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Why I Chose This Topic
Genetics Dad
Father diagnosed with Type 2
Father-in-law died from complications with type 2
Definition of Diabetes Mellitis Epidemiology Clinical Aspects Treatment Effects of Exercise Exercise Testing Exercise Prescription Summary Conclusion
Outline
Diabetes mellitus is a group of diseases characterized by high blood glucose concentrations resulting from defects in insulin secretion, insulin action, or both.
Abnormalities in metabolism of CHO, protein and fat are present.
People with diabetes have bodies that don’t produce or respond to insulin.
Without effective insulin, hyperglycemia (elevated blood glucose) occurs.
What is diabetes mellitus?
Absolute deficiency of insulin Marked reduction of beta-cells in pancreas Thought to involve an autoimmune response-
no known means to prevention Exogenous insulin must be supplied Prone to ketoacidosis Accounts for 5% to 10% of diagnosed cases Can occur at any age although most affected
people are children and young adults
Type 1
Relative insulin deficiency-insulin resistant◦ Elevated, reduced or normal insulin levels
Risk factors include: (test on diabetes website)◦ Genetics◦ Older age◦ Obesity (particularly abdominal)◦ Sedentary lifestyle◦ Gestational diabetes◦ Pre-diabetes◦ Race or ethnicity
Type 2
Most cases do not require exogenous insulin
Do not develop ketoacidosis except in cases of unusual stress
Accounts for 90% to 95% of diabetes cases
Usually occurs after the age of 40 but is developing in young adults and youth
NO CURE-only management!
Type 2 con’t
Types of Diabetes
Gestational Other types
Glucose intolerance during pregnancy
Due to contra-insulin effects of pregnancy
20% to 50% of women with gestational diabetes develop type 2 within 5 – 10 years
5
Results from specific genetic syndromes, surgery, drugs, malnutrition, infections, or other illnesses
Depending on pathophysiology, may or may not require insulin
Total: 25.8 million children and adults in the US-8.3% of the population have diabetes
Diagnosed: 18.8 million Undiagnosed: 7 million Pre-diabetes: 79 million New Cases: 1.9 million new cases were
diagnosed in 2010 Cost: $174 billion! In 2007 Medical costs are 2.3 times more for diabetics
Epidemiology
Non-H
ispa
nic whi
tes
Asia
n Am
erican
s
Non-H
ispa
nic bl
acks
Hispa
nics
0.0%30.0%60.0%90.0%
7.1% 8.4% 12.6% 11.8%
Percentage of Ethnic Group with type 2 diabetes
Diabetes Does Discriminate!
Symptoms
Type 1 Type 2
Frequent urination Extreme thirst Extreme hunger Unusual weight
loss Extreme fatigue
and irritability
Any of the type 1 symptoms
Frequent infections Blurred vision Cuts/bruises that are
slow to heal Tingling/numbness in
hands/feet Recurring skin, gum or
bladder infections OR NO symptoms!
Diagnosis Criteria
Diabetes FPG≥126 mg/dlCPG≥200 mg/dl2hPG≥200 mg/dl
Pre-diabetesImpaired fasting glucoseImpaired glucose tolerance
FPG100-125 mg/dl2hPG140-199 mg/dl
Normal FPG<100 mg/dl2hPG<140 mg/dl
*2bPG, 2-hour plasma glucose level
*FPG, fasting plasma glucose * CPG Casual plasma glucose
Diagnosis
Adults with diabetes have heart disease death rates 2 to 4 times higher than those without diabetes
Adults with diabetes have a 2 to 4 times greater risk of having a stroke
Complications-heart disease and stroke
Leading cause of kidney failure in US◦Accounts for 44% of cases in 2008
Neuropathy-about 60% to 70% of diabetics have some form of nerve damage
Amputation-about 60% of non-traumatic lower limb amputations occur in diabetics
Other complications
Insulin therapy ◦Type 1◦Some type 2
Individual nutritional care plan
Exercise-especially for type 2Oral medication/type 2
Treatment
Generic name Trade Name
Onset Peak Duration
Rapid actingInsulin lisproInsulin aspartInsulin glulisine
HumalogNovoLogApidra
<15 min 30-90 min 1-3 h
Short actingRegular Humulin R
Novolin R 30-60 min 2-3 h
3-6 h
Intermediate actingNPHLente
Humulin NNovolin NHumulin L
2-4 h 4-10 h 10-16 h
Long actingInsulin glargineUltralente
LantusHumulin U
2-4 h Does not peak
18-36 h
Types of insulin
Generic name Trade name Concerns with exercise
BiguanidesMetforminMetformin(liquid)
Glucophage, Glucophage XR,Riomet
Glucosidase inhibitorsAcarboseMiglitol
PrecoseGlyset
May produce hypoglycemia with postprandial exercise
MeglitinidesNategliniderepaglinide
StarlixPrandin
May produce hypoglycemia with postprandial exercise
Oral agents used for treatment of type 2 diabetes
Generic name Trade name Concerns with exercise
SecretagoguesAcetohexamideChlorpromideTolazimideTolbutamideGlimeprideGlipizideGlyburide
Generic onlyDiabineseTolinaseOrinaseAmarylGlucotrol, Glucotrol XLDiabeta, Glynase, PresTab, Micronase
Can produce hypoglycemia during or after exercise
ThiazoladinedionesPioglitazoneRosiglitazoneDipeptidyl peptidase-4 inhibitorsSitagliptin
ActosAvandia
Januvia
No hypoglycemia unless given with another drug
Oral agents-con’t
Generic name Trade name Comments and concerns with exercise
Exantide Byetta Exantide is used in treatment of type 2 and is found to increase postprandial insulin response, delay gastric emptying, suppress glucagon secretion, and reduce appetite
Pramlintide Symlin Pramlintide is a synthetic hormone similar to human amylin. It may be used in combination with insulin therapy for treatment of either type 1 or 2. Pramlintide works by suppressing glucagon secretion and delaying gastric emptying.
