No Rest for the Idle: Exercise is Still Recommended Sherrie Evenson, MS ACSM Registered Clinical Exercise Physiologist ACSM Cancer Exercise Trainer

Transcription

1 No Rest for the Idle: Exercise is Still Recommended Sherrie Evenson, MS ACSM Registered Clinical Exercise Physiologist ACSM Cancer Exercise Trainer ON THE ROAD TO DIABETES EDUCATION BEST PRACTICES WASHINGTON STATE AADE 2011 Conference April 1 and 2 nd 2011

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3 No Rest for the Idle

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5 Transitioning to Delete

6 Brit. J. industr. Med., 1953, 10, 245.MORTALITY IN RELATION TO THE PHYSICAL ACTIVITY OF ORK A PRELIMINARY NOTE ON EXPERIENCE IN MIDDLE AGE BY J. N. MORRIS and J. A. HEADY

7 Hmmm have you noticed? Research That Started it All: Physical Activity & Drivers Conductors Brit. J. industr. Med., 1953, 10, 245.MORTALITY IN RELATION TO THE PHYSICAL ACTIVITY OF ORK A PRELIMINARY NOTE ON EXPERIENCE IN MIDDLE AGE BY J. N. MORRIS and J. A. HEADY

8 The Risk of Light Duty The mortality from coronary heart disease at years of age among the heavy workers was found to be rather less than half that of the light workers. Coronary heart disease shows the strongest trend and the greatest excess in the light occupations, but, as said already, mortality among light workers is at least a third greater than among heavy in all the other conditions Mortality data: Brit. J. industr. Med., 1953, 10, 245.MORTALITY IN RELATION TO THE PHYSICAL ACTIVITY OF ORK A PRELIMINARY NOTE ON EXPERIENCE IN MIDDLE AGE BY J. N. MORRIS and J. A. HEADY

9 Brit. J. industr. Med., 1953, 10, 245.MORTALITY IN RELATION TO THE PHYSICAL ACTIVITY OF ORK A PRELIMINARY NOTE ON EXPERIENCE IN MIDDLE AGE BY J. N. MORRIS and J. A. HEADY

10 Back When It Was New Brit. J. industr. Med., 1953, 10, 245.MORTALITY IN RELATION TO THE PHYSICAL ACTIVITY OF ORK A PRELIMINARY NOTE ON EXPERIENCE IN MIDDLE AGE BY J. N. MORRIS and J. A. HEADY

11 Back When It Was New Seven conditions were isolated in which there was Brit. J. industr. Med., 1953, 10, 245.MORTALITY IN RELATION TO THE PHYSICAL ACTIVITY OF ORK A PRELIMINARY NOTE ON EXPERIENCE IN MIDDLE AGE BY J. N. MORRIS and J. A. HEADY

12 Back When It Was New Seven conditions were isolated in which there was greater mortality among middle-aged men engaged Brit. J. industr. Med., 1953, 10, 245.MORTALITY IN RELATION TO THE PHYSICAL ACTIVITY OF ORK A PRELIMINARY NOTE ON EXPERIENCE IN MIDDLE AGE BY J. N. MORRIS and J. A. HEADY

13 Back When It Was New Seven conditions were isolated in which there was greater mortality among middle-aged men engaged in light jobs than heavy ones These conditions are coronary heart disease, cancer of the lung, appendicitis, diseases of the prostate, duodenal ulcer, diabetes, and cirrhosis of the liver - a particularly interesting group, as several of them are among the "new" diseases of increasing importance as health problems. Brit. J. industr. Med., 1953, 10, 245.MORTALITY IN RELATION TO THE PHYSICAL ACTIVITY OF ORK A PRELIMINARY NOTE ON EXPERIENCE IN MIDDLE AGE BY J. N. MORRIS and J. A. HEADY

14 Back When It Was New Seven conditions were isolated in which there was greater mortality among middle-aged men engaged in light jobs than heavy ones These conditions are coronary heart disease, cancer of the lung, appendicitis, diseases of the prostate, duodenal ulcer, diabetes, and cirrhosis of the liver - a particularly interesting group, as several of them are among the "new" diseases of increasing importance as health problems. The possibility was considered that there may Brit. J. industr. Med., 1953, 10, 245.MORTALITY IN RELATION TO THE PHYSICAL ACTIVITY OF ORK A PRELIMINARY NOTE ON EXPERIENCE IN MIDDLE AGE BY J. N. MORRIS and J. A. HEADY

