Exercise and Type 1 Diabetes

Transcription

1 Exercise and Type 1 Diabetes QuickTime and a decompressor are needed to see this picture. 1

2 Characteristics of Type 1 & Type 2 Diabetes Mellitus ACE Mtng 2011 Rate of New Cases of Type 1 & Type 2 Diabetes among Youth < 20 yrs 2

3 Comparison of Diabetes Types Type 1 Type 2 LADA Onset Rapid Slow Rapid Family Hx Uncommon Common Maybe? Antibodies GAD, ICA, IA-2 TCF4 GAD, ICA, IA-2, TCF4 Lifestyle & excess Wt Normal Overweight Obese Prognosis Insulin dependent May progress, IF antibodies Treatment Insulin, diet, exercise Diet, oral drugs/insulin, exercise Normal Mildly obese Insulin dependent Progresses to insulin 3

4 Differences between Diabetes Insulin Activation of Glut-4 4

5 Cumulative Incidence 12/12/2011 Age Cardiometabolic Risk - Graphic Genetics Insulin Insulin Resistance? Syndrome Lipids BP Glucose Overweight / Obesity Cardiometabolic Risk Global Diabetes / CVD Risk Abnormal Lipid Metabolism LDL ApoB HDL Trigly. Age, Race, Gender, Family History Smoking Unhealthy Eating Physical Inactivity Hypertension Inflammation Hypercoagulation EDIC Findings: Cardiovascular Events 0.12 Cumulative Incidence of First of Any Event Risk reduction 42% 95% CI: 9% to 63% P = 0.02 Conventional Intensive DCCT/EDIC N Engl J Med 2005: 353: Years from Study Entry 5

6 Cumulative Incidence 12/12/2011 EDIC Findings: Cardiovascular Events Risk reduction 57% 95% CI: 12% to 79% P = 0.02 Conventional Intensive DCCT/EDIC N Engl J Med 2005: 353: Years from Study Entry 6

7 The Pancreas & Blood Glucose Control 7

8 Overview of Insulin Action McMahon G and Dluhy R. N Engl J Med 2007;357: Insulin Delivery 8

9 Management of Type 1 Diabetes Contemporary Diabetes Care Team Approach Physician(s) Diabetologist Exercise Physiologist or Professional Management Team Diabetes Educator Registered Dietician 9

10 Let s Talk About Exercise Or Physical Activity What Is The Most Common Effect On Diabetes? Glucose Changes with Exercise: Depends upon Pre-exercise Glucose & Insulin DM - NC DM - WC Control Time [mins]

11 Glucose Maintenance During Exercise: What Happens? How does this occur? Glucose Use Glucose Production Exercise Recovery minutes Normal Insulin: Glucose use ~ Glucose output In diabetes, when: Insulin is LOW [ blood glucose]: Glucose use < Glucose output Counterregulatory hormones hepatic glycogen breakdown Insulin is HIGH [ blood glucose]: Glucose use > Glucose output Insulin glucose from liver Acute Effects of Higher Intensity Exercise 11

12 Moderate Exercise vs. Short-term High Intensity Exercise QuickTime and a decompressor are needed to see this picture. How Does Glucose go up With Exercise? QuickTime and a decompressor are needed to see this picture. 12

13 Exercise Effects on Glucose Lowering via Glucose Transporters Chronic Effects of Aerobic Exercise 13

14 Chronic Effects of Aerobic Exercise Studies Involving Resistance Exercise in Type 1 Diabetes 14

15 Resistance Training Outcomes Type 1 Diabetes: What are Short-Term Benefits of Exercise? Acute reduction in blood glucose ONLY IF pre-exercise is < 250 mg/dl ( insulinized ) Improved insulin sensitivity Reduced pre-exercise insulin dosage Use of glucose is intensity dependent Transient changes favorable changes last ~ hours!! 15