Other injectable meds
Insulin and counter regulatory hormones don’t respond to exercise in the normal manner
Balance between peripheral glucose utilization and hepatic glucose production may be disturbed= hypo/hyperglycemia
Effects of diabetes on ability to exercise
Insulin allows glucose to enter the cells of insulin-sensitive tissue
Oral and injectable agents for type 2 diabetes are meds that help the pancreas secrete more insulin, alter CHO absorption, reduce liver glycogenolysis, increase insulin sensitivity, or a combination of effects
Meds may cause hypoglycemia◦ Pay attention to med timing, food intake, blood
glucose level before and after exercise
Effects of medication on exercise
Muscle contractions increase glucose uptake
Both aerobic and resistance exercises increase GLUT4 abundance and BG uptake
Insulin action and glucose tolerance is increased (type 2)
Dependent on several factors ◦ Use and type of meds to lower blood glucose◦ Timing of meds◦ Blood glucose level prior to exercise◦ Timing, amount, and type of previous food intake◦ Presence and severity of diabetic complications◦ Use of other meds ◦ Intensity, duration and type of exercise
Acute effects of a session of exercise
Weight loss (type 2) Improved insulin sensitivity Possible prevention of type 2 For those with type 2-possible improvement in blood glucose control
Improved CV health ◦Lower triglycerides◦Lowers blood pressure
Chronic effects of exercise
Exercise testing using protocols for populations at risk for CAD recommended in individuals who:◦ Have type 1 and are over 30 yrs◦ Have had type 1 longer than 15 years◦ Have type 2 and are over 35 yrs◦ Have either type 1 or 2 and one or more other
CAD risk factors◦ Have suspected or known CAD, or◦ Have any microvascular or neurological diabetic
complications
Exercise testing
Methods Measures endpoints
AerobicCycle (ramp protocol 17 W/min; staged protocol 25-50 W/3 min stage)Treadmill (1-2 METs/stage)
12-lead ECG, HR
BPRPE (6-20)
Serious dysrhythmias>2 mm ST-segment depression or elevationIschemic thresholdSignificant T-wave change
SBP >250 mmHg or DBP >115 mmHgOnset of peripheral pain
High risk for CAD testing
People with diabetes who don’t meet any of the criteria for CAD may be tested with use of protocols for the general healthy population
Primary objectives are to:◦Identify the presence and extent of CAD◦Determine appropriate intensity range
for aerobic exercise training
Exercise testing
Must be individualized according to med schedule, presence and severity of diabetic complications, and goals of program
Hypoglycemic meds=additional 15 g of CHO before or after exercise
15 to 30 g CHO (fat free) every hour during vigorous or exercise>60 min
Proper hydration Good foot care-proper shoes and socks Athletes will most often know their limits but
trial and error with beginners-monitor BG!!
Exercise programming
Active retinal hemorrhage or recent retinopathy therapy
Illness or infection Blood glucose >250 mg/dl and ketones are present
Blood glucose <70 mg/dl If blood glucose is <100 mg/dl, CHO should be consumed
Exercise contrandications
Modes Goals Intensity/frequency/duration
Time to goal
AerobicLarge muscle activities
Increase aerobic capacity, time to exhaustion, work capacity, BP response to exercise, Reduce CV risk factors
50-80% peak HR50-80% VO2peak
Monitor RPE4-7 sessions/week20-60 min/session
4-6 month
StrengthFree weightsWeight machinesElastic tubing or bands
Increase max repsImprove performance for competitive patients
low resistance, high reps for mostHigh resistance OK for patients with well controlled diabetes
4-6 months
Exercise prescription
Modes Goals Intensity/frequency/duration
Time to goal
AnaerobicHigh-intensity intervals
Only for athletes in good diabetic control
Same as for nondiabetic athletes
FlexibilityStretching/yoga
Maintain/ increase ROMImprove gait
Limited data; 2-3 x’s/week may suffice
4-6 months
NeuromuscularYoga
Improve balance and coordination
FunctionalActivity-specific exercise
Increase ADLsIncrease vocational potentialIncrease self confidence
Individualized to each client
Exercise prescription
Diabetes is a disease that should be taken seriously
Some type 2 can be managed with diet and exercise
If there are no significant complications with diabetes mellitus, patients can enjoy exercise with very few limitations
Exercise for type 2 patients is a must!!
Conclusion
American College of Sports Medicine, A. D. (2010). Exercise and type 2 diabetes. Medicine and Science in Sports & Exercise.
Diabetes Statistics. (n.d.). Retrieved February 24, 2012, from American Diabetes Association: www.diabetes.org
Durstine, J. M. (2009). ACSM's Exercise Management for Persons with Chronic Diseases and Disabilities. Champaign: Human Kinetics.
Farrell, P. (2003). Diabetes, exercise and competitive sports. Gatorade Sports Science Institute Sports Science Exchange , 1-6.
LaFontaine, T. (2004). Exercise considerations for individuals with type 1 diabetes. Strength and Conditioning Journal , 16-18.
Mahan, L. E.-S. (2008). Krause's Food and Nutrition Therapy. St. Louis: Saunders Elsevier.
References