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16 Led to the Study of Physical Current recommendations for all adults (ACSM/AHA): 150 min/wk of moderate physical activity (30 min on 5 days/wk) Or 60 min/wk (20 min on 3 days/wk) of vigorous physical activity Or Combination of both

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18 A New Look at Old People

19 A New Look at Old People Biological anthropology: what is the biological basis for daily PA?

20 A New Look at Old People Biological anthropology: what is the biological basis for daily PA? We are uniquely and remarkably designed to move

21 A New Look at Old People Biological anthropology: what is the biological basis for daily PA? We are uniquely and remarkably designed to move 21 st century living doesn t mix well with a body long adapted for physical endurance

22 A New Look at Old People Biological anthropology: what is the biological basis for daily PA? We are uniquely and remarkably designed to move 21 st century living doesn t mix well with a body long adapted for physical endurance Ultimate causes of diseases of affluence

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24 Just Another Day in the Life

25 Just Another Day in the Life Hunter-gatherers walked or ran 6-9 miles a day

26 Just Another Day in the Life Hunter-gatherers walked or ran 6-9 miles a day Spent lots of energy gathering and hunting high-quality food

27 Just Another Day in the Life Hunter-gatherers walked or ran 6-9 miles a day Spent lots of energy gathering and hunting high-quality food Endurance running and walking likely allowed people to survive

28 Just Another Day in the Life Hunter-gatherers walked or ran 6-9 miles a day Spent lots of energy gathering and hunting high-quality food Endurance running and walking likely allowed people to survive Swings in feast and famine; body adapted by developing ways of storing and using energy

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30 Farming: Recent Development (relatively speaking)

31 Farming: Recent Development (relatively speaking) Compared to huntergatherer lifestyle, very recent

32 Farming: Recent Development (relatively speaking) Compared to huntergatherer lifestyle, very recent Harnessing energy from soil & sun; grow, prepare, & distribute food

33 Farming: Recent Development (relatively speaking) Compared to huntergatherer lifestyle, very recent Harnessing energy from soil & sun; grow, prepare, & distribute food Allowed for much more population growth: camps, towns, villages

34 Farming: Recent Development (relatively speaking) Compared to huntergatherer lifestyle, very recent Harnessing energy from soil & sun; grow, prepare, & distribute food Allowed for much more population growth: camps, towns, villages Still experiences of feast and famine perhaps even more extremes

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36 Industrialization: Modern Life

37 Industrialization: Modern Life Just a few generations ago

38 Industrialization: Modern Life Just a few generations ago Many mega-cities

39 Industrialization: Modern Life Just a few generations ago Many mega-cities Food: from whole to processed

40 Industrialization: Modern Life Just a few generations ago Many mega-cities Food: from whole to processed Traveling: From walking/running 6-9 miles/day, or working in fields Now walking a few blocks and driving average of 32 miles/

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42 Mind-Body Conflict

43 Mind-Body Conflict Physical body designed for activity

44 Mind-Body Conflict Physical body designed for activity and a brain scheming for efficiency with the technology to achieve it

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46 No Going Back, But

47 No Going Back, But Our bodies need movement!

48 No Going Back, But Our bodies need movement! Ways we store and use energy ARE protective

49 No Going Back, But Our bodies need movement! Ways we store and use energy ARE protective but for SHORT periods of time, not lifetimes of inactivity fueled by processed diets

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51 Irony of Modern Living

52 Irony of Modern Living Downside to modern living: chronic diseases and disabilities of lifestyle

53 Irony of Modern Living Downside to modern living: chronic diseases and disabilities of lifestyle Upside to modern living: low mortality and morbidity from chronic diseases

54 Irony of Modern Living Downside to modern living: chronic diseases and disabilities of lifestyle Upside to modern living: low mortality and morbidity from chronic diseases Many of the effects of sedentary lifestyles normalize, or at least

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56 Exercise: Evidence-Based

57 Exercise: Evidence-Based Improves health & fitness

58 Exercise: Evidence-Based Improves health & fitness Helps maintain function

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60 Exercise is Medicine Is a Pill Too Good to be True?

