmHg)
UBS
LBS
RT & WL WL
Dunstan et al., Diab Care, 25: 1729-1736, 2002
*
* * *
*
Resistance Exercise: Clinical Trial in Type 2 Diabetes
18
Portland 2011 - T2DM
-10-8-6-4-202468
10
Ab
solu
te C
ha
ng
e
Weight
(kg)
HbA1c
(%)
WB
LTM
(kg)
WB- Fat
(kg)
Trunk
Fat (kg)
SBP
(mmHg)
DBP
(mmHg)
PRT Controls
Castenada et al., Diabetes Care, 25:2335-42, 2002
P=.01
P=.05
NS
NS NS P=.01 P=.01 P=.07
Resistance Training and Glycemic Control in Type 2 Diabetes?
Portland 2011 - T2DM
Resistance Training Outcomes
Results yielded:
~1% reduction in
HbA1c Clinical implications
Decrease in meds
Favorable blood
pressure and
morphologic changes
Castenada et al., Diabetes Care, 25:2335-42, 2002
19
Portland 2011 - T2DM
Key Points for Medical & Allied Health Practitioners – “TOOL BOX”
• Pre-exercise: • Ensure Client‟s file
includes ABC‟s: • A1C - glucose
control
• Blood pressure • Presence/status
of Complications
• Encourage intensive management of diabetes
• Aid in „planning’ for each day‟s activity, exercise, or recreation
• Educate client on: • Frequent Glucose ‟s
• Self-Monitoring of Blood Glucose
• Balanced nutrition • RD?
Portland 2011 - T2DM
Client Assessment – “TOOL BOX”
Evaluate client, especially for CAD
Routine screening of asymptomatic diabetic patients is not recommended
Assess for: Diabetes Control
Hypertension Control
Diabetes complications - awareness
Age
Prior physical activity habits
Functional ability or limitations
20
Portland 2011 - T2DM
Safe Exercise: Routine Blood Glucose Checks - “TOOL BOX”
ALWAYS check pre-exercise glucose
IF glucose 100 - 250 mg/dl okay to exercise
IF glucose >250 mg/dl Use caution for exercise
IF glucose < 100 mg/dl - give 15-30 g CHO
Re-check glucose to ensure BG > 100 mg/dl
ALWAYS check post-exercise glucose
Portland 2011 - T2DM
• Walking more [steps] each
day for type 2 diabetes
• “Steps” are linked with:
• glucose metabolism
• aerobic fitness
• weight management
• Use of PEDOMETER
• Tudor-Locke -- FSP (2004)
Strategies for An Active Lifestyle
21
Portland 2011 - T2DM
Practical Recommendations for Persons with Diabetes Mellitus - “TOOL BOX”
Self-Blood Glucose Monitoring
Before and after each exercise session.
Keep a daily log: Glucose values
Medication
Time, effort, and distance of exercise session.
Plan for an exercise session:
When ? How much activity ?
If needed, carry extra carbohydrate feedings
Exercise with partner: until glucose response is known.
Wear a diabetes I.D.; Never leave home without it.
Wear good shoes: Proper-fitting and comfortable footwear can minimize foot irritations, and limit orthopedic injury to the foot and lower leg.
Practice good hygiene
Modify caloric intake
Portland 2011 - T2DM
Common Pathways in Diabetes Complications
Oxidative
Stress
Cellular
Dysfunction
AGE Formation
Cell
Damage
Hexosamine
Pathway
ROS
ROS
Glucose
Peripheral & Autonomic Neuropathy
Nephropathy
Retinopathy
Vascular
Damage
Diabetes complications (eye, kidney, nerve, blood vessels) arise from a number of triggers perturbing a limited number of metabolic pathway(s) (Brownlee, 2001)
22
Portland 2011 - T2DM
Peripheral Arterial Disease [PAD] Leg pain linked with PAD
limits weight-bearing activity ~40% have intermittent
claudication with exercise
Walking - most effective for claudication Interval-like training for 3-5
mins exericse followed by brief rest to ease symptoms
May require cardiac rehab for initial exercise
Exercising With Complications:
Standards of Care of Practice [ADA, 2011] - “TOOL BOX”
Cardiovascular Disease [CVD] IF diagnosed with CVD,
THEN….client likely needs stress test
No CVD: client may need stress test IF moderate-to-vigorous intensity
No CVD: Low-to-moderate intensity may be OK
Physician judgement
Portland 2011 - T2DM
Nephropathy
Exercise may urinary protein
No evidence that vigorous exercise rate of progression
No likely exercise restrictions specific to kidney disease!
Exercising With Complications:
Standards of Care of Practice [ADA, 2011] - “TOOL BOX”
Retinopathy May need dilated exam
Proliferative Retinopathy [PDR] - no vigorous or static exercise
Resistance training
Lower intensity activities
Cardio & resistance activities
23
Portland 2011 - T2DM
Peripheral Neuropathy
Motor & Sensory nerves
Pain sensation & loss of sensation in extremities
Risk of infection/injury
Limit weight-bearing exercise
Encourage alternate activities:
Swim, bike, water aerobics
Autonomic Neuropathy Affects HR HR rest & HR exercise
Risk of exercise-induced injury or adverse event
Thermoregulation
Gastric emptying
Papillary function
Risk of CVD in diabetes
Cardiac assessment
Exercising With Complications:
Standards of Care of Practice [ADA, 2011] - “TOOL BOX”
Cardiometabolic Risk - Graphic
Abnormal Lipid Metabolism
LDL ApoB HDL Trigly.
Cardiometabolic
Risk Global Diabetes / CVD Risk
Overweight / Obesity
Inflammation Hypercoagulation
Hypertension
Unhealthy Eating
Age, Race, Gender,
Family History
Glucose BP Lipids
Age Genetics
Insulin Resistance ?
Smoking
Physical Inactivity
Insulin Resistance
Syndrome
24
Portland 2011 - T2DM
An Active Lifestyle BEGINS with
YOUR 1st Step
Portland 2011 - T2DM
Current knowledge of type 2 diabetes + exercise
Challenges facing exercise program development for heterogeneous type 2 diabetes
Exercise & Diabetes: Redefining Exercise Programs
25
Portland 2011 - T2DM
Remember to Empower Your Client
We don’t plan to fail,
but we do fail to plan
Meaning:
Your Client Must have a PLAN of Action