Lec 1 nutrition therapy diabetes mellitus and physical activates

Dr. Diham Mohamed Osman Gritly 1

Postgraduate Diploma in Diabetes Education (PDDE(

lec 1 Nutrition therapy: Diabetes Mellitus and physical activates

Prepared by;

Dr. Siham M.O. Gritly


Objectives

• the participant will be able to:• Describe the benefits of exercising. • Describe the different types of exercise. • Identify the risks of exercise for people with diabetes. • Give recommendations for exercising. • Know how to assess the person with diabetes before the

exercise session. • Monitor the person with diabetes during the exercise session. • Recognize that individuals have barriers to exercise. • Give recommendations for particular cases


glossary

• Physical activity; Bodily movement produced by the contraction of skeletal muscle that requires energy expenditure in excess of resting energy expenditure. includes cardiorespiratory fitness, muscular fitness, and flexibility

• Exercise; A subset of physical activity: planned, structured, and repetitive bodily movement performed to improve or maintain one or more components of physical fitness (Strength, Power, Balance, Flexibility, Cardiovascular Endurance, Local Muscle Endurance, Strength Endurance


• Physical fitness is “a set of abilities individuals possess to perform specific types of physical activities

• Fitness is the state or conditions of being healthy, or good health and condition as a result of exercise and balance nutrition


• Maximal oxygen consumption (VO2); is An important measure of sports fitness; aerobic capacity, where the amount of oxygen body can consume and turn into energy

• -respiratory quotient (RQ) -is the ratio of carbon dioxide expired/moles of oxygen consumed or the ratio of oxygen used in metabolism (and therefore heat generated), to carbon dioxide eliminated)

• The respiratory quotient (RQ) is calculated from the ratio: RQ = CO2 eliminated / O2 consumed


Diabetes Mellitus and physical activates

• Physical activity (exercise) is an important component of diabetes management with physiological and psychological benefits.

• Regular exercise is highly recommended for many people who have either Type 1 or Type 2 Diabetes Mellitus (DM).


• physical exercise and balance nutrition provide better performance; including:

• -Cardiovascular health (blood flow, blood pressure and oxygen delivery)

• -Respiratory function• -Hormones• -Immune response• -Muscles and bones• -Metabolism


Health professional recommended physical activity program including

• 1-Aerobic exercise provides health benefits; moderate physical activity about 30 minutes or three 10-minutes exercise daily is recommended by most of the fitness professionals

• 2-resistance exercise; exercise that increase muscular strength and endurance is recommended. 8-10 exercises that stress the major muscle group of the body at least twice a week


• 3-flexibility and balance exercise; activities that help increase flexibility 2 days a week for 10 minutes is recommended

• 4-exercise programs especially design for older individual should based on physical fitness level and health status


Types of exercises aerobic exercises

Aerobic exercise; consists of rhythmic, repeated, and continuous movements of the same large muscle groups for at least 10 min at a time. Examples include walking, bicycling, jogging, continuous swimming, water aerobics, and many sports. When performed at sufficient intensity and frequency, this type of exercise increases cardiorespiratory fitness


Intensity of aerobic exercise

Intensity of aerobic exercise.This will be described as “moderate” when it is at 40–60% of V̇� o2max ( 50–70% of ∼maximum heart rate) and “vigorous” when it is at >60% of V̇� o2max (>70% of maximum heart rate). “Resting heart rate averages 60 to 80 beats/min in healthy adults”


Maximum oxygen consumption V̇� o2max

An important measure of sports fitness is aerobic capacity or VO2 max, which is the amount of oxygen your body can consume and turn into energy. Maximum oxygen consumption;-VO2 is the Ability to Deliver and Use Oxygen• As work rate is increased, oxygen

uptake increases linearly, No further increase in VO2 with increasing work rate


Cardiorespiratory fitness (also known as cardiorespiratory endurance or aerobic

fitness

The ability of the circulatory and respiratory systems to supply oxygen during sustained physical activity. The standard for measurement of cardiorespiratory fitness is a test of maximal oxygen uptake (V̇� o2max), using indirect calorimetry on a treadmill or bicycle ergometer


Anaerobic exercises

Anaerobic exercises may last only two minutes or less, but this type of workout actually burns more calories than aerobic exercise. Unlike aerobic exercise, anaerobic exercise burns a higher percentage of calories from glycogen These are less adapted to the needs of most people with diabetes


Anaerobic exercise include, strength-based activities, such as sprinting or

bodybuilding

Anaerobic exercise is high in intensity and short in duration


Resistance exercise.

• Resistance exercise.• Activities that use muscular strength and

endurance to move a weight or work against a load.

• Examples include weight lifting and exercises using weight machines. ‘When performed with regularity and moderate to high intensity, resistance exercise increases muscular fitness’.