16 Type 1 Diabetes: What are Long-Term Benefits of Exercise? Improved insulin sensitivity Reduced daily insulin dosage Enhanced glucose and fat metabolism Health-related changes Change in glucose control? Type 1 Diabetes: Exercise Program with NO Complications Aerobic Frequency 3-7 d/wk DAILY? Intensity 50-80% HR Reserve RPE: 4-6 (1-10 scale) Time min 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 16

17 Hypoglycemia: Exercise in Type 1 Diabetes Rate of Insulin Absorption ANS Dysfunction Peak Time For Insulin Action Glucose High Bolus Late Onset Hypoglycemia Co-existing Condition + Meds Too Little CHO 17

18 Exercise & Diabetes: Redefining Exercise Programs Current knowledge of type 1 diabetes + exercise Challenges facing exercise program development for heterogeneous type 1 diabetes 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 SMBG Balanced nutrition RD? 18

19 Safe Exercise: Routine Blood Glucose Checks - TOOL BOX ALWAYS check pre-exercise glucose IF glucose mg/dl okay to exercise IF glucose >250 mg/dl Use caution for exercise IF glucose < 100 mg/dl - give g CHO Re-check glucose to ensure BG > 100 mg/dl ALWAYS check post-exercise glucose 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 exercise: When? How much activity? If needed, carry extra carbohydrate feedings Use technology Wear a pedometer 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 19

20 Management of Diabetes Mellitus: Therapeutic Steps in Management Medical management Use of medications to manage glucose insulin Symlin + meal Frequent monitoring of blood glucose Proper diet and exercise Common Pathways in Diabetes Complications Glucose Peripheral & Autonomic Neuropathy AGE Formation Hexosamine Pathway Cellular Dysfunction Oxidative Stress ROS ROS Cell Damage Vascular Damage Nephropathy Retinopathy Diabetes complications (eye, kidney, nerve, blood vessels) arise from a number of triggers perturbing a limited number of metabolic pathway(s) (Brownlee, 2001) 20

21 Diabetes Complications: Standards of Care of Practice [ADA, 2011] Cardiovascular Disease [CVD] May need evaluation Not all need stress test to participate in low level of physical activity/exercise Peripheral Arterial Disease [PAD] Poor blood supply to lower extremities Loss of pulse in foot Cold feet Leg pain linked with PAD Intermittent claudication Proportion of Patients with Cardiovascular Disease Increases with Duration of Diabetes 48% 21% 24% 29% 15% Years after DM Diagnosis 21

22 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 moderateto-vigorous intensity No CVD: Low-tomoderate intensity may be OK Physician judgement Peripheral Arterial Disease [PAD] Leg pain linked with PAD limits weight-bearing activity ~40% have exercise leg pain 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 Diabetes Complications: Standards of Care of Practice [ADA, 2011] Retinopathy Deteriorating vision Leading cause of blindness in diabetes May need dilated exam Proliferative Diabetic Retinopathy [PDR] requires medical evaluation Nephropathy Kidney disease - unable to filter the blood Progressive disease More than 50% of renal dialysis patients have diabetes! 22

23 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 Ø Resistance training Lower intensity activities Cardio & resistance activities Nephropathy Exercise may urinary protein No evidence that vigorous exercise rate of progression No likely exercise restrictions specific to kidney disease! Diabetes Complications: Standards of Care of Practice [ADA, 2011], con t. Peripheral Neuropathy Affects both motor & sensory nerves Pain sensation & loss of sensation in extremities Loss of protective sensation in feet ~30% of those > 40 yrs have impaired foot sensation Risk of infection/injury Autonomic Neuropathy [AN] Affects HR rest HR rest & HR exercise Cardiac AN [CAN] alters postural BP and HR Risk of CVD in diabetes Many other organs involved 23

24 Exercising With Complications: Standards of Care of Practice [ADA, 2011] - TOOL BOX Exercise Programming: Type 1 Diabetes 24