61 Exercise is Medicine Is a Pill Too Good to be True? Recent studies on creating an exercise pill

62 Exercise is Medicine Is a Pill Too Good to be True? Recent studies on creating an exercise pill Must be functionrelated to be funded

63 Exercise is Medicine Is a Pill Too Good to be True? Recent studies on creating an exercise pill Must be functionrelated to be funded Many diabetic drugs mimic effects of exercise

64 Exercise is Medicine Is a Pill Too Good to be True? Recent studies on creating an exercise pill Must be functionrelated to be funded Many diabetic drugs mimic effects of exercise To do everything exercise does on multiple pathways,

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66 Do better to throw them on the floor and pick them up three Exercise Pill

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68 Adopting and Maintaining

69 Adopting and Maintaining % 58.00% % % 39.00% % % Adults with Diabetes Other American Adults

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71 Getting a Workout

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73 Alarming Trends

74 Obesity continues to increase Alarming Trends

75 Alarming Trends Obesity continues to increase Clinically severe obese Increase 500% in those with a BMI over 50

76 Alarming Trends Obesity continues to increase Clinically severe obese Increase 500% in those with a BMI over 50 Delayed response: rise in diabetes has followed the rise in obesity (about 10-15

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78 WHO (2006):

79 WHO (2006):

80 WHO (2006): The number of fat malnourished people in the world now equals the number of hungry malnourished people in the world 1.1 million in each group In 3 rd world countries wealthy individuals are obese, and the poor are thin; In the United States, the wealthy are more likely to be thin and the poor more likely to be obese

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82 Diabesity : Risk Ever Growing

83 Diabesity : Risk Ever Growing One in three Americans born in 2000 or later will develop diabetes

84 Diabesity : Risk Ever Growing One in three Americans born in 2000 or later will develop diabetes One in two in high risk ethnic populations

85 Diabesity : Risk Ever Growing One in three Americans born in 2000 or later will develop diabetes One in two in high risk ethnic populations Sarcopenic

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87 Research on Exercise & Type 2 Diabetes (T2DM) Improves Prevents blood or delays glucose T2DM control Up to Reduces morbidity & mortality

88 *Lifetime risk

89 Long Term Complications of Diabetes *Lifetime risk

90 Long Term Complications of Diabetes Vascular Disease: CVD/PAD 67% of Peripheral Neuropathy 40% of people with Autonomic Neuropathy 22% of T2DM *Lifetime risk

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92 Effects of Exercise on Long Term Complications

93 Effects of Exercise on Long Term Complications Vascular Disease: CVD/PAD Aerobic & Peripheral Neuropathy Mild/ moderate Autonomic Neuropathy Autonomic function can

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95 Other Long-Term

96 Other Long-Term Retinopathy Improved work capacity with mild/mod exercise Little research in T2DM but Nephropathy/ microalbuminuria Includes 30% of those with T2DM Aerobic & RT improves function

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98 How Often is Exercise

99 How Often is Exercise One study: Exercise advice or referral to patient with diabetes occurred during 18% of office visits

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101 I m tired of doctors telling me to quit smoking, start exercise and eat right where can I find a doctor who s more like me?

102 I m tired of doctors telling me to quit smoking, start exercise and eat right where can I find a doctor who s more like me? There are two in the waiting room

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104 Inactivity Physiology: Is Sitting Too Much Hazardous to

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106 Everyone sits. Right now, for

107 Everyone sits. Right now, for Sitting has been around for a long time

108 Everyone sits. Right now, for Sitting has been around for a long time 75% of work day

109 Everyone sits. Right now, for Sitting has been around for a long time 75% of work day We sit more than we sleep Sleep 7-8 hrs hours awake of those sitting

110 Everyone sits. Right now, for Sitting has been around for a long time 75% of work day We sit more than we sleep Sleep 7-8 hrs hours awake of those sitting Some of the most physically active people sit a good part of the day

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114 Exercise Non-exercise 900 minutes waking hours (7 AM-10 PM)

115 Moderate exercisers: Exercise Non-exercise 900 minutes waking hours (7 AM-10 PM)

116 Even if we are Successful Moderate exercisers: 30 min/day Exercisers Exercise Non-exercise 900 minutes waking hours (7 AM-10 PM)

117 Even if we are Successful Moderate exercisers: 30 min/day Exercisers Exercise Non-exercise 900 minutes waking hours (7 AM-10 PM)

118 Even if we are Successful Moderate exercisers: 30 min/day Exercisers Vigorous exercisers: 60 min/day Exercise Non-exercise 900 minutes waking hours (7 AM-10 PM)

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120 Studies of Sitting Time &

121 Studies of Sitting Time & Sitting time is independently associated with allcause mortality and cardiovascular disease (regardless of BMI) Obesity related to watching 4+ hours television National average = ~4

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123 Why is the Science of Sitting Important?