Muscular Strength; tests muscular strength of the upper body, (Push Up Strength Test), or Muscular Endurance which tests

the ability of the muscles to exert force over an extended period of time

Muscular fitness.This refers to strength (the amount of force a muscle can exert) and muscular endurance (the ability of the muscle to continue to perform without fatigue)Muscular endurance is assessed by counting the maximum number of repetitions of a muscular contraction a person can perform to fatigue (Repetition Maximum Testing 1 RM)


Flexibility and balance exercise. This term refers to the range of motion available at

joints.

Flexibility; the capacity of the joints to move through a full range of motion; the ability to bend and recover without injuryFlexibility is an important component of fitness and physical performance


• stretching for 5 to 10 minutes helps your body warm up and get ready for activities and cool down afterwards


The benefits of exercise for diabetic patients

• Improves cardiovascular fitness in type 1 and 2 diabetes. • Reduces cardiovascular risk factors, such as

hypertension and hyperlipidaemia in type 1 and 2 diabetes.

• Contributes to the flexibility, endurance, and muscle strength.

• Improves glucose control in type 2 diabetes. • Increases peripheral use of glucose. • Decreases glucose hepatic output. • Increases insulin sensitivity


• Decreases counter regulatory hormones. A counter regulatory hormone is a hormone that opposes the action of another.

• Helps maintaining weight in addition to meal planning among people with type 2 diabetes whose weight is normal, and helps to reduce weight in obese people.

• Gives a sense of well being and a better quality of life in people with types 1 and 2 diabetes.


What are the risks of exercise for people with diabetes?

• Developing hypoglycaemia during or after exercise, especially in a person on insulin.

• Increased hyperglycaemia in poorly controlled

persons and under-insulinised persons with pre-exercise blood glucose levels of 250-300 mg/dl (14-17 mmol/l).


• Myocardial infarction or arrhythmia in persons with diabetes who also have atherosclerotic disease, if exercise is not properly paced.

• Possible worsening of microvascular diabetes complications especially retinopathy


• Damage to soft tissue/joints in the presence of peripheral neuropathy.

• Damage to the feet, when not wearing the proper shoes


Recommendations for exercising

• Adequate fluid intake during exercise.• Use of proper footwear.• Wearing an identification bracelet.• Avoidance of exercise in extreme temperatures

(heat or cold).• Inspection of feet after exercise.• If possible, exercise with a friend.


Recommendations For type 1 diabetes

• Individuals with type 1 diabetes should avoid exercise if fasting blood glucose is higher than 250 mg/dl and ketones are present.

• recommendation can be made for hypoglycaemia prevention and improving metabolic control.

• self-monitoring of blood glucose needs to be integrated into the exercise programme and the information to be used to adjust the insulin dosage and food intake

• Increase intake of carbohydrates if glucose levels are < 100 mg/dl


General recommendations for type 2 diabetes:

• Individuals with type 2 diabetes should avoid exercise if blood glucose is higher than 400 mg/dl.

• Monitoring blood glucose before, after and during physical activity is necessary to keep blood glucose within an appropriate range.

• Frequency: at least 3 days per week.• Duration: according to the individual.• Intensity: 50-70% of person’s maximal heart rate

(maximum heart rate = 200-age)• heart rate averages 60 to 80 beats/min in healthy adults


• People using hypoglycaemic agents or insulin should self-monitor their blood glucose to determine glycaemic response to exercise.

• They should adhere to the recommended different phases of exercise as follows:

• Warm-up: 10 - 15 minutes• Actual exercise: 30 - 45 minutes• Cool down: 5 - 10 minutes.


• Insulin administration • Avoid exercise during peak insulin action. • Reduce insulin dose if exercise is anticipated. • Administer insulin away from the working

limbs.


Exercise is highly recommended—for most people with type 2 diabetes, including those with complications.

A person with type 2 diabetes can use exercise to help control their blood sugar levels and provide energy their muscles need to function throughout the day.


What is Fitness Assessment

• fitness assessment provide an accurate measure of the current fitness and health level of an individual

• A fitness assessment provides a baseline measurement of

• 1-cardiovascular endurance,• 2- body composition,• 3- muscular endurance, • 4-muscular strength• 5- flexibility.


Assessment of the person with diabetes before exercise

• History and physical examination• They must detect diseases of the heart, blood vessels,

eyes, kidneys, and nervous systems

• Persons with diabetes especially at risk must have a more detailed medical examination. This includes people:

• aged > 35 years • with type 2 diabetes for longer than 10 years • with type 1 diabetes for longer than 5 years


• with any additional risk factors for coronary heart disease.

• with microvascular disease (retinopathy, nephropathy).

• with peripheral vascular disease, autonomic neuropathy.

• Always examine feet and footwear.


• Basic tests • These can be done depending on the individual

situation• Cardiovascular system: ECG, exercise ECG.• Peripheral arterial disease: toe pressure, ankle

Doppler• Retina: retina screening (fundoscopy)• Kidneys: urine microprotein• Peripheral neuropathy test: 10 g monofilament test.


