Exercise and Type 2 Diabetes - Healing, Teaching & · PDF file1 Exercise and Type 2 Diabetes Larry S. Verity, PhD, FACSM School of Exercise & Nutritional Sciences ... Stevens, et al

1

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


Rate of New Cases of Type 1 & Type 2 Diabetes among Youth < 20 yrs


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


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


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


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


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


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


Management Team

Exercise Professional

Registered Dietician

Diabetes Educator

Contemporary Diabetes Care Team Approach

Physician(s) Diabetologist


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


Mechanisms of Action of Pharmacologic Agents for Diabetes


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


• 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


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


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


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


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


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


12


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


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


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.


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


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


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


Morphologic Changes with Activity: Composition & Health Risk Issues


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


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


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


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


-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


-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?


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


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?


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


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


• 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


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


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


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


Nephropathy

Exercise may urinary protein

No evidence that vigorous exercise rate of progression

No likely exercise restrictions specific to kidney disease!



Retinopathy May need dilated exam

Proliferative Retinopathy [PDR] - no vigorous or static exercise

Resistance training

Lower intensity activities

Cardio & resistance activities

23


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



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


An Active Lifestyle BEGINS with

YOUR 1st Step


Current knowledge of type 2 diabetes + exercise

Challenges facing exercise program development for heterogeneous type 2 diabetes

Exercise & Diabetes: Redefining Exercise Programs

25


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

Documents

Exercise and Type 2 Diabetes - Healing, Teaching & · PDF file1 Exercise and Type 2 Diabetes Larry S. Verity, PhD, FACSM School of Exercise & Nutritional Sciences ... Stevens, et al