124 Why is the Science of Sitting Dealing with different parameters than exercise training Important?

125 Why is the Science of Sitting Dealing with different parameters than exercise training Recommendatio ns could be distinct from exercise training focusing on the Important?

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127 Studies in Diabetes and Screen Time

128 Studies in Diabetes and Screen Time Metabolic syndrome: twice risk in those with over 4 hrs screen time compared to 0-1 hours

129 Studies in Diabetes and Screen Time Metabolic syndrome: twice risk in those with over 4 hrs screen time compared to 0-1 hours Obesity & T2DM: Linear trend with television watching time

130 Studies in Diabetes and Screen Time Metabolic syndrome: twice risk in those with over 4 hrs screen time compared to 0-1 hours Obesity & T2DM: Linear trend with television watching time For every 2 hours TV watched, 20% increased risk of T2DM

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132 Diabetes and Breaks from

133 Diabetes and Breaks from Every 40 min. walked, decrease 19% risk of T2DM

134 Diabetes and Breaks from Every 40 min. walked, decrease 19% risk of T2DM For every 2 hours standing/light physical activity, 10% reduced risk for diabetes

135 Diabetes and Breaks from Every 40 min. walked, decrease 19% risk of T2DM For every 2 hours standing/light physical activity, 10% reduced risk for diabetes Breaks in sitting associated with reduced insulin resistance

136 Diabetes and Breaks from Every 40 min. walked, decrease 19% risk of T2DM For every 2 hours standing/light physical activity, 10% reduced risk for diabetes Breaks in sitting associated with reduced insulin resistance Linear associations between blood glucose, insulin resistance and plasma triglyceride levels measures and prolonged sitting

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138 Power in a Little More than

139 Power in a Little More than Muscle cells are silent at rest with very low metabolic rate

140 Power in a Little More than Muscle cells are silent at rest with very low metabolic rate Metabolic rate of muscle can increase 100fold during contraction

141 Power in a Little More than Muscle cells are silent at rest with very low metabolic rate Metabolic rate of muscle can increase 100fold during contraction Special red, oxidative muscle cells used in low intensity physical activities such as standing

142 Power in a Little More than Muscle cells are silent at rest with very low metabolic rate Metabolic rate of muscle can increase 100fold during contraction Special red, oxidative muscle cells used in low intensity physical activities such as standing Even standing and taking slow steps involves complex coordination

143 Power in a Little More than Muscle cells are silent at rest with very low metabolic rate Metabolic rate of muscle can increase 100fold during contraction Special red, oxidative muscle cells used in low intensity physical activities such as standing Even standing and taking slow steps involves complex coordination Neuromuscular firing in postural muscles

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145 If you can t be more active, Light intensity physical activity seems to be a powerful substitute for sedentary time especially in the presence of

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147 The Role of Exercise and Exercise and Type 2 Diabetes: American College of Sports Medicine and the American Diabetes Association: Joint Position Statement Medicine & Science in Sports & Exercise: December Volume 42 - Issue 12 - pp

148 Acute Effects of Exercise on Diabetes Fuel Metabolism During Exercise BG uptake is increased in contracting muscles Intensity and duration of physical activity are the most important factors influencing fuel use Rest: predominantly FFA Physical activity: shift to mixture of fat, glucose and muscle glycogen Increasing intensity: increased use of CHO (primarily glycogen) Depleted glycogen: increased use of circulating BG along with FFA from adipose tissue Longer duration: utilizes lipid stores in muscle

149 Acute Effects of Exercise on Diabetes Muscle glucose uptake during exercise is not insulin-dependent BG uptake into exercising muscle is normal even when insulin-dependent pathway is impaired with T2DM (at rest and postprandial) as it is a different pathway BG uptake into muscles remains elevated after exercise for several hours Aerobic and resistance exercise increase abundance of glucose transporter proteins even in the presence of T2DM