Monitoring during exercise

• 1. Metabolic control before physical activity• Avoid exercise if fasting level is > 250 mg/dl

(14 mmol/l) and urine ketones present, or• if > 16.6 mmol/l irrespective of whether

ketosis is present.• Increase intake of carbohydrates if glucose

levels are < 100 mg/dl (6 mmol/l).


• 2. Blood glucose monitoring before and after physical activity– Identify when changes in insulin or food in take

are necessary.

– Gain knowledge of the glycaemic response to different exercise/physical activity conditions.


• 3-Food intake – Consume added carbohydrates as needed for

avoiding hypoglycaemia.

• Carbohydrate-based food should be readily available during and after exercise, e.g. Fresh juice, commercially available high-energy drinks


• 4- Insulin administration

– Avoid exercise during peak insulin action.

– Reduce insulin dose if exercise is anticipated.

– Administer insulin away from the working limbs.


Barriers to exercise

• Barriers may be real, e.g.• lack of motivation,• presence of debilitating illness,• physical disability, e.g. polio, blindness, lack

of available space, time, and security.• foot problems,• neuropathy.


• There may also be perceived barriers, such as;• having to go to the gym, • exercising being expensive • and a waste of time, • not liking it or being tired.


How to help patient to overcome barriers

• Encourage group exercising.• Allow the person with diabetes to choose what

he/she likes and can afford to do.• Discuss with the person and agree about a specific

target, such as walking 30 minutes every day, and so on.

• Explain that simple, regular exercise is possible in most cases, such as walking, climbing stairs, going uphill, and even the usual daily chores that can be organised.


• Show a few exercises that the elderly people can perform regularly every day.

• In young people, playing football or basketball, doing gym in a group, or jogging are suitable suggestions


Recommendation in particular situation

• Exercises for people with retinopathy• Diabetic retinopathy is a complication of diabetes that

affects the eyes. It's caused by damage to the blood vessels of the light-sensitive tissue at the back of the eye (retina).

• Not recommended: excessive jogging, high-impact aerobics, weight lifting, and boxing.

• Recommended: mild exercises, such as walking, low-

impact aerobics, and endurance exercising


• Exercises for people with nephropathy• nephropathy loss of protein in the urine, and eventually

chronic kidney disease requiring dialysis .• Moderate exercise is allowed (working at 65% of heart

rate).• Heart Rate; Resting heart rate averages 60 to 80 beats/min

in healthy adults. In sedentary, middle aged individuals it may be as high as 100 beats/min. In elite endurance athletes heart rates as low as 28 to 40 beats/min

• In overt nephropathy: exercise is self-limiting.


• Exercise for people with current or previous foot disease, Charcot’s arthropathy:

• No weight-bearing exercises.• Avoid repetitive exercises, e.g. prolonged walking, jogging,

step exercises.• Recommended: swimming, bicycling, rowing, chair

exercises, and arm exercises.• Amputees can do exercise in a wheel chair, with arms and

body. • In case of arthritis or arthrosis: mild exercising, e.g. walking,

relaxed gym.


• Exercise in children• Encourage them to do regular physical activity,

such as sport, outdoor play, football, gym. • Pay attention to the need of balancing glycaemic

control with normal playing. • To achieve control, parents, teachers, and

caregivers have to work together. • Hormonal changes in adolescents may

complicate control


• Exercise in the elderly• Advancing age and obesity may hinder aerobic

exercising.

• Encourage mild exercise, e.g. walking regularly.


references• American Diabetes Association. 2002. Diabetes and Physical

activity. Position statements: Diabetes Care, 26 (suppl 1):73S.• Fitness Instruction Manual. 2001. Academy Vocational Training• Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C.

2004. Physical Activity/Exercise and Type 2 Diabetes. Diabetes Care 27: 2518-2539.

• American Diabetes Association (2002). Clinical Practice Recommendations:2002. Diabetes Care 25 (suppl. 1):S64-S68.

• Sareen Gropper, Jack Smith and James Groff, Advanced Nutrition and Human Metabolism, fifth ed. WADSWORTH


• Melvin H Williams 2010; Nutrition for Health, Fitness and Sport. 9th ed, McGraw Hill

Heymsfield, SB.; Baumgartner N.; Richard and Sheau-Fang P. 1999. Modern Nutrition in Health and Disease; Shils E Maurice, Olson A. James, Shike Moshe and Ross A. Catharine eds. 9th edition

• Guyton, C. Arthur. 1985. Textbook of Medical Physiology. 6th edition, W.B. Company

• http://www.livestrong.com/article/500155-example-of-anaerobic-exercise/#ixzz2S1NYa5jd

•

http://www.livestrong.com/article/500155-example-of-anaerobic-exercise/

http://www.livestrong.com/article/500155-example-of-anaerobic-exercise/

Lec 1 nutrition therapy diabetes mellitus and physical activates

Health & Medicine

Transcript of Lec 1 nutrition therapy diabetes mellitus and physical activates