150 Acute Effects of Aerobic Exercise on Diabetes Post-exercise glycemic control/bg levels: Aerobic exercise effects Moderate intensity exercise in those without diabetes rise in peripheral glucose uptake matched by rise in hepatic glucose production BG level doesn t change unless exercise is prolonged and depletes glycogen Moderate intensity exercise in those with T2DM BG uptake rises more than hepatic glucose production so BG levels fall Plasma insulin levels also normally fall, so exerciseinduced hypoglycemia risk is minimal (unless exerciser is taking insulin or insulin secretagogues)

151 Acute Effects of Resistance Exercise on Diabetes Post-exercise glycemic control/bg levels: Resistance exercise effects Has not been reported for T2DM In those with IFG, resistance training results in lower fasting BG levels for at least 24 hours after exercise Greater reductions: vigorous versus moderate intensity

152 Acute Effects of Combined Aerobic & Resistance Exercise on Post-exercise glycemic control/bg levels: Combined aerobic & resistance exercise effects, and other types of training Combination of aerobic & resistance exercise: more effective than either alone Due to: Greater caloric expenditure? Duration? Mode? Mild-intensity exercise like tai chi and yoga have shown mixed results Issues: small sample sizes, different forms of yoga

153 Acute Effects of Exercise on Diabetes Insulin Resistance Improvements in insulin action (both acute and chronic) is the primary benefit of physical activity on T2DM Most of the improvements are acute Decrease on BG levels during mild- and moderate- intensity exercise and last for 2-72 hours after Insulin action is enhanced with increased duration and intensity

154 Chronic Effects of Exercise on Diabetes Metabolic Control: Insulin Resistance and BG Levels Aerobic exercise improves whole-body insulin sensitivity Even after 1-wk of aerobic training Aerobic exercise increases fat stores in muscle and improves fat oxidation capacity T2DM fat oxidation is decreased; shifts toward CHO oxidation Resistance training also improves insulin action and BG control in T2DM

155 Lean Obese Source: Physical Activity and Type 2 Diabetes: Therapeutic Effects and Mechanisms of Action. JA Hawley and JR Zierath, 2008.

156 Two Components of Metabolic Flexibility More fat oxidation More CHO oxidation Respiratory Exchange Quotient (RQ) Fasting Lean Obese Insulin-stimulated Source: Physical Activity and Type 2 Diabetes: Therapeutic Effects and Mechanisms of Action. JA Hawley and JR Zierath, 2008.

157 Pre-wt Loss Post-wt Loss Pre-exercise Post-exercise

158 More fat oxidation More CHO oxidation Weight Loss, Exercise and Metabolic Flexibility Effects of weight Fasting Insulin-stimulated Pre-wt Loss Post-wt Loss Pre-exercise Post-exercise

159 Weight Loss, Exercise and Metabolic Flexibility More fat oxidation More CHO oxidation Effects of weight Fasting Insulin-stimulated Pre-wt Loss Post-wt Loss Effects of exercise Fasting Insulin-stimulated Pre-exercise Post-exercise

160 Chronic Effects of Exercise on Diabetes Lipids and Lipoproteins Aerobic training decreases total and LDL-C and increases HDL-C in those with T2DM in some studies but not others May see more effect when exercise intervention is combined with weight loss Hypertension More than 60% T2DM are hypertensive Risk of vascular complications is % higher for those with both diabetes and hypertension than either alone

161 Chronic Effects of Exercise on Diabetes Mortality and CV Risk Observational studies show a lower risk in those with T2DM times higher in low-fit compared to high fit men >10 MET capacity lowest risk Body Weight/Weight Loss May need ~60 min/day of exercise for weight loss Supervision of Exercise BG control and better compliance seen when exercise is supervised

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163 The Fitness Tripod Aerobic Exercise for the Heart Cardiovascular Endurance Heart-lung fitness Achieved with aerobic exercise

164 The Fitness Tripod Aerobic Exercise for the Heart Cardiovascular Endurance Heart-lung fitness Achieved with aerobic exercise Stretching for Flexibility Flexibility Joint range of motion Achieved with stretching exercises

165 The Fitness Tripod Aerobic Exercise for the Heart Cardiovascular Endurance Heart-lung fitness Achieved with aerobic exercise Resistance Training for the Muscles Stretching for Flexibility Muscular Strength / Endurance Muscle fitness Achieved with resistance Flexibility Joint range of motion Achieved with stretching exercises

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167 FITT Recommendations: Aerobic

168 FITT Recommendations: Aerobic Moderate Aerobic Exercise Frequency: 5 days/ week Intensity: noticeable increases in heart rate and breathing Time: 30 minutes (in at least 10 min increments); total of 150 minutes per week

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170 FITT Recommendations: Aerobic Vigorous Aerobic Exercise Frequency: 3 days/ week Intensity: substantially increases in heart rate and breathing Time: minutes (total of 75 minutes) Type: rhythmic, involving large muscle groups: jogging/

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172 FITT Recommendations: Aerobic Combination of Moderate-Vigorous Aerobic Exercise Frequency: 3-5 days/wk Intensity: substantially increases in heart rate and breathing Time: minutes Type: Combination

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174 FITT Recommendations: Resistance Training Frequency: 2-3 nonconsecutive days/ week Intensity: to muscle fatigue, not failure Moderate for older and/or deconditioned adults (RPE 11-13) Time: Adults: 2-4 sets of 8-12 reps Older adults: 1 set of reps

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176 Rating of Perceived Exertion 6

177 Rating of Perceived Exertion 6 7 Very, very light

178 Rating of Perceived Exertion 6 7 Very, very light 8

179 Rating of Perceived Exertion 6 7 Very, very light 8 9 Very light

180 Rating of Perceived Exertion 6 7 Very, very light 8 9 Very light 10

181 Rating of Perceived Exertion 6 7 Very, very light 8 9 Very light Fairly light

182 Rating of Perceived Exertion 6 7 Very, very light 8 9 Very light Fairly light 12

183 Rating of Perceived Exertion 6 7 Very, very light 8 9 Very light Fairly light Somewhat hard

184 Rating of Perceived Exertion 6 7 Very, very light 8 9 Very light Fairly light Somewhat hard 14

185 Rating of Perceived Exertion 6 7 Very, very light 8 9 Very light Fairly light Somewhat hard Hard

186 Rating of Perceived Exertion 6 7 Very, very light 8 9 Very light Fairly light Somewhat hard Hard 16

187 Rating of Perceived Exertion 6 7 Very, very light 8 9 Very light Fairly light Somewhat hard Hard Very hard

188 Rating of Perceived Exertion 6 7 Very, very light 8 9 Very light Fairly light Somewhat hard Hard Very hard 18

189 Rating of Perceived Exertion 6 7 Very, very light 8 9 Very light Fairly light Somewhat hard Hard Very hard Very, very hard

190 Rating of Perceived Exertion 6 7 Very, very light 8 9 Very light Fairly light Somewhat hard Hard Very hard Very, very hard 20

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192 FITT Recommendations: Frequency: 2-3 days/wk Intensity: Mild tightness without discomfort Time: seconds per stretch; 10 minute session; 1-4 reps each

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194 Safe Exercise for People with Diabetes

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196 FITT with Diabetes: Aerobic Frequency: at least 3 days/week; not more than 2 consecutive days between sessions Intensity: at least moderate Those already doing moderate exercise should try to include some vigorous (intensity seems to have the most impact on BG control) Time: minimum of 150 minutes per week (more for weight loss about 7 hrs/wk)

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198 FITT with Diabetes: Resistance Training

199 FITT with Diabetes: Resistance Training Frequency: at least twice weekly - nonconsecutive days Intensity: Moderate (or vigorous for optimal strength increase, insulin action, and BG control) Time: 5-10 exercises Early in training: 1 set reps Progress slowly to more vigorous: 1-4 sets 8-10 reps to near fatigue

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201 FITT with Diabetes: Flexibility Frequency: 2-3 days/wk Intensity: Mild tightness without discomfort Time: seconds per stretch; 10 minute session; 1-4 reps each stretch

202 FITT with Diabetes: Flexibility Frequency: 2-3 days/wk Intensity: Mild tightness without discomfort Time: seconds per stretch; 10 minute session; 1-4 reps each stretch Include stretching, but not as a substitute for other forms of training

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204 Increase total daily expenditure for additional health benefits and a larger caloric deficit Daily movement

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206 BG Control: Hyperglycemia & Exercise Hyperglycemia is rare in exercisers with T2DM Very few are as profoundly insulin-deficient as T1DM Generally do not need to postpone exercise due to high BG especially if feeling well If BG is > 300 mg.dl (without ketosis) and strenuous physical activity is going to be performed, ensure adequate hydration

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208 BG Control: Hypoglycemia & Exercise

209 BG Control: Hypoglycemia & Exercise Hypoglycemia minimal concern if controlled by lifestyle Glucose monitoring before and after can be done Longer duration and low intensity activities do generally cause decreased BG but usually not to the level of hypoglycemia

210 BG Control: Hypoglycemia & Exercise Hypoglycemia minimal concern if controlled by lifestyle Glucose monitoring before and after can be done Longer duration and low intensity activities do generally cause decreased BG but usually not to the level of hypoglycemia Hypoglycemia more concern if insulin or insulin secretagogues* are used with exercise (increased BG uptake) Pre-exercise BG of <100 mg.dl supplement with up to 15 gm CHO prior to exercise, depending on insulin dose, exercise volume and BG levels CHO supplement less likely needed for short,

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212 Medication Effects on Exercise Diabetes Medications Medication adjustments with regard to exercise are usually only needed when insulin or insulin secretagogues are used May need to reduce insulin or oral medication before (and sometimes after) exercise. Particularly short-acting insulin* doses, and especially if exercising during insulin peaks BG monitoring before and after exercise necessary; sometimes during if low BG levels are suspected May need to adjust with CHO and/or medication regimen Longer-acting insulins, absorbed subcutaneously during exercise, do not often

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214 Medication Effects on Exercise Other Medications

215 Medication Effects on Exercise Other Medications Medications for co-morbidities often taken by those with T2DM generally do not effect exercise response.

216 Medication Effects on Exercise Other Medications Medications for co-morbidities often taken by those with T2DM generally do not effect exercise response. Exceptions: Beta-blockers blunt HR, lower max exercise capacity (though increase capacity in those with CAD); may block symptoms of hypoglycemia Diuretics may lower fluid/blood volume, increasing risk of dehydration and electrolyte imbalances Statins may cause myopathies

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218 Peripheral Neuropathy &

219 Peripheral Neuropathy & Recent studies have shown moderate walking does NOT increase risk of foot ulcers or re-ulceration in those with peripheral neuropathy (replaces previous guidelines to avoid weight-bearing exercise) Exercise should be

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221 Daily inspection of feet and proper, wellfitting shoes should be a part of comprehensi ve foot care in those with peripheral Shoes & Foot Hygiene

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223 Autonomic Neuropathy &

224 Autonomic Neuropathy & Can have silent ischemia, and inappropriate HR and BP responses to exercise

225 Autonomic Neuropathy & Can have silent ischemia, and inappropriate HR and BP responses to exercise Should have physician approval and possible stress testing to screen for exercise response abnormalities

226 Autonomic Neuropathy & Can have silent ischemia, and inappropriate HR and BP responses to exercise Should have physician approval and possible stress testing to screen for exercise response abnormalities Exercise tolerance can be impaired

227 Autonomic Neuropathy & Can have silent ischemia, and inappropriate HR and BP responses to exercise Should have physician approval and possible stress testing to screen for exercise response abnormalities Exercise tolerance can be impaired Max HR can be lower than normal best to measure directly

228 Autonomic Neuropathy & Can have silent ischemia, and inappropriate HR and BP responses to exercise Should have physician approval and possible stress testing to screen for exercise response abnormalities Exercise tolerance can be impaired Max HR can be lower than normal best to measure directly Higher incidence of orthostatic hypotension

229 Autonomic Neuropathy & Can have silent ischemia, and inappropriate HR and BP responses to exercise Should have physician approval and possible stress testing to screen for exercise response abnormalities Exercise tolerance can be impaired Max HR can be lower than normal best to measure directly Higher incidence of orthostatic hypotension May see resting tachycardia (fast HR) and slower HR recovery after exercise

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231 How to do Deal with Co- Known cardiovascular disease Prevalence of CVD higher in those with T2DM Exercise should be supervised at least initially, preferably in cardiac rehab Can also have complications such as dyslipidemia, hypertension, neuropathies, PAD and microvascular damage Exercise stress testing may be indicated

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233 Aging, T2DM & Exercise Higher risk of chronic disease co-morbidities with higher age Pre-exercise evaluation and stress testing more likely to be indicated depending on factors involved Use more caution regarding low initial intensities, slow progression, fall prevention

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235 Obesity, T2DM, & Exercise Will need to work up slowly to greater volumes of exercise for adequate energy expenditure Greater risk of comorbidities Increased risk of injury due to load on connective tissue Allow for stress adaptation Add variety, including

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237 General Principles re: Stress

238 General Principles re: Stress Try to avoid creating exercise barriers such as unnecessary testing

239 General Principles re: Stress Try to avoid creating exercise barriers such as unnecessary testing Exercise stress testing is advised primarily for previously sedentary individuals with diabetes who want to undertake activity more intense than brisk walking

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241 Based on 53,000 patients years of data from the UK Prospective Diabetes Study

242 Based on 53,000 patients years of data from the UK Prospective Diabetes Study Helps identify people at higher risk for underlying CVD

243 Based on 53,000 patients years of data from the UK Prospective Diabetes Study Helps identify people at higher risk for underlying CVD Calculates expected 10-yr CV risk based on age, sex, smoking, diabetes duration, lipids, BP, ethnicity, and HbA 1c

244 Based on 53,000 patients years of data from the UK Prospective Diabetes Study Helps identify people at higher risk for underlying CVD Calculates expected 10-yr CV risk based on age, sex, smoking, diabetes duration, lipids, BP, ethnicity, and HbA 1c

245 UKPDS Risk Engine Based on 53,000 patients years of data from the UK Prospective Diabetes Study Helps identify people at higher risk for underlying CVD Calculates expected 10-yr CV risk based on age, sex, smoking, diabetes duration, lipids, BP, ethnicity, and HbA 1c index.php

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247 ECG Stress Testing May be indicated for those with one or more of the following: Age >40 yrs, with or without CVD risk factors other than diabetes Age >30 yrs AND Type 1 or 2 diabetes of >10 yr duration Hypertension Cigarette smoking Dysplipidemia Proliferative or preproliferative retinopathy

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249 ECG Stress Testing

250 ECG Stress Testing Any of the following, regardless of age Known or suspected CAD, cerebrovascular disease and/or PAD Autonomic neuropathy Advanced nephropathy with renal failure

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252 The Really Big Question: How to Motivate Exercise

253 The Really Big Question: How to Motivate Exercise 1. Selfefficacy:

254 The Really Big Question: How to Motivate Exercise 1. Selfefficacy: people need confidence that they can

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256 Misery Loves Company

257 Misery Loves Company 2. Social support can really help. Find a buddy

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259 Movement: Gotta Love It or Just Decide To

260 Movement: Gotta Love It or Just Decide To You may learn to love it

261 Movement: Gotta Love It or Just Decide To You may learn to love it You may not

262 Movement: Gotta Love It or Just Decide To You may learn to love it You may not You will love how it makes you feel

263 Movement: Gotta Love It or Just Decide To You may learn to love it You may not You will love how it makes you feel People have to care about feeling better

264 Movement: Gotta Love It or Just Decide To You may learn to love it You may not You will love how it makes you feel People have to care about feeling better People who join thinking it will be fun have lower

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266 The Exception, Not the Rule

267 The Exception, Not the Rule Successful behavior is choosing what we most want, NOT what we want in the moment

268 The Exception, Not the Rule Successful behavior is choosing what we most want, NOT what we want in the moment

269 The Exception, Not the Rule Successful behavior is choosing what we most want, NOT what we want in the moment

270 The Exception, Not the Rule Successful behavior is choosing what we most want, NOT what we want in the moment Relying on luck is

271 The Exception, Not the Rule Successful behavior is choosing what we most want, NOT what we want in the moment Relying on luck is Thank u!

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273 Basic Moves: Stretch and Strengthen for Lifetime Fitness

274 Basic Moves: Stretch and Strengthen for Lifetime Fitness

275 Basic Moves: Stretch and Strengthen for Lifetime Fitness